A W H I T E P A P E R S E R I E S

PATIENT CENTRIC CARE IS AT THE CORE OF NEARLY EVERY DEBATE IN HEALTHCARE. THIS PAPER TALKS ABOUT THE CHANGES THAT INDUSTRY STAKEHOLDERS NEED TO UNDERGO IN ORDER TO ACHIEVE THE GOAL OF TRUE PATIENT CENTRICITY.

Collaborating for Patient Centric Healthcare

A P P L I C A T I O N S

“Is the change in healthcare for real?” is a question that has become a refrain in the US healthcare

community for a while now. At the first look the answer seems like there is no real change as US

healthcare expenditure is rising and is likely to reach 21% of GDP by 2021.1 In fact, the Federal

Healthcare spending is expected to increase to 28% by 2016, up from the current 23% (2012).2 A

certain segment of the industry continues to believe that a lot of current initiatives are nothing but

‘old wine in a new bottle’. However, deeper analysis shows that the cost curve has started bending

– as National health expenditures rose just 3.8 percent from August 2011 to August 2012, and

Medicare spending increased by only 3.2 percent (significantly lower than the four decade average

of 10%) in the fiscal year ending September 2012.3 We can hence conclude that some change is

happening in patient care.

TABLE OF CONTENTS

INTRODUCTION

HEALTHCARE REFORMS – USHERING REAL CHANGE

RELOOK AT THE CARE ECOSYSTEM – A FUTURISTIC OULOOK

ATOS SYNTEL SERVICES ALIGNED FOR CARE ENABLERS

MARKET MAP

CONCLUSION

REFERENCES

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Introduction

The difference lies in the approach with which healthcare is being handled. Since long healthcare stakeholders are working within well defined boundaries and have strict definitions of roles each stakeholder has to play. Careful analysis of recent trends indicate that the tenets of patient centricity (access, enhanced care delivery, member and provider engagement and transparency ) have been established by the industry and collaborative efforts are being put to achieve that. Efforts are mooted to transform from transactional B2B model to a more holistic B2C model. Processes are being viewed from an enterprise level instead of individual system level. The focus is now on service value than volumes. In addition, a truly disruptive change is the cross industry collaboration in the form of Payer-Provider, Payer-Government or Payer-Employer coming together for an effective change.

2. Healthcare Reforms – Ushering Real ChangeAmerican Healthcare is experiencing a rapid change which is likely to redefine the way business is conducted and services are delivered. Current trends could be termed as disruptive of the old order and the near future could see many basic definitions rewritten and adopting new meaning. These contemporary trends are redefining the way business is conducted, giving a big thrust to Patient Centric care.

• New models of care delivery like Accountable Care Organization (ACO) and Patient Centred Medical Homes (PCMH) are emerging ascompetition to traditional business. By 2014, it is estimated that nearly 30% of private payers will acquire provider arms, which would boostthese emerging delivery models. Adoption of newer payment methodologies that reward quality, as against volumes and ones that reflectmore outcome based payment structures will gain wider acceptance.

• Reforms led thrust towards retail business, driven largely by individual market growth, is estimated to grow significantly between 2010 and2019. Shift from defined benefits to defined contribution model is yet another thrust towards individual business.

• The shift in focus from B2B to B2C model is pushing payers to develop expertise around ‘know your member initiatives’ by derivingintelligence from clinical, non clinical, social and behavioural data streams.

• Opening up of Exchange driven market is pushing payers to create differentiation in terms of pricing, service, quality, and provider network.• Leveraging alternative channels of care including Retail Clinics, Primary Care Outfits, Triage, and Telemedicine is on the rise.• Shift from transactional to transformation business model is helping business create market differentiation as compared to commodity

services player• Expanding service portfolio by diversifying into related businesses; member experiences and perceptions would be influencers here.• Greater adoption of technology, for example, meaningful use driven adoption of Electronic Medical Record (EMR) technologies.• New delivery models focused on outcomes and cost/ quality based reimbursements driving intense focus on drug efficacy (unregulated

pharmaceutical market) and results. For example, cut in expected spend of branded drugs by 4.3%.

Fast Facts• An estimated 31 million Americans are said to be taking care from ACOS.4

• Individual Market will triple between 2010 and 2019. 10

• Approximately $214 billion cuts in Medicare expenditure• Beginning in 2015, a 300-bed hospital with poor quality metrics could be penalized by more than $1.3 million per year. 10

• Pharmaceutical industry though an unregulated market, Health reform changes will cut into expected spending on brand-name drugsby 4.3%.10

• An estimated $5 billion savings is expected from the Medicare Shared Savings Program through 2013 – 2019 as per the CongressionalBudget Office. 11

3. Relook at the Care Ecosystem – A Futuristic Outlook

Current systems of care delivery are throwing up multiple interpretations of how best to address the demands exerted by:• Efficiency, cost and quality linked directives by the government• Accountability sought by employers• Discerning member to select best suited options of care

Primary stakeholders continue to drive internal efficiencies, but inter-stakeholder collaboration will be required to drive outcomes and business sustenance. Payers are emerging as key protagonists in the new scenario and assume the role of “care enablers” where they are the primary drivers of care delivery.

There are various issues that need to be considered in order to assess the preparedness towards meeting the goals of patient centric care such as:Is my core engine ready to scale up to meet the growing needs of the market?With growth in individual line of business along with influx of Medicare and Medicaid population, systems need to be scalable, have streamlined operations, capable of managing new models of delivery and payment reimbursement.

Steps towards system modernization and / or consolidation efforts would be required to address these challenges. Additionally, it calls for equipping “care owners” with appropriate infrastructure by rendering integrated network management, performance management, and enrolment management solutions.

“Move work to the experts” could be a useful process change to streamline utility functions such as medical coding compliance, HCC audits etc.Do I know my member well, or do I need more data for better insight?From constructing a wellness program to successfully managing interventions and care management programs, the need for reliable, insightful, comprehensive and actionable is critical. The data points to the acute need of a consolidated member view spanning across multiple data sources - clinical, non clinical, drugs related, social media, behavioural information, medical device feeds extensible to future data sources.Is my member view dictated by LOB considerations?

Government

• Exchange led competition• ICD led specificity• MLR driven efficiency• Universal Coverage• Subsidy driven Compliance• Reduced payouts for Medicare• Focus on accountable treatment

Employer

• Cost and Quality conscioustreatment

• SLA based Care Management• Defined Contribution

Cost and QualityControl Outcomes

Employee progressReport

Payers (Care Enablers)

• Consolidated Member View• Efficient BAU operations• Focus on Individuals• Technology Adoption in Provider networks• Alternate channels of Care - Retail Clinics,

Primary care outfits, Triage,• Innovative Reimbursement models

Providers (Care Owners)

• Transparency in Care reporting• Meaningful use driven adoption of

EMR• ACO driven Provider consolidation• Incentive based reimbursement• Shift in ownership of the Care

Continuum - Primary to Tertiary

Pharmaceutical andLife Sciences

• Integrating Medical devices inCare Management

• Outcomes research to showcaselong term savings

• Newer channels of marketing andcommunicating to Providers andMembers

• Greater Market segmentationand drug researchcustomization

EMRPerformanceData CareEnablement

• Drug Efficacy• Market

Segmentation• Member

HealthOutcomes

• MedicalDeviceUtilization

• DrugEfficacy

Patient

Futuristic Outlook of the Healthcare Ecosystem

Payers need to ensure that they break down the Line of Business (LOB) silos across their systems, thereby enabling an Integrated Care Management approach in terms of intervention programs, disease management, case management and wellness programs.

It is the same with providers irrespective of inpatient, outpatient or speciality services, there needs to be an integrated member service line.

Are my partners enabled to service member better – are they technology / data enabled?Health information exchanges provide an opportunity for an integrated EMR system to establish a patient-centric environment thereby promoting better communication and collaboration among clinicians and staff throughout the organization. This coupled with evidence based medicine act as effective enablers driving care quality

Acknowledging the view that specialty drug costs have to be seen in the context of overall health outcomes, it is important that pharmaceuticals companies be privy to data outcomes to enable delivery of better products tuned to the market segment being served.

Sharing of outcomes and trends data between pharmaceutical industry and other stakeholders to enable customized and targeted drug research.

Have I tapped into alternate channels of treatment?With rising cost pressures, payers need to track and measure the effectiveness of wellness programs and intervention management programs. Available alternative channels of care include retail clinics, primary care outfits, triage, home medical devices and telemedicine; moving towards 24x7 services.

All pervasive implementation will support early warning signs ensuring timely care intervention and effective utilization of provider services

Am I reporting on outcomes?The success of care initiatives depends on outcomes based approach and an effective tracking and reporting mechanism of member’s health progression. This allows for required intervention at appropriate stages.

4. Atos Syntel Services Aligned for Care Enablers

Aos Syntel services can help strengthen the goal of improved Patient Centric Care through its range of services and solutions for care enablers. Some of these offerings include:

LegacyModernization

DataEnablement

Know yourConsumer

Regulatory

iTAPIntegrated

TestAccelartorPlatform

COBOAutomated

Migratorof

CognsReports

nSure10

ICD10 Businessand Technology

Solutions

Signa OneMU Compliance

Dashboard

BPTRBusinessProcess

TestRepository

PTFPerformance

TestingFramework

ElicitARHealthcare

ClaimsData Analytics

Clinical DataProvenance

HL7 Gateway

Smart MoveCross Platform

Technology

Consumer 3600

Dicom

Smart MapAutomated

DocumentationTool

Smart DataData Quality

Enriching Tool

ConTextSentiment

Analysis Tool

Atos Syntel Services Aligned for Care Enablers

5. Market Map

Critical enablers to patient centric care and readiness (as available from public sources) of WellPoint and Aetna towards them have been compared in the below table

Enablers to Patient Centric Care WellPoint (Known Initiatives) Aetna (Known Initiatives)

Collaboration with Care Owners

Primary Care Launched the PC2 Initiative Collaborating with Nova Health

Secondary Care Acquired Care More Collaborating with Carilion Clinics

Teritary Care Launched multiple ACO initiatives

Collaborating with Baylor Health, Aurora Health etc

Health information Exchange Enabler Not known from Public Sources Medicity to enabled data exchange and integration

Triage Not known from Public Sources iTriage enabled

EMR/EHR Enablement for Provider Not known from Public Sources iNexx can support care coordination exchange of office notes

Evidence Based Medicine Collaborating to enable EBM Not known from Public Sources

Detailed Member View Not known from Public Sources Not known from Public Sources

Central Population health Management Not known from Public Sources Active Health Management

Back End Service Support Not known from Public Sources Providing back end support to collaborating Providers

Collaboration with Pharmaceutical Industry Not known from Public Sources Not known from Public Sources

6. Conclusion

Though the churn has begun, the goal of patient centricity would remain a distant dream, unless there is a metamorphosis of the roles of each stakeholder in the industry.

Government is playing the role of primary stimulator instead of being just regulator of healthcare. Working example of this is the shared savings program, which has been a big push for tiered models of care to get prominence in the industry.

Similarly, healthcare payers will have to take up the role of ‘care enablers’. They being the goldmines of data, knowhow and having the intent.

Providers now need a technology enabled transformation from their traditional role to a more encompassing role of ‘care owners’.

While the pharmaceutical industry is not yet governed by a central drug pricing body, it will need to be more responsible and transparent on drug research and pricing. Collaboration with other stakeholders especially, in light of new model of delivery and reimbursement is vital to ensure the right drug reaches the right patient.

Employers will take up the role of secondary stimulators to ensure that employees receive the required health cover bending the healthcare cost curve.

Collaboration Acquisition

7. References

• Health-Care Spending to Reach 20% of U.S. Economy by 2021• Federal Spending Estimates• Health Sector Economic Indicators, Center for Sustainable Health Spending• ACOs deliver care to 31 million Americans• Healthcare Payers Must Embrace a New Business Model to Manage Disruptive Change, Robert Booz, 2012• Predicts 2012: U.S. Healthcare Payers Must Focus on Business Models, Consumer Outreach and Analytics, Christina Lucero, Robert

Booz, 2012• Findings: Healthcare CIOs Must Ensure That Data Warehouse Skill Gaps Don't Derail This Key Priority, Vi Shaffer, 2010• Framework for Making Patient-Centered Care Front and Center, Sarah M Greene, 2012• Hype Cycle for Healthcare Payers, Robert Booz, 2012• Health reform: Prospering in a post, PwC Health Research Institute• ACOs: Controlling Costs while Improving Care• Aetna Building National ACO Network• Aetna Accountable Care Solutions• Accountable Care Organizations: Overview and Pilots• WellPoint to Buy CareMore Health Group for $800 million

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