As health systems become more prevalent, they are having increasing levels of control over treatment decisions, in coordination with physicians and managed care organizations. As a result of this increased level of control, health systems are in a unique position to improve the health of their covered lives and the experience of care while lowering costs, thus meeting all parts of the Triple Aim. At the same time, the changing landscape offers pharmaceutical manufacturers new opportunities to demonstrate their products’ value at the population health level.
Health systems are quickly gaining speed as a major force in driving the development, use, and enforcement of clinical pathways. Evidence of this growth can be seen in the sharp increase in hospital and health system mergers and acquisitions, which rose by 18% in 2015 compared with the previous year.1 This trend has resulted in the formation of “super-regional systems,” which are forming in almost every major market. As a result, health systems have an increasing reach and ability to impact major policy and market changes. This trend is unlikely to diminish, as seen with the Health Maintenance Organization (HMO) Gatekeeper Model or the previous attempts by hospitals to acquire physician practices.
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As health systems become more prevalent, the focus intensifies on the Triple Aim and its goal of providing value-based care at the population level. As a result, many clinical pathway developers are attempting to make progress on all three aims—improved health, increased satisfaction, and lower costs—by incorporating a population health perspective.
TREATMENT DECISION CONTROL AND THE TRIPLE AIM
The focus on population health can be seen as not just a component of the Triple Aim but also as a result of the broadening of control over treatment decisions beyond physicians to include managed care organizations (MCOs), beginning in the 1990s, and now health systems as well. When applying the Triple Aim to conceptualize this shared control, the physician’s focus is on individual patient care, the MCO is concerned about cost controls, and the health system is focused on population health management (Figure 1).
This brave new world is perhaps best illustrated in a recent advertisement by Mount Sinai, a major New York health system, which carried the tagline: “If Our Beds Are Filled, It Means We’ve Failed.”2 This demonstrates the shift in hospitals’ focus from bed volume and decreasing lengths of stay to the broader perspective of population health management.
POPULATION HEALTH AND CLINICAL PATHWAYS
The shift to a population health perspective requires a new way of thinking for all key stakeholders to ensure that clinical pathways are appropriately designed, adopted, and implemented. One relationship between two stakeholders that requires a new approach is the one between health systems and pharmaceutical manufacturers. As health systems expand and take on increased financial risk, they find themselves benefiting from the right type of relationship with pharmaceutical manufacturers to achieve improved health for the population for which they are being held responsible. This means that pharmaceutical manufacturers have the opportunity to reach a new treatment decision-maker with information and resources to improve their population health goals.
The onus is now on health systems to optimize control over pharmaceuticals and relationships with pharmaceutical manufacturers. This is a new territory for health systems as they acquire increasing responsibility for and control over medical and pharmaceutical costs, as well as control over prescribers. Some of the controls available to optimize treatment decisions come from the health systems’ ability to increase financial incentives for providers, implement alerts and controls through electronic medical records (EMR), and apply effective clinical guidelines and pathways (Figure 2).
Specifically, health systems will be served best by developing proficiencies and processes that: (1) obtain treatment control from payers; (2) determine optimum treatment selection and contracting based on value; (3) implement clinical pathways that incorporate the most effective treatments and programs that support population health management; and (4) ensure the utilization of preferred agents through prescriber compensation and EMR enforcement of clinical pathways.
Health systems that optimize their relationships with pharmaceutical manufacturers through the above steps will be in a far better position to improve the health of their covered lives and the experience of care while lowering costs, thus meeting all parts of the Triple Aim.
DEMONSTRATING VALUE TO HEALTH SYSTEMS
The pharmaceutical manufacturers who will succeed in this new environment will be those that are able to articulate their products’ value in terms that matter to health systems as they develop their clinical pathways. In addition to demonstrating value, manufacturers will have greater opportunities to contract with health systems in unique ways, such as indication-based pricing, total cost guarantees, and outcomes-based risk contracts. Also, there are opportunities for manufacturers to assist with health systems’ population health initiatives, which may appear in the form of beyond-the-pill–type programs, for example, programs that support adherence or offer provider tools for diagnosis, appropriate treatment, and behavioral determinants of health for conditions like diabetes, such as nutrition, diet, smoking cessation, and exercise. By working together, health systems and pharmaceutical manufacturers can achieve tremendous advances through the formation of outcome-based clinical pathways that focus on achieving improvements in patient satisfaction, reduction of costs, and ultimately, population health improvement.
References
1. Ellison A. The rise of ‘super regional systems’ and what it means for healthcare. Becker’s Hospital Review. https://www.beckershospitalreview.com/hospital-transactions-and-valuation/the-rise-of-super-regional-systems-and-what-it-means-for-healthcare.html. Published February 24, 2016. Accessed August 11, 2016.
2. Mount Sinai. If our beds are filled, it means we’ve failed. Advertisement. https://www.mountsinaihealth.org/static_files/MSHL/Files/2015-Campaign-Our-Beds.pdf. Accessed August 11, 2016.
