The Post-ACA World at a Glance

The business of healthcare is unlike any other. Healthcare stands among the most highly regulated of industries, and to complicate business even further, these government and industry-mandated regulations are ever-changing. Today, healthcare organizations must possess the agility to continually transform their current practices and constantly navigate new waters. Following the Affordable Care Act (ACA), key changes must now be made to the current care paradigm. These changes center around three initiatives in 1) expanding preventive care programs, 2) adopting a pay for performance (P4P) reimbursement system, and 3) sharpening the focus on patient-centered outcomes. These sweeping changes will require significant improvements to healthcare’s current workflows and IT infrastructures.

So, how can healthcare organizations effectively respond to these evolving regulations? The answer lies in establishing a strategic approach to care coordination. Why is care coordination so critical in the post-ACA era? Simply stated, when care is coordinated across the entire treatment journey, the patient can be treated in a holistic view. With this broader perspective, the patient can receive the right care at the right time, driving improvements to patient outcomes. The technologies that can enable these outcomes – enterprise resource planning (ERP), electronic medical record (EMR), and customer relationship management (CRM) solutions – are no longer just nice to have. Understanding the need for these enabling technologies are key to surviving the post-ACA world.

To reach the goal of coordination in service delivery and patient care, the ACA has multiple provisions that specifically address how patient services should be managed. This shift requires that healthcare organizations take a three-pronged approach at improving preventive care, pay for performance, and patient-centered outcomes.

1. Preventive Care

In accordance with this first initiative, health plans are now being urged to cover a host of preventive care services including vaccines and screening tests, at no additional cost to the patient. Aside from this increased need to keep expenses low, this also means that information systems must be capable of processing a greater volume of patient data and securely share this information with all involved in the patient’s care journey. From home healthcare providers to primary care physicians, specialists, nurses, pharmacists, health insurance companies, among others, all patient care services must be coordinated, documented, and made accessible so that the patient does not receive unnecessary or insufficient services. This is where coordinating care at the organizational level becomes key. Organizations need to adopt ERP/EMR/CRM solutions that allow full integration to their existing IT infrastructures, all to enable a secure and seamless path for sharing critical patient data and to drive insights into operational costs. Fortunately, this is a viable option and one that can meet the demands for expanding preventive care.

2. Pay for Performance

Secondly, the P4P initiative requires healthcare organizations to shift to a “quality-based” care model in which compensation is no longer simply tied to the service rendered, but to the outcomes of that service. In the past, healthcare organizations have been notorious for lacking transparency into procedural costs, inventory, and patient outcomes. However, hiding this information will no longer be tolerated in the post-ACA world. Again, the technology is available to embrace the P4P initiative. Modern ERP solutions that can regulate supply chain management, revenue cycle management, and also report key performance indicators are essential to meeting this second challenge.

A work in progress

Since the inception of the Affordable Care Act, healthcare organizations have experimented with P4P models. However, to successfully make the shift to a quality-based care model, healthcare organizations must first determine what constitutes quality care. How can this be achieved? Healthcare organizations are data-generating centers. These organizations own volumes of information on patient treatments and associated outcomes. Healthcare organizations can define what quality care is by performing comparative effectiveness studies to determine best practices and prescribe care plans accordingly. We know the steps that need to be taken to track data and achieve coordinated care, but we must now match that with the right technology to allow us to reach these actionable insights.

3. Patient-Centered Outcomes

The emergence of a quality-based, consumer-driven model is increasingly forcing healthcare businesses to focus on patient-centered outcomes. Today’s patients are digitally connected and technologically savvy and real-time access to health information is expected. To meet these changing expectations and to comply with ACA’s third initiative in reaching patient-centered outcomes, patient relationship management via CRM is now essential. Currently, most healthcare organizations rely on EMRs to manage all patient health information. However, EMR systems contain highly sensitive information and the systems and its security controls are complex. As a result, patient access is limited. Instead, CRM systems can improve patient access to their personal health records via user friendly patient portals. When CRM systems complement EMR systems, a complete view of the patient can be achieved and patient-centered outcomes can be fully realized. This approach not only builds patient loyalty and deepens relationships, but also drives process efficiency and business growth.

The business of healthcare is complex. The regulations are high and demands that organizations be forward-thinking to ensure their workflows and infrastructures comply with these ever-evolving regulations. Fortunately, we have the technology to survive in the post-ACA world; knowing how to harness the technology that healthcare businesses already own is the key to thriving.

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