As I was catching up with the end of 2016 online material, I happened upon an interesting article in Harvard Business Review. I just received a referral from CORE Institute and was going to look into learning more. First, the referral was from an orthopaedic surgeon. The patient will be a complicated patient who has a history of a cerebral vascular accident back in 2014. Her husband knew me because he fixes my home appliances that I somehow break. What was interesting was that the patient had a reverse total shoulder arthroplasty. When her husband popped in to get his wife on my schedule, he brought along the referral and time frame guidelines for this procedure. In my local area, the first time I ever treated anyone with this procedure, when I asked the surgeon about progression time frames, the surgeon said, "Selena, use your best judgment."
Harvard Business Review described a new payment model that CORE developed with one payer. This payment model seems risky yet intriguing. CORE seems to hold all the risk in this payment model. From a business perspective merged with a clinical perspective, that feels scary to me. Being totally responsible for everything entailed in caring for a medical condition seems as though the unknowns and outliers would end up creating uncontrollable costs. Although, the interesting twist, CORE decides what medical conditions that it will be fully responsible. This payment model seems to merge what I remember back in the day of capitated plans. Yet, capitated plans were for all subscribers and not for carved out medical conditions. There is a hint of bundled payment, but on a grander scale because the payments are set at a rate that allows CORE to provide wellness and preventative programs.
The article describes how well CORE is actually doing with this model. Profits are not discussed. What is shared is how the payment model is affecting patients. It appears there was a substantial reduction in readmission rates. Wasteful procedures are being carved out of care. My interpretation of a few changes is that patients are returned to the highest level of independent living possible (meaning less time in rehabilitation). I don't view this as negative because CORE has tools in place pre-surgically predicting the discharge location.
What is becoming more and more apparent, it isn't enough to just manage a patient in a lone bubble of care. Predictive analytics is becoming more important than ever. To be successful requires having data, knowing how to analyze the data and then having enough data to create predictions to improve care.