Biggest Challenges in US Healthcare

Over the past few decades, the healthcare industry has been placing a keener focus population versus individual health than ever before.  Though there are several motives for this change, the two primary causes are driven by 1) the shift in payment sources for delivery of health care services and, 2)  the division of clinical responsibilities amongst key healthcare provider groups.  However, even with clear focus on population health many state health agencies (particularly state Medicaid) and primary care providers (PCPs) face an uphill battle with implementing successful population health strategies that are adequate for patient populations facing complex medical conditions or severe socioeconomic barriers to care.

Why independent community practices matter

To understand today’s challenges faced by the healthcare industry, we must understand the historical context of healthcare in the US.  In the early 20th century, the neighborhood primary care physician  was largely the gatekeeper between patients and their healthcare needs.  Not only did PCPs use to make house calls on their patients – a practice which led to knowing the patient, their family, and the patient’s medical history in detail – but PCPs would also undertake visiting the patient outside of the primary care setting by conducting rounds at hospitals where their patients may have been admitted, or following up with them at home once they were discharged.  Fast-forward to the latter part of the 20th century in which growing patient panels, more diverse patient-populations, and increased social barriers to care-access led to a new model where the PCP is still the “quarterback” of care, but in which they are largely reliant on information from other healthcare providers to identify when, and to what extent, engagement with their patients was needed.  At the same time, technological innovations which led to the improved ability of patients to safely undergo complex medical treatments ultimately drove health insurance as we know it today to become the backstop from patients and their families potentially having to pay out-of-pocket for expensive medical procedures.

However, with these advances came unexpected complexities wherein the standard insurance product was put in place to largely cover costs of expensive complex medical procedures, but recurring annual health and wellness services (typically administered by a PCP) required an ever-increasing deductible or co-pay (or in the case of state-administered plans, were overly restrictive).  Additionally, provider consolidation led to a focus on acute and post-acute treatment rather than proactive preventive visits to ensure patients avoided high-cost hospital stays in the first place.  With this increased focus on inpatient services rather than outpatient care, the advent of new roles further widening the communication gap between PCP and patients began to emerge (one example is the hospitalist role to manage care in an acute setting since PCPs no longer go to visit their patients in the hospitals).

Healthcare Industry

As the US healthcare industry has transitioned to meet the needs of patients and the requirements of insurance companies, the coordination of care, communication among stakeholders, and technology required to make this new model broadly operationally efficient has been lagging.  The individuals most impacted by this asynchronous move-forward between care delivery, communication, and reimbursement has been those located in medically underserved communities where social and clinical needs are already a challenge in-and-of-themselves and where operational inefficiency leads to quantifiably worst health outcomes as well as higher overall costs.  The result of this growing disparity between those providers who have the time, resources, and expertise to adopt to these new models of healthcare delivery and those who do not is widening.  Many providers are currently being forced to decide between maintaining the status quo which will lead to more and more challenging economic scenarios, and figuring out where to begin to implement sustainable operational population health strategies.

Health Disparities

Clinify Health works with physician practices caring for underserved and low-income communities to simplify the transition to new alternative models of healthcare delivery and reimbursement.  Our team of experts will support your practice with the strategic operational, technological, and financial components required to be successful in alternative payment models by leveraging Clinify Cloud® our clinical decision-optimization platform that tailors your point of care service delivery to achieve the highest cost and quality outcomes and share in the financial reward of overall population health expense reduction.  Are you ready to work within a healthcare model that rewards you for the care you are already diligently providing to your patients?

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