2022’s Request for a better healthcare ecosystem
Despite the movement from some of healthcare’s major players, many have not yet clearly articulated their ecosystem strategy. Nor are they set up with talent, operations, and technology that can fully realize value from either curating or participating in integrated, omni-site, patient-centered ecosystems.
Strategically, stakeholders need to decide whether they will act as curators or participants across the ecosystems that they touch. Stakeholders who wish to curate an ecosystem will need to ensure meaningful improvement in outcomes for a specific set of patients. This approach will require being clear on which industry-agnostic services they leverage and how they augment those services with healthcare-specific capabilities to create a differentiated ecosystem. Other stakeholders who want to provide point-solutions will need to ensure their value proposition is both competitively distinctive and compatible with a variety of ecosystems.
In addition, most stakeholders will need to make foundational upgrades across ecosystem layers, including:
Technology upgrades to leverage increasing data liquidity. Stakeholders must ensure that all created data is stored in a standard format and easily accessible. For many organizations, this upgrade will be accomplished by a transition to the cloud and the development and curation of data lakes. This approach also will enable the reconciliation of broader sets of data, including, for example, patient-generated and social/demographic data.
Operating model upgrades to drive insights through data and analytics. By building and integrating APIs and services that increase data availability, stakeholders will enable advanced analytics and automation techniques, such as predictive models and decision engines. Increasing the types and quantities of data that can be used to drive decisions is critical for a robust healthcare intelligence layer.
Data-first talent model upgrades to capture value. To effectively capture the value from the improved infrastructure and intelligence layers, organizations and participants can adopt new technologies that generate insights and change stakeholder behaviors based on these insights. These talent upgrades include, for example, teaching stakeholders how to use these insights to make decisions, and require change management and targeted re- or up-skilling.
External and partner services upgrades to expand engagement. Enabling provider, patient, and other stakeholder engagement across the ecosystem will likely require an external-facing orientation focused on collaborations and partnerships in line with stakeholder needs, particularly in the engagement layer, but also to optimize infrastructure and intelligence.
Additionally, healthcare stakeholders will need to shift behaviors of healthcare participants across patients, providers, and other healthcare stakeholders to realize value from ecosystems. This shift requires curators and stakeholders to ensure adoption of new technologies, services, and capabilities in an already crowded space. Ecosystem curators and stakeholders offering point solutions therefore need to consider not only which technology and services they will provide, but also how those capabilities will sit within workflows and journeys, build on existing behaviors, and are linked to incentives.
Payers
Payers, who have access to members and claims data and a core competency in understanding, adjusting to, and shaping regulation in a highly regulated industry, are well-positioned to act as curators of specific healthcare ecosystems. That said, payers likely have to actively position themselves for this role by curating an end-to-end experience for members and providers that can be improved upon over time, especially as the payer core value proposition begins to be “unbundled.” This would include individual point solutions that begin displacing core payer functions. Some payers are already integrating with pre- and post-acute care delivery systems and finding higher returns.
Curating an ecosystem requires a few steps:
Determine which ecosystem or sub-ecosystem to curate. Given the range of member needs and the ways in which patients engage with healthcare stakeholders, ecosystems must be customized to different types of care needs and journeys (for example, healthy individuals versus dual-eligible patients with multiple chronic conditions). Payers should decide which ecosystems they want to curate rather than simply participate in.
Build partnerships that will allow stakeholders to create a seamless experience for patients. Effectively curating an ecosystem requires the ability to create a seamless experience for patients. This requires an underlying data infrastructure that follows patients throughout their healthcare journey and enables interoperable transfer of data across healthcare stakeholders. It involves intelligence that turns that data into insights, and engagement capabilities that lead to stakeholder action. In many cases, the underlying technology required for each layer of future healthcare ecosystems already exists and is relatively mature. Therefore, payers may be able to curate ecosystems most efficiently if they partner with existing technology players and apply healthcare-specific talent and operating models to orient that technology. In this context, payers will need to effectively manage the risks of partnership, including security and privacy concerns.
Integrate patient and provider services into the ecosystem through contract, partnership, or acquisition on a use-case basis and with incentives in mind. Curating a successful ecosystem requires operating in an agile, patient-oriented way. Building the ecosystem on a use-case basis allows payers to gradually transition to these new ways of operating, while also ensuring a robust set of services that focus on the patient/patient-profile selected. For example, if a payer decides to focus on simple chronic patients, they may first decide to integrate services that enable remote monitoring for providers treating patients with diabetes. Additionally, payers can weigh investing in the capabilities required to build new payment models in order to best enable ecosystems. Given the increasing complexity of ecosystems and the requirement for stakeholders to work together to optimize the quality of care for patients, payers are likely to focus on payment models that effectively align incentives across ecosystem stakeholders.
Providers
While provider systems have made significant capital investments, to date these investments have not delivered their expected productivity improvements. The evolution toward ecosystems presents an opportunity for these providers to increase their return on this invested capital. Leveraging historical—and potential future—investments to create a more longitudinal and personalized care experience could be a potential “unlock” for productivity. Additionally, the emergence of ecosystems may drive care delivery innovation as it enables providers to leverage a broader array of services for patients beyond responding to acute needs.
In an ecosystem-driven world, providers can either participate in an ecosystem curated by another stakeholder, as a professionalized deliverer of episodic or acute care, or they can curate a care-oriented ecosystem for certain populations across the care continuum. Providers are most likely to act as ecosystem curators for subsets of the population with intense, chronic needs; lower-need, healthier populations have less interaction with providers and are not likely to participate in an ecosystem curated by a provider.
The goal for providers who choose to curate ecosystems would be to deliver a fully integrated experience, centered around the patient, and incorporating informal caregiver engagement. These care-oriented ecosystems will need to extend throughout the entire care continuum. Providers who wish to pursue this strategic path will need to do the following:
Develop a strategy for bringing together care experiences across the entire continuum (that is, seamlessly linking pre-acute, acute, and post-acute care). This kind of integrated network integrity likely requires deployment of a few critical enablers:
Mechanisms that make scheduling and referrals processes more seamless and proactive. These mechanisms could include open scheduling, centralized referral recommendation tools, or care navigators who schedule follow-up appointments with emergency department patients upon discharge.
Integrated network strategy across all provider types and locations. This strategy ensures that affiliated physicians are able to practice at the facility that makes the most sense to the patient.
Creation of a network for high-needs patients. This network will fulfill all of the clinical needs of the selected patient segment, for example, focusing physician outreach/recruitment on specialties where patients are most likely to see an out-of-network provider.
Aligned provider incentives. Providers within the ecosystem of care must realize ecosystem-oriented payment arrangements or joint incentives, such as through joint venture arrangements.
Re-work the traditional concept of organization via “service lines.” A truly integrated experience will revolve around a patient's holistic needs. In the current system, patients transfer from one service line to another (for example, from radiology to oncology, to surgery, back to oncology, to social services). A team-based approach centered around the patient (for example, someone with a complex cancer diagnosis) will be more in line with an ecosystem view, but requires organizational, financial, and operational changes.
Integrate tools and care approaches that address non-clinical behaviors that influence health status, potentially through partnerships with other organizations (clinical care explains only about 15 percent of overall health outcomes).
Deploy tools that help personalize the ecosystem experience for each individual patient. Data liquidity in the infrastructure layer and innovation in the engagement layer (for example, deployment of digital tools) will be particularly important to enable this personalized experience.
For providers that make a strategic choice to be a participant in an ecosystem, it will be important to have a distinctive value proposition. This means, at minimum, providing high-value care for specific patient needs. To maintain this value proposition, providers may choose to act as specialty aggregators that bring together distinctive services for a specific specialty (for example, orthopedics) to support an ecosystem. Providers who pursue this strategic path will need to do the following:
carefully consider which specialties or practice areas they will offer (for example, based on competition trends in those areas, long-term economic sustainability)
ensure that there is a clear quality and affordability value proposition so that they have a “right to play” in various ecosystems curated by others
ensure that the infrastructure, intelligence, and engagement capabilities they have in place can easily integrate into others' ecosystems
