The shift to value-based care has continued to gain momentum despite regulatory uncertainty. This transition is driving an increased focused on population health management. Various tools and strategies have emerged to support population health initiatives, but every organization defines population health a little differently. There is no such thing as a "one-size-fits-all" population health management strategy.
At Becker's 8th Annual CEO & CFO Roundtable in Chicago in November, Allscripts hosted an executive roundtable to explore how healthcare organizations are implementing risk-based contracts and pursuing population health goals. Executives in attendance also discussed how they measure financial and operational success in this new world.
The many definitions of 'population health'
In 2016, the United States spent roughly double per capita on healthcare than other wealthy countries. However, this heightened level of spending hasn't translated into better health. The U.S. has the shortest life expectancy and highest rates of infant mortality compared to other 10 countries included in the study, according to a study published in JAMA. The study also found that Americans sought care at comparable rates to patients in other countries. However, clinical care alone cannot address the social determinants of health that have a significant influence on individual health and care outcomes.
"If doctors tell patients to eat more fresh vegetables and they live in a food desert, they might as well have told those people that they should fly to the moon," said Michael Blackman, MD, medical director of population health and analytics at Allscripts. "How do we set patients up with a food bank or whatever they need? Even if clinicians don't do this, do they have someone they can refer patients to who can help?"
How an organization defines population health translates into how it defines value. When thinking about population health, key questions include how to build a smart community, how to share data appropriately and how to work together to achieve desired outcomes.
The processes and data required for value-based care
The processes and metrics that support value-based care have, to date, largely required additional support from clinicians and staff in order to be successful. Determining who handles this work is often an evolving process.
"Everything initially got pushed to primary care physicians to handle. This led to skyrocketing burnout rates in primary care," said the chief medical information officer of a large health system on the West Coast. "Then we said, 'Oh, the internists and primary care docs can't do it, so the staff will do the work.' But they were already busy doing other things. Phone calls went unanswered as staff focused on work related to pre-charting. Now we have a separate team that deals with primary care pre-visits. When I see a patient a lot of information in the EMR is pre-filled, so I'm not responsible for checking all the boxes."
The chief quality and transformation officer at a critical access hospital in the Northwest noted that her organization has created two new positions to handle data and process-related work. A management epidemiologist helps with statistical analytics, while a management engineer deals with process improvement. She noted, "In a small organization, it's much harder to manage. You don't have a bench full of people; everyone does six jobs. Care coordination is a big piece."
The processes needed to support value-based care can sometimes contribute to a confusing experience for patients once they've left the care site. Many patients receive calls from the care coordinator at the primary care clinic, the care coordinator from the transitions of care management office, the post-op person and more. "They are getting four or five calls, all asking how they are doing. Patients are going to stop answering the phone. We need to approach this as a coordinated system, rather than as a bunch of people trying to boost quality and reduce readmissions," said the medical director of a large health system in the Midwest.
Health systems leaders are coming to realize that achieving high-quality clinical care with a personalized touch only when teams are all on the same page and supported by the appropriate tools and techniques. The chief quality and transformation officer observed, "In the past, quality teams came in and told us what we were doing wrong and what needed to be improved, but they didn't tell us how to do it. Today, we teach everyone the tools and techniques to make improvements. That's the key difference — we help them."
As risk-based contracts become more prevalent, many health systems are moving to a single care model for all patients
Health systems transitioning to value-based care largely serve a mix of patients, some covered by fee-for-service insurance and others covered by risk-based payer contracts. Most organizations recognize, however, that having two models of care is inefficient.
"Once you get to a certain point, it doesn't make sense to say, 'This group of patients is in my risk contracting piece and I'm going to treat them this way,'" said the former vice president of population health at an academic hospital on the East Coast. "We changed the whole organization toward a better and more efficient model of care. That means defining the right measures for all patients. It takes time, effort and resources. You also have to have the right cultural environment."
Dr. Blackman said having dual reimbursement models doesn't make sense from a clinical perspective. "If you have multiple payers and multiple contracts with slightly different criteria, no clinician walks in the room and gives patients different care for the same disease process based on payer," he said.
To be successful in the current reimbursement environment, the hospital CEO must wholeheartedly support the transition to value-based care. The healthcare organizations that have been most successful with change management initiatives are those that have promoted cross-functional cooperation. This is no different for risk-based contracts. The chair of the department of integrated information technology and professor of health IT at a university in the Southeast observed, "There's only one person in the organization that can enable cross-silo work and that's the CEO. If the CEO doesn't buy in, then no one else will be all in either."
Success with risk-based contracts requires integration across an organization. This is especially true as more hospitals have greater incentive to use primary care to save money in the hospital setting.
How access to benefits information in real time can lead to better, lower-cost patient care
Providing clinicians with real-time information about patient benefits can lead to more efficient care. The CMIO of the large health system on the West Coast said his organization has turned on real-time pharmacy benefit information in its EHR. He noted, "When physicians are presented with a drug alternative that saves the patient money, 40 percent of the time they change the prescription to the cheaper medication."
If a patient is covered by a Medicare ACO, clinical systems often will show physicians only those skilled nursing facilities (SNFs) that are in the patient's plan. In connected care networks, physicians do rounds in certain SNFs, so those facilities are prioritized for patient care. The medical director from the large Midwest health system explained, "The SNF waiver means that you must refer to a predefined SNF network for Medicare patients."
Some health systems voluntarily spend money to move patients out of the hospital to home care faster. The same leader said, "One of the important reasons to identify bundled patients up front is to determine at what point you spend money to get them to home care versus waiting for the payer to pay for it. We are willing to spend a little more on claims because it shortens the patients' length of stay."
Health systems must take a strategic approach to population health
For hospitals to find success under value-based care, these organizations must make population health a central focus. However, integrating population health management initiatives into operational models is often easier said than done.
"Population health is more than prescribing one medication instead of another or ordering one test instead of a different one," the health IT university chair from the Southeast said. "You need to look at the 40 percent of the diabetic patients you didn't see this year and determine how many emergency room visits they had that you were unaware of. You have to identify those types of issues, so you can address them from an organizational perspective."
Population health data is also important, but that information must be validated. The former VP of population health said, "Two adjacent Census tracts that are three-block areas can have completely different community health needs. You can't assume that data sets will automatically show you the real needs of the population. You need people to validate the information."
Health systems need to take a strategic approach to population health. This includes figuring out where technology can help identify the right actionable data that is delivered to providers at the point of care or point of need.
According to the vice chair for system integration and medical director practice innovations of a large physician group in the Northeast: "We need to start at the beginning, where we figure out who the population is and where processes and technology will enable us to deliver the right kind of care, whether that's in the doctor's office, at home or in a SNF. This will require investment and leadership."
Conclusion
Patients and public policy makers are all demanding higher quality and more value from the healthcare system. Value-based care and population health are seen as ways to achieve these goals. The shift to value-based care requires many steps. These include new processes, robust data and collaboration across different disciplines within healthcare organizations.
Incorporating clinicians in this evolution is critical. Catherine Costa, RN, assistant vice president of connected communities at Allscripts, observed, "I liken risk payment models to when we first rolled out electronic medical records. There were no clinicians at the table — it was just a technology project. I feel like we are there again. We need to have a voice to say whether risk is affecting the quality of the care we're giving."