Slicing and Dicing the Populations Within Population Health: One Industry Expert’s View

Nov. 10, 2013
In mid-September, The Advisory Board Company hosted its National Population Health Symposium in Washington, D.C., convening provider thought leaders from across the U.S. to share their experiences in migrating to risk-based payment models and population health management. Among the conference’s leaders was Lisa Bielamowicz, M.D., executive director and chief medical officer for the Washington, D.C.-based organization. Afterwards, Bielamowicz shared her perspectives on what’s being learned now in terms of the key subgroups of patients within population health initiatives.

In mid-September, The Advisory Board Company hosted a population health colloquium in Washington D.C., convening provider thought leaders from across the U.S. to share their experiences in migrating to risk-based payment models and population health management. Among the Advisory Board Company experts who spoke and helped lead the conference was Lisa Bielamowicz, M.D., executive director and chief medical officer for the organization. Bielamowicz, who leads the organization’s research and strategy efforts in physician alignment and population health, spoke recently with HCI Editor-in-Chief Mark Hagland regarding some of the learnings shared at that event, and what she and her colleagues are uncovering more broadly as they advise provider organizations on population health management initiatives. Below are excerpts from that interview.

What are the latest trends you and your colleagues are uncovering in the population health management arena?

We’ve actually been surprised how many health system and physician group leaders have seen their strategies turn lately; they’re beginning to be fertile, they’re starting to design contracts that are giving them the competencies they will need to succeed in care management for population health, and potentially in moving towards total risk incentive.

That being said, it is the rare system that has more than 30 percent of their book of business in shared savings or total cost incentive. And those organizations are finding that in order to break even on shared savings—say I do what a good network can do, which is to reduce unnecessary 10 percent of ED [emergency department] and inpatient utilization, I need to have such a tremendous amount of my revenues at risk, to offset the cut in utilization that would provide fee-for-service revenues to make up for those savings. And it’s important to recognize that most of the large physician groups are multispecialty groups that do a lot of utilization in diagnostic imaging, and so on, and it turns out that the need to fill CT scanners and OR suites is just as critical to the revenues of multispecialty groups.

So what we’re hearing from physicians and hospitals working in the shared-savings model, is that even cutting that first shared-savings contract is not enough to move out of that feet-in-both-camps situation, because being involved in one shared-savings contract is not enough, and they want to get to as much capitation as possible.

Lisa Bielamowicz, M.D.

So what seems readily doable is that first 10-percent cut in inpatient and ED utilization, then?

Yes, a strong network can do that, and we’ve seen it done.

What are the critical success factors to getting to that first 10 percent?

We dug into about 40 of the highest-performing population managers, organizations that have been successful at total cost risk, in a sustainable way, and you have to build the right network, get the right contract, and then actually manage care. The first two of those three things are things that smart people can do; the third thing, managing care, is the hard part. And the big insight is that what we see in the average health system is that they’re trying to come up with a one-size-fits-all care management model.

I had been a big proponent of the patient-centered medical home model, and still am; but every successful organization leverages analytics in and IT in one way; and every organization also structures its care team uniquely. It also builds out its primary care infrastructure in an individual way, with regard to the staffing, as in, who’s the owner and the manager of the patient? And finally, every organization slices the three critical subgroups within its population, differently.

So, with regard to what those three groups are, everyone knows about the top-shelf group, the five percent or more of patients with huge co-morbidities and the most intensive utilization. Then, very significantly, the middle of the pyramid is what we call the “rising risk” group. And we’ve found that managing this group is extremely important to managing total-cost risk. This is someone with two or three primary diseases, who typically is overweight and smokes, but about whom we know it’s just a matter of time before he or she becomes a high-cost patient. And the key is not just managing the already-high-cost patients, but finding a way to manage the rising-risk is the key. It’s like the “I Love Lucy” chocolate factory episode, with the conveyor belt! And then the third group is composed of  the healthy or relatively healthy, who don’t see a doctor more than once or twice a year. And that group is very important, too. So we have to keep those people healthy and engaged, in that risk context.

And what we’ve found is that yes, it is very important to be able to analyze claims and manage risk with those high-risk patients. But to be truly honest, it’s actually not that necessary to have analytics for the already-high-risk patients; in reality, most doctors and nurses will already know who they are. Where it’s incredibly important is to have analytics for the rising-risk population, so you can have a system that allows you to prioritize where you devote your limited care-team time. With a high-cost patient, I can essentially marry them to a nurse practitioner and be done with it. But with the rising-risk patients, you have to put them into a patient-medical home and then use predictive analytics to figure out how to manage their care.

Now, with the healthy and relatively healthy patients at the bottom of the pyramid, there’s an IT architecture that’s critical to make them “sticky” to us. Two or three years ago, if you’d asked me where a patient portal fits into this, I would have said it’s a phase-three kind of thing. But now, I’ve come to realize that a patient portal is incredibly important early on. If you look at Group Health, pretty much half of certain primary care interactions are online already. Can I schedule a visit online, can I check my lab results and see my meds? And ultimately, you get to full-on e-visits or simple chronic disease management online, etc. This allows us to better manage people who aren’t super-sick, and therefore, scale or doctor and nurse time, and also, it helps us with patient retention as well. For example, on a personal level, I go to a practice with a great patient portal. And so now if my doctor left, I would still stay with that group practice.

And you get a lot of pushback on where the relationship actually lies, from doctors. Would my patient ever go to Wal-Mart or Walgreens? I think that any generation is totally more open for a more convenient solution. And particularly, patients under the age of 50, the Generation Y and Generation Me people—unless you have a significant illness, your relationship with a doctor is completely subsumed by my getting what I want when I want it. And if you can’t build connections with patients outside 9 AM to 5 PM, you are going to lose.

How do you shift the thinking of physicians in practice around all this, and with what tools do you engage them and help them to optimize medical practice?

Getting physicians oriented to all these details, well, I say, you have to go through anger, denial, and fear before you get to acceptance around change—it’s like the Kubler-Ross model! So you have to say these things more than once. And the patient portal concept is a great example of starting this discussion going even in the mostly-fee-for-service space. If you can offline a patient from a visit around simple things like med check-ins to the portal, you could add another 500 patients to your panel; so it does help your practice to become more efficient. And when it comes to actual population health, you have to start look at stratifying patients. And there’s a fee-for-service imperative with this as well; if I start building a medical home with diabetics, you can offset the investment in things into things like a disease registry and a personal health nurse coach, you can add in more patients. So that’s the kind of thing you can start to do even before your risk level starts to flip.

And per IT and analytics, I think we don’t pay nearly enough attention to workflow in any of this stuff. And in particular in the care management space, it’s 10 percent strategy, 20 percent getting the right tools and data, and the rest is the tough work around changing workflow or adjusting tools to the workflow. At one point do I need the data? At what point do I need the tools? All of this stuff has to be really, really thoughtful. And when I look at the true pioneers, I look at Montefiore in the Bronx, and they’ve been able to standardize their approach to possible interventions. And this gets back to an IT need that a lot of systems will have in the next few years, is that they needed a care management information system. The nurse in the clinic or doctor doesn’t need to be arranging Meals on Wheels, but it needs to be a seamless process, and you need a system that can cue up and order all of these things.

What would your advice to CIOs and CMIOs, with regard to everything we’ve been discussing here?

There are certain things we need to do system-wide, such as implementing electronic health records [EHRs]; and when you’re making these big platform choices, I’ve become wary of big ambulatory EHR vendors that say ‘We can modify our system to meet any workflow,’ because then you’re hardwiring crappy workflow. So you have to have a vendor partner that can hold your hand and work with you on workflow design together. And don’t always think that something that is super-customizable to your environment is the best thing; because most of us have crappy workflow.

So the discussion around workflow with clinicians is going to have to be nuanced, then?

Definitely. Doctors are extremely smart people, and they’re problem-solvers. But they’re already busy 10-12 hours a day in their practice. So you’ll have to compensate doctors for doing this work, but also draw on the resources of the practice leadership and care team, to own part of this. I mean, do you have an awesome practice manager to spearhead this stuff? We have to make the team owners of a lot of this stuff. And having a lot of EHR platforms—even in employed physician groups, even in the most financially integrated groups, people a few years ago would say, we have to be on the same EMR platform; now it’s about getting the information you need, and they’re turning to HIE. So something I’ve been advising larger medical groups and health systems, if you want to bring that 100-doc medical group into your system, and they’re on athenahealth, maybe you don’t need to bring them into Epic or Allscripts. It’s all about meeting the doctors’ needs at the level at which they’re practicing.

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