It’s one thing to say our industry needs to shift from fee-for-service to outcomes-based payment. It’s quite another to get there. Population health has certainly become THE healthcare buzzword, and rightfully so. Early successes show promise in improving the quality of patient care and reducing costs. Today, population health is everywhere. Last February’s HIMSS14 conference was inundated with related tools, analytics engines, and apps. Frameworks abound and vary significantly, but the key components of identifying high-risk, vulnerable populations remain consistent: engaging the patient, mapping/tracking care, managing care transitions, and analyzing effectiveness.
This move reminds some of us of when we first began taking Medicaid and Medicare risk in HMOs in the early 1990s. It seemed like a pretty good deal then—higher per member per month (PMPM) cost of care, throw in a little inpatient case management, and voila! However, that euphoria quickly dissipated when we began losing millions on hospital admissions.
Today we not only have history’s “lessons learned,” but also have the successful deployment and use of integrated EMRs, evidence-based guidelines, population health tools, and case/care coordination managers. Despite this strong foundation, questions remain about our industry’s overall readiness to share risk and improve patient outcomes:
- Is there a consistent population health definition?
- Do we understand the terms of our current risk-sharing contracts?
- Do we have the right tools to support population health’s key components?
- Are the tools truly integrated, and do they provide the complete patient view across the continuum of care? Is data still captured/maintained in silos?
- Do we have processes and technologies in place to effectively engage patients?
- Is our case management/care coordination effective?
- Can we monitor outcomes and connect them to financial incentives?
Early outcomes hint that we are not there yet. A recent survey, conducted by eHealth Initiative and Premier, Inc. sought to assess how accountable care organizations (ACOs) in commercial and federal markets are leveraging health information and technology. Preliminary findings from the 62 responding ACOs show diverse HIT capabilities. Promisingly, most reported infrastructures that support quality measurement, population health management, and physician payment/adjudication. However, fewer reported having the necessary capabilities to support two of the most critical elements—risk management and patient engagement. Further demonstrating more work is needed is a recent Advisory Board Company’s report that today’s care management/care coordination is ineffective, partly due to duplicate efforts across siloed sites and systems. Recent field experience confirms this. Until we move to a centralized care management structure with tools that integrate with the continuum of care, and data that is interoperable between interfacing systems, we will continue to struggle.
Another area requiring our collective focus is physician and patient engagement. Until physicians are operating under a true, value-based incentive program we will not fully achieve the “Triple Aim” vision of high quality, accessible, efficient healthcare for all Americans. Reaching patient populations who will benefit most from population health programs is traditionally challenging. They may be elderly, living in isolation, unable to afford medications, in communities with limited communications networks, and many with accompanying behavioral health diagnoses, such as depression, added to their chronic illness. For them, traditional case management methods are ineffective. Organizations offering centralized case management/care coordination that engages patients in the hospital prior to discharge, coupled with motivational interview techniques and interactive technology, are proving more effective.
Still, there are pockets across the country proving that where there is a will, there is a way. More than 100 practices serving eight counties in Western New York, adopted the Agency for Healthcare Research and Quality’s (AHRQ’s) patient-centered medical home model. The model’s built-in population health components, supported by strong regional health information exchanges and incentives, have demonstrated success. The community shares resources, technology, and data to create an initiative for diabetes care that has yielded significant results.
What can we takeaway from all of this? Centralized care management/care coordination models with tools that integrate across the continuum produce results. Changing the paradigm from just managing patients as a “check the box” activity to adopting new processes, tools, and communication techniques that allow us to more actively engage patients, ultimately improves outcomes. Adopting and adapting to open data standards will make information more accessible and interoperable. Breaking data silos and leveraging tools that empower us to monitor progress and measure results against program metrics are critical to demonstrating success.
The Centers for Medicare & Medicaid Services (CMS) has set high outcome improvement and cost reduction goals necessary to achieve the promised financial incentives. Winners in this arena will focus on integrated systems and processes, remaining patient-centric at all times, and continuously monitoring progress.
Linda Lockwood is solution director, Advisory Services, CTG Health Solutions, Buffalo, N.Y.
Michael Garzone is solution director, Technology Services, CTG Health Solutions, Buffalo, N.Y.
