This week’s Population Health Colloquium in Philadelphia kicked off with a panel discussion during which chief population health officers were asked about their biggest challenges today. Their answers ranged from a lack of trust to physician burnout and healthcare affordability issues.
“Right now, the biggest challenge is what I would identify as a lack of trust and a bit of cynicism about what's going on,” said Shiva Chandrasekaran, M.D., chief medical officer of regional operations at Lumeris, a company that works as a health system and medical group enablement partner and operating partner for population health programs. He was formerly chief population health officer and ACO Director at Einstein Healthcare Network, which is now part of Jefferson Health.
“I've seen these models come and go. We are seeing care coordinators managing care coordinators. Shared savings is a black box that nobody seems to be able to make sense of. To do this work, it requires clinical teams to trust payers, to trust their large health system aggregator employers, to trust the analytics platform, to trust claims data. What I'm seeing is just the first 10 minutes of every meeting is just getting people to trust each other. Just getting people to believe that the payer really cares about my patients who are here in the room, that my health system employer actually doesn't want to fill their beds. They actually want my patients to not be in the hospital, that that analytics platform isn't just there to collect a PMPM payment for me, but it's actually trying to deliver data to me that's going to be useful for me to use and that my EMR vendor is not simply something chosen by some executives in my health system, but it's actually here to help me get home at night. There is that frustration and level of cynicism about value-based care when people like me are very excited about value-based care and population health. That disconnect leads to an inability to unlock a lot of the creative work that many of our clinical teams could be providing for us. If is fun to try to get people past that cynicism into hope, but it's getting harder each year that the payment model doesn't move as quickly as people want it to.”
Stephen Nuckolls, the CEO of a medical practice called Coastal Carolina Health Care and its ACO, Coastal Carolina Quality Care Inc. in New Bern, N.C., echoed the comments of Lumeris’ Chandrasekaran about the challenges of establishing trust as value-based care programs get off the ground. He also spoke about the challenges of dealing with CMS on ever-changing benchmarks that erode the potential shared savings. “Hospital systems or medical practices like us are not going to trust the system unless we have fair benchmarks so that we can sustain ourselves,” he said.
Jamie Reedy, M.D., Horizon Blue Cross Blue Shield’s senior vice president of health solutions and chief population health officer, spoke about affordability and physician burnout as key concerns. In addition to her role at Horizon, for the last 23 years, she has run a pediatric clinic for uninsured children and Medicaid children at a regional health department in New Jersey. “I do that part time, but it keeps me focused on why I went to Horizon. What keeps me up at night is affordability and primary care access. In this particular clinic, I see all of the challenge that exist in our healthcare system more broadly that make it really difficult for patients and families to get the care that they need. With every single patient I see it comes down to affordability. So my what keeps me up at night at Horizon is trying to figure out how do we drive affordability using all of the levers that we have, most of which rely on really significant transformation in our provider community.”
Yet as she speaks with physicians in communities across New Jersey, “the physician burnout is so incredibly real that it's hard to imagine getting past that even with all of the innovative alternative payment models that we are devising and all of the support infrastructure that we're putting in place,” Reedy said. Horizon Blue Cross Blue Shield recently conducted a “voice of the provider” survey with several thousand independent primary care physicians across New Jersey who have not yet joined health systems or a larger group, but are independent. “Our goal with that survey was to find out what support those physicians needed to remain independent, to participate in our value-based care programs and to deliver better care at the right cost,” Reedy explained. “And it was eye-opening to hear about the burnout, but also about their strong desire to actually partner with us as a health plan to create the right care team structure to deliver the right care, to hear about the passion that they have, the desire to do better data exchange and put data right at their fingertips at the point of care. And so that voice of the providers survey is really driving all of the innovative work that we're doing internally to try and improve our affordability roadmap.”
Kara Odom Walker, M.D., executive vice president and chief population health officer for Nemours Children's Health, said her biggest challenge is how to invest in new models that support prevention and wellness in in the whole child. “It is incredibly difficult to reorient toward a prevention model in a healthcare system that is very used to just paying for the problem in front of us rather than the long-term investment,” she said.
Odom Walker noted that Medicaid is the largest payer for much of pediatric care. Fifty percent of all kids are on Medicaid, yet they're only 7 percent of the spend. “It gives us an insight into where we are actually committing our dollars and resources. We know child poverty is on the rise and some of the consequences we're seeing and not connecting the dots between housing and food and what happens in schools and how we invest in mental health result in long-term consequences,” she added. “I'm a family physician by background and I see this trajectory unfortunately, going into adulthood and entire lives if we don't figure out how to invest in adverse childhood experiences at Nemours. We have a clinically integrated network that's been successful at shared savings. We continue to advocate for the ways that we can create new payment models. But I do think fundamentally, we don't have all the dollars in the healthcare system and so really reorienting toward how we create care at the right place and pace to create this investment for the long term is a challenge.”
Looking out three to five years, Horizon Blue Cross’ Reedy mentioned the ongoing consolidation between payers and providers into “payviders.”
“This seems to be accelerating quite a bit and I don't see that it's going to change. We spend a lot of time talking to our Blues colleagues about why that's happening in their market and the benefits that they're seeing,” Reedy said. “That integration is bringing a lot of scale and opportunity for them to align more closely with not just primary care but the specialty colleagues, and really align the payment models. We're spending a lot of time thinking about whether we want to continue to still just be a care enablement organization that's responsible for enabling our providers to give great care or do we want to start to dip our toe or jump all in into the care delivery space? I think every health plan that's not there is thinking about this right now. We are looking at opportunities across the gamut from simply supporting with fee schedules in a different way in a more holistic reimbursement strategy all the way to potentially owning assets, and, looking at where that fits in our broader clinical and population health strategy.”
Looking out three to five years, Lumeris’ Chandrasekaran is worried about the workforce contraction. “I have colleagues who are 5 to 10 years senior to me who are leaving the profession. I trained residents when I started my career and the math just doesn't work,” he said. “There are not going to be enough folks to replace all of those physicians and nurse practitioners who are leaving. The current model is predicated on every Medicaid, commercial and Medicare Advantage patient having an attributed primary care provider that they see once a year in office visits, and that's simply not going to be possible. Imagine trying to do that with 70 percent of the workforce. It's just not going to happen. We're not thinking enough about what we're going to do to replace that.”