Population health progress report

Khan: There has been some good progress over this past year, but overall the accountable care organization (ACO) market had a mixed year as several organizations either opted out or announced their intentions to do so. On Dec. 1, 2014, the Centers for Medicare and Medicaid Services (CMS) released its long awaited proposed rule to update the regulation and operation of the Medicare Shared Savings Program (MSSP). This is a good step forward. However, it falls short in two major areas. One area is the MSSP risk adjustment methodology, and another area is the Medicare beneficiary assignment. The proposed rule is open for comment until Feb. 6, 2015, so we will see if these regulations will continue to shift and evolve.

Bennett: The original goals of improving quality of care and patient experience as well as decreasing costs have been met with multiple and varied results. There have been substantial gains in some areas in quality of care and some successes in decreasing costs, but these are not universal. A major gain for this movement has been the awareness of the “triple aim” and collaboration of healthcare professionals in all sectors. We are now seeing competitors on the payer and clinical spectrums working together to combine and structure all the health information available statewide and/or across multiple states to make that information available to the care providers (e.g., Cal INDEX, California Integrated Data Exchange was formed by Blue Shield, CA, and Anthem BCBS, two major payer organizations). The paradigm shift in healthcare will not happen overnight and will require multiple transformations to ensure the ability to care for entire populations.  

All of the organizations we work with to improve their IT infrastructure have substantially engaged in organizational change to meet the objectives. If we continue to share outcomes and learn from both the positive and negative results, we will be successful in meeting the aims for population health. This is the greatest challenge at this point. Areas of patient engagement and satisfaction, as well as models of care delivery, are ripe for scientific discovery within this changing environment. We need to continue the national and international focus and move forward.

Drozdowicz: As is to be expected in any new arena, initial results are mixed. We have, in general, seen improvement in quality, measures and patient satisfaction scores. We have not seen consistent cost savings, though there are some organizations that have achieved or exceeded desired financial results. We agree with thought leaders who argue that improved quality should result in lower, not higher, costs. Achieving the financial goals may be delayed by the learning curve of new care and reimbursement models, the need to build the operational and IT infrastructure to support those models, and time required for improved quality to translate to reduction in utilization and lower costs. In many cases, the organizations we are working with are just learning to operate under mixed fee-for-service and value-based reimbursement models. These are early times for all – and until organizations make investments in their people, processes and supporting technology in place to manage these types of arrangements, we should expect to see continued variation in results.  

Niloff: Results have been mixed. Some organizations have made more progress than others. Technology implementations have been slower than anticipated, often hampered by challenges in data acquisition and interoperability. The most successful organizations have employed a focused approach and achieved improvements in quality metrics and savings from their care management programs. Such success is dependent on focus, resources and aligned incentives.

Hardy: It’s important, especially at this early stage, to ask, “What’s working? Where are organizations seeing success, and what commonalities can we identify among those seeing the greatest success?” 

We have to distinguish between organizations that have successfully implemented effective population health management IT and those that haven’t. The former have the benefit of technology specifically designed to support new roles and new responsibilities among clinical staff, which means as an organization they’re not forced to tackle the challenges of population health while simultaneously battling cumbersome workflows and messy, piecemeal reporting.

As more organizations adopt technology that’s truly built for the population health management model, we’ll see an acceleration of progress as well as accelerated evidence-based winnowing of population health management best practices.

White: We’ve seen many of our Allscripts TouchWorks electronic health record (EHR) clients attain industry-leading successes in areas around quality and population health.  It’s been a critical initiative for us to continue to partner closely with our clients as they navigate increasing industry pressures, and we are encouraged by their achievements and forward movement, particularly while simultaneously navigating regulatory changes such as Meaningful Use.

Varma: Healthcare organizations are moving in the right direction, but there’s much more that needs to be done. Provider organizations already know that it’s possible to control costs for patients. However, they are still figuring out how to do this effectively, at scale, while keeping their businesses strong. Good population health management leads to reduced costs and lower revenues for providers.

Hunt: St. Vincent’s Health Partners (SVHP) has achieved operational success in its foundational goal of defining a narrow network of physicians representing primary care and more than 40 specialties in addition to St. Vincent’s Medical Center (our flagship medical center), four skilled nursing facilities, four home health agencies and an advanced practice registered nurse (APRN) group, allowing extension into all post-acute care environments. SVHP is the first organization to be nationally recognized by the Utilization Review Accreditation Commission (URAC) as clinically integrated and aligns with the Federal Trade Comission’s and Department of Justice’s healthcare guidelines. The focus of the narrow network initially has been on transitions of care and the need to support patient care.

SVHP has also established functional and operational differences between medical management (population

health management) and medical services (services directly provided to the patient).  The Care Coordination and Integration Division works collaboratively with payers and employers to actualize population health and is recognized for the improvements in utilization.  The SVHP’s Playbook sets an organizational standard that each member is expected to meet with regard to evidence-based quality care.

SVHP has helped its membership participate with commercial ACO-like reimbursement models, transform to initiate CMS’ Bundled Payment Care Initiative, and prepare the organization for the move from fee-for-service to quality reimbursement. The current contracts reflect these initiatives and the potential for shared savings. SVHP is preparing to accept full-risk contracts in the near future by investigating the total cost of care.

Being able to measure, capture, and manage the total cost of care depends on the meaningful use of prospective data (practice management, EMR and procedure) and retrospective data (claims) to be able to adjudicate and manage populations aggressively. The significant challenge is to have timely information that is impactful and useful to provide high-quality cost-effective care. SVHP continues to use data aggressively from as many sources as possible. The aggregation of the data remains manual with improving automaticity. Barriers being successfully overcome in pursuit of this goal include reluctance of physician practices to share data and the lack of portability with various technologies. Although still in its infancy, population health management is providing a compelling contribution towards achieving the “triple aim.”

van Terheyden: We are still in its early days. While everyone can see the benefit and the necessity given the looming need to manage healthcare costs and ACOs, the integration of data and the lack of significant commercial drivers have hindered progress. Currently, everyone is focused on Meaningful Use and to a lesser degree, ICD-10, so there are fewer resources available to focus on data integration.

For the larger systems who have integrated data and systems, it is easier to share this data. For most others, the data is distributed and hard to access. Sharing data does not always work in favor of competitive interests. Until this changes, healthcare organizations will not have reliable and complete access to the required data sets to manage their population.

HMT: How much have healthcare organizations kept on track to produce the prospective outcomes they perceived they could deliver – at least initially?

Khan: Several pieces have to fall into place before we will see the real impact on outcomes. In the past, due to misalignment of interests between key stakeholders in the industry such as the payers, providers and the consumers, it was very difficult to come to an agreement on what the goals are. At this moment, we finally have some alignment of interests and are beginning to see a will to work together, however there are significant cultural barriers that need to be addressed before we share a common vision and work full steam ahead to achieve that.

Bennett: From our perspective, none of our clients are “off track.” They have all reached a certain level of health information exchange (HIE) development, adoption and sustainability. They are implementing further enhancements in clinical and analytical capabilities. Population health is a complex undertaking. Still, our clients and partners are implementing incrementally according to their schedules.

It is early yet to see prospective outcomes. For instance, most healthcare organizations are only just beginning to report on their 2014 results. Cost benefits are already being achieved at the same time some clinical quality improvements are happening. We know that attaining actual improved clinical outcomes will take time. In order to achieve the desired improved care outcomes, healthcare professionals will need to understand how to engage patients to be active participants in their care, and patients need to be more proactive in taking personal responsibility for their health. This will happen once science meets operations and we understand what motivates or detracts from one’s ability to manage his/her own health.

Drozdowicz: We have seen targeted programs – specific to given patient populations – achieve positive outcomes. Broader-based programs have produced mixed results thus far, with some organizations announcing success and others looking to restructure their organization and processes to increase the likelihood of success. Where we are largely focused on providing technology to make these organizations successful, the key ingredients in our successful customers include having strong clinical and IT champions to lead change in their respective organizations.

Niloff: Many organizations are still primarily working on program development, IT implementation and provider engagement – all fundamental elements for successful population health programs. Few new programs are fully implemented, so it is too soon for them to realize significant improvements in outcomes. That said, we are seeing early successes including improved quality metrics, reduced costs among patients in care management programs, reductions in ambulatory drug costs, reduced rates of admissions and readmissions, and reduced emergency room encounters.

White: There’s been opportunity to identify and, subsequently, learn in these first few years of accountable care:

1. To understand where the gaps in service are for their networks and how engaging patients will keep them in network (i.e. engage and assess the market and business model and embrace an organization’s capacitaties).
2. To build the organization correspondingly and reach out to partners that have the capacity to reach specific goals.
3. To identify and empower physician champions to execute the strategies.