What Keeps Chief Population Health Officers Up at Night?
At the Population Health Colloquium in Philadelphia last week, several chief population health officers spoke about their health systems’ recent accomplishments as well as the current challenges they are facing.
Grayling Yarbrough, M.H.A., vice president of population health for Sentara Health, the largest healthcare system in Virginia, spoke about challenges with scaling up a clinician network to build on the success of its accountable care organization.
In addition to having hospitals across the state, Sentara’s health plan is the largest Medicaid payer in the state of Virginia, and its medical group is the largest medical group in the Hampton Roads area. Yarbrough leads the clinically integrated network known as Sentara Quality Care Network (SQCN) pronounced “sequin," which has about 4,500 providers and serves about 233,000 lives across various value-based care and risk contracts. The ACO, a subset of that, has a little less than 2,000 providers serving about 60,000 beneficiaries.
Yarbrough said being able to scale their network is a key issue. “We just had our two most successful years in our ACO, achieving $22 million in shared savings, most recently, and then $18 million the year before that, a significant jump up from our first two years in the ACO program,” he explained. “What comes with success is, of course, greater expectations. So the first question is, how do we scale our network? As I recruit new independent providers into our CIN, our real value to them is in our ACO success, so how do we move them into the ACO program? We also need to scale our ability to report eCQMs [electronic clinical quality measures] for them. That is a challenge that keeps me up at night — having the technological infrastructure to really add in large amounts of independent providers and successfully report eCQMs for them. We have a great infrastructure for operationally integrating new providers, from the contract to the credentialing to working with care management and those operational aspects. But how do we integrate to make sure that we can successfully report those eCQMs and continue to have the success that we've had thus far?”
Kara Odom Walker, M.D., M.P.H., executive vice president and chief population health officer for Nemours Children's Health, said that her organization takes care of about 70% of all children across the Delaware Valley, and that gives it the opportunity to lean into population health.
“We just worked with the State of Delaware on a first-in-the-nation pediatric global budget model, where we are trying to take that success and expand it, and spread and scale the work we've done to elevate lifelong trajectories for children,” she said. “I will say that's exciting. It's also a place where uncertainties exist because Medicaid, Medicaid, Medicaid, right? We are trying to navigate where those dollars will land, where state budgets will land, how they will pivot, how they will change eligibility and enrollment. This is a time where we have to manage through that very carefully, and we're trying to move fast with innovative new models — doing more with less, using data to our advantage, trying to deploy the workforce more efficiently and effectively is all part of what we are currently navigating.
"We are working to both adapt payment models and also work with more partners,” Walker said. “It can't just be the state; it has to be the MCOs [managed care organizations], it has to be community-based organizations, it has to be schools to lean into this model effectively. I think we're going to learn as we go, but managing through the uncertainties at the federal level is creating delays, and we'll just see how we manage through all that.”
Rebecca Adkins, M.H.A., senior vice president, population health at Philadelphia-based Jefferson Health, said one key challenge is the changing landscape of where they are seeing costs.
“We're seeing value-based contracts where 30% to 40% of our cost is in drugs or might be in specialty therapies,” she explained. “These therapies are amazing, incredibly innovative, and life-saving, but you almost need a new finance delivery mechanism. You're asking people to make a 10-year bet on that drug or that therapy paying off on a one-year budget. So what is the mechanism to build that into risk and manage that? I think it is really challenging.”
Adding to the complexity is working not just us within a health system’s population health department, but also understanding what's happening with post-acute, home care and community-based organization partners, Adkins added. “What keeps me up at night is that I have one year to manage the population and get measured on that and deliver everything we need to deliver. That's really where we utilize our partnership with Jefferson Health Plans, employee health benefit plans, our different populations to say, OK, I stood something up over here; how fast can I take it and run that program somewhere else?”
Arshad K. Rahim, M.D., M.B.A., senior vice president and chief medical officer, population health for Mount Sinai Health System in New York, said we're past what he would call the honeymoon of value-based care.
“What keeps me up is how to be able to drive and scale services to offer the best care for populations in the most cost-effective manner, and that's primarily doing more with the same, or sometimes even doing the same or more with less,” he said. “It is what I live every day in terms of managing a P & L and also figuring out how our value-based care services remain relevant, respected and scaled and also positioned for growth when you're in a pretty fee-for-service market like we are in New York City. We have increasing numbers of vulnerable populations, so it's truly a mission and passion for me to figure this out, not only for my loyalty to my community, but also for the future of Mount Sinai Health System. I think it's absolutely critical, but it definitely leads to some sleepless nights.”
“The fear of what's going to happen to Medicaid, what's already maybe happening in the exchanges, is definitely concerning, as is the lack of clarity,” Rahim added, “although I don't want clarity if it's a really bad outcome. We are all waiting with bated breath.”
Sentara’s Yarbrough also mentioned concerns about Medicaid. “As I mentioned, our health plans is the largest Medicaid payer in the State of Virginia. He noted that in 2023, the State of Virginia brought people back in for redetermination, and also rebid the state's Medicaid contracts. "So you had a significant pricing change as well as a significant risk change. You had redetermination after three years of a pause coming out of COVID and that really influenced both the risk level of the Medicaid population and also the rate level,” he said. “That impacted our Medicaid plan and the other Medicaid plans as well, negatively. That has led to significant shift in terms of how we're serving those Medicaid members in our Medicaid attribution through that value-based care contract. So I would say stabilization is important in terms of rate-setting and risk-setting for the Medicaid program.”
