The specialized IT applications required for population health management are generally too expensive and complex for small, independent practices.
So some physicians may reject this approach, which can improve outcomes and prepare practices for value-based reimbursement.
Nevertheless, it is possible to assemble the jigsaw puzzle of population health management—a care delivery model that emphasizes the overall health of a patient population, not just what happens in office visits—without overburdening a practice financially. Some groups have joined accountable care organizations (ACOs) or other kinds of networks to spread out the costs of the required infrastructure.
“Part of the reason we’re doing this is because the payment policy is changing,” says Matthew Callaway, MD, a co-founder of SAMA Healthcare Services, a primary care practice in El Dorado, Arkansas, that is engaged in population health management. “We have to do something to stay on top of the wave as far as payment models go. Hopefully, we’ll not only stay solvent as a practice, but we’ll also have better patient outcomes.”
Starting down the path
Independent practices must ultimately band together to manage population health effectively, experts agree. Yet there are things they can do to start down this path on their own. By improving their quality scores and their care coordination, these modest initiatives can help practices succeed in government programs such as the Merit-based Incentive Payment System (MIPS) and the Comprehensive Primary Care Plus (CPC+) program for patient-centered medical homes.
First, practices should use their electronic health record (EHR) to the greatest possible extent and make sure they’re applying all the functionality and the data fields in the system, advises Michael Barr, MD, MBA, executive vice president, quality measurement and research group, for the National Committee on Quality Assurance (NCQA).
Even without any external data, he notes, practices can use their clinical and administrative data to identify many of their patients’ care gaps and have staff members contact those who need to come in for preventive care or treatment of chronic conditions.
If practices decide to acquire population health management tools, Barr says, they should pick applications that best support their goals and match their resources. For example, if a practice has the resources to do patient outreach and needs to identify the patients who have care gaps, they should look for a dashboard-type application for that supports that kind of activity.
“If they have no outreach people, but they have a patient portal, they might look for a solution that has a strong patient engagement piece that can be used with that portal,” Barr suggests.
David Nash, MD, dean of the school of population health at Thomas Jefferson University in Philadelphia, says that a handful of population health management applications can be used in small and medium-sized practices. Most third party software, however, is designed and priced for large organizations, he says.
Nash recommends that practices interested in full-scale population health management join some kind of larger organization, such as an ACO or a clinically integrated network. There are also online courses on this care delivery model from Thomas Jefferson University and the American Association of Physician Leaders, he says.