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How to make population health work


Experts explore the operational requirements, from care coordination to patient engagement.

As value-based reimbursement  grows in importance, physicians must learn how to manage the health of their patient populations to lower costs and improve quality. While a small or medium-sized practice can do only part of this on its own, there are several core competencies that all practices and ACOs must master in order to manage population health. 

They must be able to:

  • proactively address the health needs of their whole patient population or at least all high-risk patients,

  • manage and coordinate care both during and between visits, 

  • engage patients in their own care and reach out to those with care gaps,

  • measure quality and efficiency and report on quality measures, and

  • develop a viable business model that will eventually produce a return on investment.


PHM basics

All of the organizations in our sample have concentrated on building patient-centered medical homes (PCMHs). This is partly because primary care is central to PHM, and because a PCMH recognized by the National Committee on Quality Assurance (NCQA) must include several basic PHM components. Among these are expanded access to providers, the use of care teams, care coordination across care settings,
effective management of care transitions and performance measurement.

Beacon Health Partners, a 700-doctor ACO on New York’s Long Island has helped about 20 primary care practices transform themselves into PCMHs and achieve NCQA recognition. “Whether you become an NCQA-recognized medical home or not, what’s important is to use some of those [PCMH] principles: coordinate care in a practice, have huddles, have care team members work to the top level of their license, empower MAs [medical assistants] and other people to deliver care,” points out Simon Prince, MD, the ACO’s cofounder and its former president and chief executive officer.

The groups we interviewed tried to address the needs of their entire patient population to varying extents. Beacon, for example, has focused its care management resources on high-risk patients, because it hasn’t had the “bandwidth” to coordinate care for patients who are less sick, notes Prince. (Catholic Health Services, a local healthcare system, recently acquired Beacon, so that might change.)

In contrast, Bon Secours Virginia Medical Group (BSVMG) in Richmond, Virginia, a 624-provider group that includes an ACO, uses care coordinators and information technology to reach out to its entire patient population. Robert Fortini, PNP, the group’s chief clinical officer, says this not only improves care but also leads to better financial outcomes under value-based contracts.

Next: Multi-disciplinary care teams



Multi-disciplinary care teams

Care teams are generally defined as practice units that include clinicians and other staff members. But an increasing number of healthcare organizations recognize that to perform PHM effectively, their care teams must integrate other professionals both within their practices and in other care settings.

Fortini is a proponent of multidisciplinary care teams, including pharmacists, dieticians, physician assistants and nurse practitioners. “There are many aspects of healthcare you could do more effectively with such teams,” he says.

Along with a growing number of healthcare leaders, Fortini also sees the value of co-locating behavioral health specialists in primary care practices. “If you put a clinical psychologist into a primary care office and you attack diabetes from the behavioral health component and the medical component of that condition, your success rate goes up exponentially,” he says. 

Some practices are also incorporating social workers to help patients overcome the social, economic and physical environmental factors that contribute to their illnesses and their inability to get better. According to the World Health Organization, these social determinants of health account for up to half of the variance in individual health. 

Jennifer Brull, MD, a family physician who practices with four colleagues in Plainville, Kansas, notes that her group, a recognized PCMH, has hired a care coordinator who is also a licensed social worker. She finds solutions for patients who can’t afford their medications, assists them in finding transportation, and even helped one woman get state aid so she could heat her house. “That’s been very helpful for us,” Brull says.

Next: Care management



Care management

Nurse care managers, sometimes called care coordinators or care navigators, are the linchpin of PHM. But this important role varies a great deal from one practice or healthcare organization to another. PHM participants disagree on how best to use care coordinators and how many of them are needed.

At New West Physicians, a 100-provider primary care group in Denver,  Colorado, physicians function as care managers in the office, explains Ken Cohen, MD, the group’s medical director. Medical assistants, he notes, address care gaps, immunizations, medication adherence and compliance, and COPD and asthma screenings. They also perform chronic care tasks such as conducting diabetes foot exams and creating flow sheets to document progress. “With the MAs providing all of those functions, it allows the physician to focus on patient management issues,” he says.

New West also has case managers who manage high-risk patients, but they work mostly in hospitals and post-acute-care settings. Cohen says that it’s too expensive to hire case managers for ambulatory care. “I don’t think you’ll solve population health management by throwing a lot of case managers into the mix,” he argues. “You need to use case managers judiciously with very well defined functions.”

At the other end of the spectrum, BSVMG has embedded 52 care managers in its primary care practices and another dozen in a central location, Fortini says. These care managers call sick patients who need help and guide them through the healthcare system. “A nurse care manager can perform 100% of preventive management and almost 50% of chronic disease management with good protocols and physician oversight,” he says.

How an organization allocates work to its care managers can make a big difference in its efficiency, notes Lawrence Casalino, MD, professor of public health and chief of the division of health policy and economics at Weill-Cornell College in New York. Instead of having nurse care managers call diabetic patients to remind them to get their HbA1c tests, the nurses should be managing only high-risk patients, he says. Less-skilled employees or even college students could make the routine calls.  

BSVMG has solved this problem with technology. It uses third-party automation software that includes a patient registry to trigger robocalls, emails and texts to patients who have care gaps. The messages tell patients to make an appointment with their provider for necessary care. With the help of those tools, Fortini says, two full-time care managers can contact thousands of patients.

Next: Patient outreach and engagement



Patient outreach and engagement

Before an organization contacts its patients, it must stratify its population by health risk and identify individual care gaps. The data must be timely and actionable, as well as comprehensive. That means practices and ACOs should not only use their own EHR data, but should also try to obtain claims data from their payers.

Once the care gaps have been identified, practices must reach out to patients who need to be seen but have not scheduled visits. The leading EHRs can generate letters to patients and have patient portals that can be used to alert people about their care gaps. 

The problem with portals is that not enough patients use them in many practices. For example, Cohen says only about 5% of New West’s patients use the portal, which has been online for five years. In contrast, Gretchen Hoyle, MD, of Twin City Pediatrics in Winston-Salem, North Carolina, says that many of her patients’ parents use the practice’s portal, through which she alerts them to their children’s care gaps. 

Cohen thinks that patient engagement is less important than “building a well-functioning infrastructure and taking care of patients’ problems. In an ideal world, an engaged patient is much easier to care for than a non-engaged patient, and outcomes will be better.”

Both Cohen and Casalino emphasize the importance of a good doctor-patient relationship in getting patients to adhere to their care plans. “Patients are more likely to do something if they trust their physician and their physician has asked them to do it,” says Casalino. However, he adds, practices must find ways to enhance that relationship to engage patients with chronic conditions.

Next: Quality measurement



Quality measurement

Most physicians are already accustomed to quality reporting because of CMS’ Meaningful Use program and its Physician Quality Reporting System (PQRS). In the coming years, value-based payment systems will stress quality reporting even more, and providers’ efficiency will be measured, in most cases with claims data.

Because of PHM’s emphasis on making sure that most patients receive recommended care, it offers a mechanism to improve quality scores. And, by requiring groups to measure their clinical performance, PHM gives practices data that they can use to provide feedback to their own physicians. 

Beacon Health Partners works closely with its member physicians to improve their performance, says Prince. The ACO uses a population risk management software application to analyze claims data and produce information on both the quality and the efficiency of providers. The ACO sends them quarterly reports on their metrics and  dispatches provider relations people or medical leaders to speak with the physicians who are outliers, he notes.

New West Physicians measures not only the performances of its primary care physicians, but those of the specialists they refer to. These measurements include the use of evidence-based medicine, Cohen notes. The group has a “bench-to-bedside” program in which the primary care doctors and specialists periodically agree on new practice guidelines. Compelling new evidence is translated into practice within 12 weeks, and all doctors are expected to follow the new protocols.

Next: Financial sustainability



Financial sustainability

PHM turns the business model of fee-for-service medicine upside down. As Cohen notes, every service that a practice provides and every facility and piece of equipment is a cost center when a group takes financial risk for care. That is why New West Physicians has not invested in a surgery or imaging center.

Conversely, activities that are not revenue producing in traditional practices can help groups generate revenue by supporting PHM and optimizing value-based reimbursement. Cohen cites New West’s diabetes and nutrition centers. “Those two centers lose money every year, but they recoup their investment in terms of quality of care and population health benefits that more than offset their losses,” he says.

David Nash, MD, founding dean of the College of Population Health at Thomas Jefferson University in Philadelphia, agrees that these kinds of activities can be helpful in PHM. Whereas before a diabetes nurse practitioner or a care manager represented a cost to a practice, he says, “In the new world order, these people could be incredibly important team members. They could help you on the road from volume to value.”

On the other hand, practices must find ways to continue to generate fee-for-service income during the period when they are building the infrastructure for PHM and risk contracting. That’s why it’s so important to use government programs such as Medicare’s Chronic Care Management and Transitional Care Management programs to help pay for care managers.

In addition, targeted patient outreach can help practices increase fee for service revenue by increasing visits from patients who need preventive and chronic care.

Keith Hoerning, MD, a member of Beacon Health Partners, says the transition to PHM and value-based reimbursement is “crazy. To be honest, it’s fun to be in the early stages, yet it’s very frustrating. Because the hurdles are right in your face, and it definitely is a difficult process in which you’re not always going to see the revenue stream that’s going to match the efforts you’re putting forward.” 

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