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Todd Shryock, contributing author
How practices can benefit from data-driven patient care.
As both public and private payers focus more on value-based care, population health management has become more common as providers take a more proactive approach to caring for patients.
And while definitions vary, experts agree that population health management is about going beyond the walls of the practice to improve patient health, with the ultimate goals of better quality scores for providers and fewer long-term issues for patients, especially those with chronic conditions.
“Population health is about no longer just treating the patients who walked in the door to see you today,” says Christina Taylor, MD, an internist and chief quality officer at The Iowa Clinic in Des Moines, Iowa, where she also serves as director of the population health, quality analytics and care management team. “Whether the patients choose to come to you for care or visit other [primary care] providers, you are responsible for their healthcare and outcomes.”
This requires an approach to managing patients that many primary care physicians are not used to, as well as investments in technology and personnel that smaller practices may struggle with, but solutions are available.
Data analysis and social determinants become as important as mammograms and diabetic eye exams as value-based care drives demand for more population health analyses to manage costs.
“For folks on the frontlines, population health is an explicit recognition that delivery of care is only 20 percent of the story,” says David Nash, MD, MBA, an internist and dean of the Jefferson College of Population Health. He adds that linking physician income to performance measures at the population level is leaving doctors little choice other than to implement it.
Nash predicts that small practices eventually will be forced to incorporate population health, either because of the elimination of exemptions in the Merit-based Incentive Payment System (MIPS) or the demands of commercial insurers who also want to pay for healthy outcomes and not just patient volume.
“If CMS doesn’t get you, Aetna and Anthem will,” he says.
While payers see the cost benefits to population health, providers have seen it make a difference in the health of their patients. Anuradha Phadke, MD, an internist and director of population health at Stanford Health Care, says Stanford’s efforts have improved patient care and freed up doctor time to focus on the most serious cases.
“For instance, we’ve been able to identify which patients are poorly controlled diabetics and connect them to resources who reach out and help them bring it under control,” says Phadke. “It makes it easier for us to get the desired action by the patient without the clinician spending their time.”
Taylor says outreach to remind patients of annual physicals, vaccines, and cancer screenings are all examples of how patients benefit. “It’s all about a stronger emphasis on preventative medicine and making sure these appointments happen,” says Taylor. “You have to view it as your responsibility to shepherd patients to make sure they get checkups and preventive care.”
Some doctors have seen population health management in a negative light, because it requires an emphasis on healthier behaviors. These physicians view that as being beyond their influence.
“As physicians, we can tell people to move more and eat less, but we can’t force them to be healthy,” says Taylor. “That may all be true, but it is still our responsibility to try, and if we continue to try, we will reach some.”
Preventative care and value-based care are closely linked, because without a solid commitment to prevention, most patient problems will only get worse-and more expensive, says Taylor. As a result, she says, population health management will continue to be an integral part of moving the healthcare industry in a value-based direction.
“It’s key to keeping costs down,” she says. “If you do it right, there is less duplication in tests and less waste. You are keeping track of and coordinating a person’s healthcare.”
How small practices can get started
Experts say the challenges facing a small practice looking to implement population health management are difficult, but not impossible, to overcome.
One of the first challenges is identifying patients with chronic conditions that might benefit from outreach efforts, and the place to start is with the EHR.
Taylor suggests seeing what tools are available within the EHR that can help identify specific groups of patients with chronic diseases, such as diabetes, and then develop a plan to better manage those patients. “It should be team-based care,” she says, adding that much of the work is nonclinical and doesn’t require a doctor’s time.
“Have a nurse take a look twice a year or quarterly, to see who has been in for an appointment and how they are doing. If they haven’t been in to the office in six months, you need to get them in.” This level of commitment does not require advanced analytics or expensive software tools to implement, she adds.
Phadke says to start small and build gradually. For example, is the practice doing a better job of getting all diabetic patients into the office for regular exams? Are patients with high blood pressure getting regular screenings? Are all patients up to date on their vaccinations? Find out who needs what and contact patients to get them into the office, she says.
“Population health can be intimidating at first, but if you start with a smaller scope and a small set of measures, that will make it easier,” Phadke says.
Another entryway to population health management is to consider becoming a patient-centered medical home (PCMH), says Jay Bhatt, DO, MPH, an internist and chief medical officer of the American Hospital Association and president of the Health Research & Educational Trust.
“If you don’t want to go through the whole process to becoming a PCMH, a small practice could still work toward it, allowing them to experiment with managing a population effectively. It’s a great way to build competency.”
Why joining a larger group may be necessary
While population health management can be achieved to some degree by a small practice, if payers start to require physicians to accept some downside risk in their contracts, it may require more resources than the practice can afford.
“For those with risk-based contracts, you have to have a lot more resources and there is a lot of infrastructure that goes into it,” says Taylor. “You have to be able to analyze claims, there are expensive pieces of software you need and you have to pay analysts to turn the data into meaningful information.”
Once patients with chronic conditions are identified, it requires staff time to act on it. “It might require hiring a [nursing assistant] or additional clerical staff, and if you are doing high-risk patient management, hopefully you are doing some health coaching. But that requires a health coach or nurse,” says Taylor.
Larger organizations, like the Stanford clinics where Phadke works, have sophisticated software tools that help identify which patients need extra care as well as message the patients.
“It allows us to do a lot more with fewer personnel,” she says. “But for a small practice, the upfront cost is something they would have to consider.”
Nash doesn’t envision a long-term future for small practices that aren’t affiliated with a larger group, because he sees healthcare marching inexorably toward favoring groups and health systems that can afford high-tech tools and additional staff.
“That may not be the answer they want, but it will be incredibly hard for practices with one or two doctors to compete in the new world.”
Succeed while Staying independent
There may be ways for a practice to get the tools and support it needs for population health management that don’t require a complete sacrifice of independence.
Bhatt says to check with local hospitals to see if they have any affiliate programs that share resources and data with local physicians. “Getting into a clinically integrated network can be very helpful for small practices,” he says. “They do not have to give up their independence, but generate economies of scale and get the resources they need.”
“Shared resources are definitely a good idea,” says Phadke, adding that Stanford enables sharing through its United Healthcare Alliance, a group of clinics affiliated with the university to get the tools they need to provide better care.
Joining an Accountable Care Organization may also be an option for practices. “They can share best practices and be able to share the administrative burden of doing things like claims analysis,” says Taylor.
Phadke says the stakes involved in population health management are too high to ignore.
“CMS (via MIPS) added a financial reward or penalty for your Medicare patients,” she says. “For private payers, population health could determine whether they will contract with you, if you are underperforming on quality measures.”
Experts agree that physicians are going to need much more data on their patients to prove they are providing value, and that the demand for this data is only going to increase. It might also provide some surprises when first examined in detail.
“By measuring how you are doing on your performance and benchmarking that to your peers, it can shed light on different opportunities,” says Phadke. “Most physicians think they are performing better than they are, but if they look at population health management as an opportunity to improve, it really does help patient care.”
Regardless of what approach a practice takes to population health management, Nash says there really is no avoiding it.
“You can run, but you can’t hide from it,” he says. “We are heading toward the total accountability for the outcome of care, and with no outcomes, there will be no income for doctors, and that is a sea change.”