It Takes a (Big) Village: Laying the Foundations for Population Health

All of these initiatives have been bolstered by the June 28 Supreme Court ruling on the Affordable Care Act (ACA), which affirmed the constitutionality of the healthcare reform legislation passed by Congress and signed by President Barack Obama in March 2010. That development was important, because, along with health insurance access changes and reforms, one entire area of the ACA was a set of programs that, legislators hoped, would leverage the purchasing power of the Medicare program to revolutionize payment incentives across the healthcare industry.

Indeed, several programs either directly or indirectly related to the population health concept, and all focused on realigning financial incentives to physicians and hospitals, were created as elements in the ACA, with the requirements for these programs set to be fully articulated under the aegis of the Medicare program. Among them were three mandatory programs: value-based purchasing, avoidable readmissions reduction, and healthcare-acquired conditions reduction. Among the voluntary programs sanctioned under the ACA are the accountable care organization (ACO) shared savings program and the bundled payments shared savings program. In addition, the patient-centered medical home (PCMH) concept continues to receive strong support from both the federal government and the National Committee for Quality Assurance (NCQA), which monitors and certifies aspects of managed care-based healthcare delivery.

Now, with the constitutionality of the ACA upheld (with the exception of an aspect of the law that allowed the federal government to sanction state governments that refused to expand their Medicaid programs), all those interviewed for this article agree that they are working in a landscape of greater policy certainty.

Mark Van Kooy, M.D.

And that greater policy certainty, says Jefferson’s Nash, means that, following the June 28 Supreme Court ruling, “We’re at a tipping point. After all,” he says, “when you think about it, what is healthcare reform? It’s practicing population health-based medicine. And,” he says, soon, “you’ll be able to look beyond the Kaisers, the Geisingers, the Ochsners”—integrated health systems already well-known for their innovative approaches to care delivery and management. “And what’s the common thread there? Physician leadership with employed physicians. Now, that’s not the national model. But I think we will see more physicians in employment contracts, and that will further advance the field of population health,” he adds.

NEW ALIGNMENTS, NEW LEARNINGS NATIONWIDE

Certainly, the leaders at the organizations that are already charging ahead to leverage population health concepts believe that they and their colleagues nationwide are innovating for a purpose—or rather, several purposes—to lower care delivery costs, improve clinical outcomes, and enhance patient, and clinician, satisfaction, all at the same time—in other words, to create the new healthcare.

Referring to the white paper by Hopkins’ Bruce Leff that inspired the Presbyterian-Albuquerque team’s innovative Hospital at Home initiative, Karen Thompson, the program’s director, says, “One of the things that Dr. Leff has found, and we’ve substantiated it, is that the patient and the family, their satisfaction with the [Hospital at Home] stay, is much higher than with an inpatient hospital stay. And we were at 97 percent satisfaction, compared with 89.4 percent for the hospital, for the fourth quarter of last year. We’ve taken the same CAHPS [Consumer Assessment of Healthcare Providers and Systems] survey with our program, versus the same population in the hospital.”

Keith Figlioli

What’s more, says Melanie Van Amsterdam, M.D., lead physician for the Hospital at Home program at Presbyterian, “From the standpoint of our referring providers, they’re generally happy, one, because we get their patients out of the ER, and provide very close follow-up; the primary care providers and specialists are very happy, because we communicate with them. And provider satisfaction is pretty high,” she says, referring to the 3.5 FTE physicians involved so far in the program. “I know I’m really happy doing this work, because I get to spend time with my patients.”

Of course, a lot of careful strategic thinking and planning have to be incorporated into any population health-based concept, whether it be a hospital-at-home program like Presbyterian’s, or an ACO, bundled payment initiative, or PCMH, says Mark van Kooy, M.D., director of clinical informatics at the Pittsburgh-based Aspen Advisors. At the core of all of these types of initiatives, says the Sewell, N.J.-based Van Kooy, are a number of common elements, one of them being the ability to provide physicians in practice with intensive and extremely useful real-time data on their patients.