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Slicing and Dicing the Populations Within Population Health: One Industry Expert’s View

November 9, 2013
by Mark Hagland
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The Advisory Board Company’s Lisa Bielamowicz, M.D. shares her perspectives on the subgroups within population health initiatives

In mid-September, The Advisory Board Company hosted a population health colloquium in Washington D.C., convening provider thought leaders from across the U.S. to share their experiences in migrating to risk-based payment models and population health management. Among the Advisory Board Company experts who spoke and helped lead the conference was Lisa Bielamowicz, M.D., executive director and chief medical officer for the organization. Bielamowicz, who leads the organization’s research and strategy efforts in physician alignment and population health, spoke recently with HCI Editor-in-Chief Mark Hagland regarding some of the learnings shared at that event, and what she and her colleagues are uncovering more broadly as they advise provider organizations on population health management initiatives. Below are excerpts from that interview.

What are the latest trends you and your colleagues are uncovering in the population health management arena?

We’ve actually been surprised how many health system and physician group leaders have seen their strategies turn lately; they’re beginning to be fertile, they’re starting to design contracts that are giving them the competencies they will need to succeed in care management for population health, and potentially in moving towards total risk incentive.

That being said, it is the rare system that has more than 30 percent of their book of business in shared savings or total cost incentive. And those organizations are finding that in order to break even on shared savings—say I do what a good network can do, which is to reduce unnecessary 10 percent of ED [emergency department] and inpatient utilization, I need to have such a tremendous amount of my revenues at risk, to offset the cut in utilization that would provide fee-for-service revenues to make up for those savings. And it’s important to recognize that most of the large physician groups are multispecialty groups that do a lot of utilization in diagnostic imaging, and so on, and it turns out that the need to fill CT scanners and OR suites is just as critical to the revenues of multispecialty groups.

So what we’re hearing from physicians and hospitals working in the shared-savings model, is that even cutting that first shared-savings contract is not enough to move out of that feet-in-both-camps situation, because being involved in one shared-savings contract is not enough, and they want to get to as much capitation as possible.

Lisa Bielamowicz, M.D.

So what seems readily doable is that first 10-percent cut in inpatient and ED utilization, then?

Yes, a strong network can do that, and we’ve seen it done.

What are the critical success factors to getting to that first 10 percent?

We dug into about 40 of the highest-performing population managers, organizations that have been successful at total cost risk, in a sustainable way, and you have to build the right network, get the right contract, and then actually manage care. The first two of those three things are things that smart people can do; the third thing, managing care, is the hard part. And the big insight is that what we see in the average health system is that they’re trying to come up with a one-size-fits-all care management model.

I had been a big proponent of the patient-centered medical home model, and still am; but every successful organization leverages analytics in and IT in one way; and every organization also structures its care team uniquely. It also builds out its primary care infrastructure in an individual way, with regard to the staffing, as in, who’s the owner and the manager of the patient? And finally, every organization slices the three critical subgroups within its population, differently.

So, with regard to what those three groups are, everyone knows about the top-shelf group, the five percent or more of patients with huge co-morbidities and the most intensive utilization. Then, very significantly, the middle of the pyramid is what we call the “rising risk” group. And we’ve found that managing this group is extremely important to managing total-cost risk. This is someone with two or three primary diseases, who typically is overweight and smokes, but about whom we know it’s just a matter of time before he or she becomes a high-cost patient. And the key is not just managing the already-high-cost patients, but finding a way to manage the rising-risk is the key. It’s like the “I Love Lucy” chocolate factory episode, with the conveyor belt! And then the third group is composed of  the healthy or relatively healthy, who don’t see a doctor more than once or twice a year. And that group is very important, too. So we have to keep those people healthy and engaged, in that risk context.

And what we’ve found is that yes, it is very important to be able to analyze claims and manage risk with those high-risk patients. But to be truly honest, it’s actually not that necessary to have analytics for the already-high-risk patients; in reality, most doctors and nurses will already know who they are. Where it’s incredibly important is to have analytics for the rising-risk population, so you can have a system that allows you to prioritize where you devote your limited care-team time. With a high-cost patient, I can essentially marry them to a nurse practitioner and be done with it. But with the rising-risk patients, you have to put them into a patient-medical home and then use predictive analytics to figure out how to manage their care.