Making the leap to true population health management is turning out to be a herculean task for healthcare providers of all types. Healthcare leaders from various sectors of the industry described their trajectories to Editor-in-Chief Mark Hagland in interviews conducted for the May/June cover story of Healthcare Informatics.
Among the numerous nationally respected leaders Hagland interviewed for that cover story was Donald W. Fisher, Ph.D., president and CEO of the Alexandria, Va.-based American Medical Group Association (AMGA). Fisher and his colleagues are putting the vast bulk of their efforts into helping prepare physician group leaders for the transition to population health-driven care delivery and value-based payment. “We’re not quite there yet, and as we change to a new reimbursement system, even the large, sophisticated medical groups are going to need a few years to make the transition,” Fisher says. “You’ve got to put the infrastructure in place, and the large integrated health systems have been putting those elements in place—EHRs [electronic health records], alert systems, analytics systems, data warehouses—and some have teams of people mining the data to assess patient status.”
Below are excerpts from Hagland’s extended interview with Dr. Fisher.
Looking at the transition to population health-driven value-based payment, what kind of timeframe are we talking about for a transition these days?
We’re not quite there yet, but as we change to a new reimbursement system, even the large, sophisticated medical groups are going to need a few years to make the transition.
Where do you see the main gaps right now in terms of processes and other elements?
Some medical groups still have gaps in their primary care base; and if you’re going to do population health, you need a very good primary care base. So some are still struggling in that area. And then there is the cultural piece, which encompasses reimbursement-related goals related to this. You can try to change your culture, but if you’re still being paid FFS and still mostly paying your doctors FFS, you need to change that, and that is something they’re trying to get over pretty quickly.
What are the most advanced things that AMGA member groups are doing right now?
There are several, in different areas. Many of our member groups are attaching themselves to very large data sets. My members are using what used to be Humedica, and that was acquired by Optum, and it’s housed within the Optum Analytics shop, and it’s called Optum One. They’re using this large database to measure themselves across physicians and across sites and even comparing themselves with other medical groups across the country. And since Optum has taken over the Humedica database, they’re actually adjudicating claims, and are able to compare claims data. Second, the groups are using a couple of tools Optum has built to do predictive analytics—and they’re in four areas now—diabetes, congestive heart failure [CHF], asthma, and COPD [chronic obstructive pulmonary disease]—and what they’re doing is that they’re infusing the data, and looking at predictive analytics.
And the predictive analytics model will tell them, particularly for CHF, which patients are most likely to be hospitalized within six months. And that’s a great window of time, because they can figure out how to avert hospitalization. Aurora actually reduced admissions by over 60 percent in the third quarter of last year. That’s the first admission. And if you ask a cardiologist, they’ll say you’ve got to prevent the first admission, because it’s a downward spiral after that. And you can’t do that with claims; but with a sophisticated data warehouse that combines the clinical and claims data, you can predict. And actually, with this predictive analytics tool, you’re predicting CHF admission before the first claim. And they’re reaching out to these patients and making sure they don’t get admitted.
The thing is that you have to go beyond the data; you have to reengineer the care process. The way it is today, it’s a reactive kind of care process. If you’re using predictive analytics and data sets, you’ve got to be proactive, and reach out to patients in advance. And that requires different skill sets, different providers; it’s a very, very big job to work with these data sets and predictive analytics, but it can make a very big difference in patients’ lives; patients are just doing so much better as a result.
Are doctors understanding that things are changing, and are they moving forward into change?
Yes, they are. But even though change is coming, no one can tell you exactly how and when. We don’t know what percentage of our revenue will be FFS, will be modified risk, will be full-risk? So that’s a challenge. You don’t want to get there too fast, because you can sort of shoot yourself in the head a bit, and that can be a big challenge, if you get ahead of yourself reimbursement-wise. And I don’t agree with the idea that physicians don’t like change; they do, if it’s warranted, and they can get to it. But the perverse incentives, the fact that you still get paid more under FFS for doing more, that is completely at odds with value-based healthcare.
And not so much in our membership, but out in the country as a whole, many still haven’t invested in electronic health records yet.
My experience is that, in every medical group that is pioneering, individuals have shown leadership, and have then collaborated with physician champions, and have also early on engaged physicians in practice in developing their initiatives, in order to move forward. So it’s a process, or a series of processes, correct?
Exactly, and that’s why I’ve been at AMGA for 35 years now. Physician groups tend to move forward based on process. And leaders inevitably emerge—often a physician leader paired with a non-physician leader, who stand up and say, we’ve got to move in this direction. And I think it’s the kind of physician who has historically been attracted to these large practices, because it involves systems thinking, and working as a team.
How do physicians change in terms of their processes and habits in practice, once a group begins to move forward on population health?
First, physician satisfaction tends to go up, because it’s organized and team-based, so there’s more joy in practice. They can refer internally to specialists without fear of losing patients from the practice, and can hand duties off to mid-level practitioners. So first of all, there’s a return of joy in the practice, and their satisfaction goes up broadly. Then you see the further evolution of team-based care and their reliance on one another; you’re not out there as a lone wolf. And that gives you the confidence of knowing you’re doing everything you can for your patient. And the backbone behind that is the set of decision support tools; and there’s transparency and accountability in that as well.
What is happening with regard to clinical informaticists in all this? More and more physician groups have hired CMIOs and other clinical informaticists. How do you see their role?
We’ve seen an evolution of that team. It used to be you had a CIO leaning on a physician, with that physician informaticist creating and distributing data reports, and that was basically their job. With the advent of analytics and the use of the data to improve care quality and costs, that pushed forward the role of the CMIO—and I see them taking on an even larger role, because they’re the ones doing the translating, they see where the variations are in care and where the gaps are, and they then can help to create change. So I see this as a transition period. And you’re right, the bigger groups have really embraced the transformation role.
Are most CMIOs reporting to CMOs in medical groups?
Initially, the CMIO was reporting often to the CIO. But more and more, both the CMIO and CIO are reporting to the CMO or the CEO; and in some groups, the CIO is actually reporting to the CMIO. And analytics are changing that. And really, if you’re going to transform, it has to be led by a physician. All this is changing rather quickly across the country; and any variation on reporting relationships, you’ll see across the country.
What do you think will happen in the next five years?
I think we’ll see a significant increase in the use of analytics around robust clinical data; and you’ll see transformation around care processes, and a redefining of the roles of primary care physicians. What we’re finding is if you’re going to go population health and value-driven healthcare, you have to get a very broad primary care base; and in many markets across the country, there simply aren’t enough primary care physicians to do that. So we’re redesigning primary care to use advanced care practitioners working at the top of their license. So when they come in in the morning, they don’t see a full slate of patients; they’re seeing the most complex patients, with two or more co-morbid conditions. And the patients are more satisfied. And the physicians love it, because they’re getting to use their skill set at the level at which they’re trained; and everything else is taken care of by the advanced care practitioners.
Another thing in the next five years that’s going to e rather remarkable is, there’s a lot of disruption coming into the market now, around advances of things like wearables, like the Apple watch; and the fact that Wal-Mart and CVS and retailers are beginning to provide more primary care services, with practices as backup. So I think you’ll see a significant amount of revenue going to those non-traditional providers and leaving traditional medical groups and organizations; and it’s going to be very hard for some. And dermatologists may not even need to see patients in person. So that’s going to be disruptive, and it’s going to require a lot agility to survive.
Are you generally recommending that your member groups pursue accountable care and population health?
Yes, indeed. In fact, all of our meetings have focused on accountable care and assuming risk. So we’ve been very big proponents of the Affordable Care Act and are very big on moving to a system based on value. And if you’re going to be out-front with that, you’ve got to make sure you have the tools; so that’s pretty much what we’re doing.
Finally, what would your advice be generally, in this context, for IT leaders in medical groups and health systems?
I think they have to move beyond the technology into analytics and analytics solutions and have to work with clinicians to understand how to use the data to advance patient care. It’s a big job, and it’s becoming more important every day.