In the October 2013 cover story, HCI Editor-in-Chief Mark Hagland interviewed a wide variety of physician group leaders and industry experts regarding the journey toward population health management, which encompasses numerous vehicles and organization structures, including accountable care organization (ACO) development, care management, patient-centered medical home (PCMH) development, and avoidable readmissions reduction work, among other types of initiatives.
In the population health management arena, medical group leaders, who face greater resource challenges than do hospital leaders, also face incentive alignment issues, as well as the broad issue of the lack of off-the-shelf information technologies, are dogging everyone’s steps. Fortunately, many medical group leaders are figuring out quickly where the key gaps, both process-wise and technology-wise, are, and are working to bridge those gaps.
At the San Ramon-based Hill Physicians Medical Group in San Francisco’s expansive East Bay region, executives are deploying “virtual care teams,” composed of pharmacists, health educators, social workers, case managers, etc., to support patient care management for the 3,500 physicians in the independent practice association (IPA), northern California’s largest, notes Rosaleen Derington, Hill Physicians’ chief medical services officer.
“The good and bad thing at the same time” about working with several different health plans on population health management initiatives, Derington says the reality is that “We manage it initiative by initiative. So if we’re involved in an initiative with Blue Shield, we work on passing data back and forth to each other. And unfortunately, that doesn’t necessarily work in a next initiative with HealthNet or Aetna. So it’s very slow and laborious. So we’re seriously looking at implementing a true care management information system, where we’ll be able to pull all our disparate databases into one, so at least when we look into our database, we know we’ve got all the details on Mrs. Smith, and it’s the same Mrs. Smith. We are in the very, very early stages, talking together with one of our hospital partners, to get onto a common platform, and then a health plan, but that’s what we’re really going to have to do.”
The reality, Derington says, is that “We’re going to have to have the technology that at least aggregates all the disparate data; that’s critical. We’re looking to see if there’s anything out there that we can purchase. We have some hope that there is. There are a couple of vendors who at least seem to have that platform that could aggregate that data for us and we could then build the bells and whistles on top of that.”
A Bigger Picture Around True Integration of Processes
Meanwhile, in terms of seeing the bigger picture on population health management, there’s no one in the industry with a bigger-picture view of it all than Darryl Cardoza, president and CEO of Hill Physicians Medical Group. Cardoza co-created Hill in 1984 with Steve McDermott, who served as CEO until April 2012. Cardoza, who served as COO from 1984 through April 2012, has since been president and CEO. In other words, he’s lived and worked through early managed care, the physician practice management boom and bust, capitation, and any number of other phases in Northern California healthcare.
Indeed, Cardoza sees genuinely new opportunities with accountable care and population health management, as well as some new challenges. “We suffer from fragmentation in the American healthcare system; we are all in our own silos doing our own thing, and meeting our own business incentives, that are often conflicting and adversarial, and it just doesn’t work very well,” he says flatly. “And what the ACO model has enabled us to do is to begin to break down some of those walls, and to help us all work within the same system, and align incentives.”
The key difference between earlier forms of managed care and accountable care and population health, Cardoza emphasizes, is that “It’s not a matter of just preventing people from using certain kinds of resources, but rather, of managing the entirety of their care. And we were doing it by the seat of our pants, because we didn’t have the tools. It was just very, very difficult to use data, to consolidate it and evaluate it and draw meaning from IT; but those tools are available now.”
Asked what the learnings are for her and her colleagues around the shift from partial risk to true population health, Derington says that “When you move to population health, you’re now refining your instrument, and you’re getting to a level of precision that you don’t get to in a managed care risk contract. Now with population health, you really have to start dissecting who your members are, what groups they’re in, and you’re doing risk assessment. You become much, much more precise in terms of your identification of that population.”
Does patient engagement become an issue “Unfortunately, the goals have to be financially driven,” Derington concedes. “The product we’re selling needs to be a value-based product, to give good quality for the price we’re asking. And if you can incent the member/patient to take care of themselves in a way that they maximize the value of that product, that’s what it’s about. And there need to be incentives for them in maximizing that value, such as lowering co-pays for compliance, and such.”
Strategic IT learnings
What have the strategic learnings been so far at Hill? “IT has evolved for us,” Cardoza says. “Several years ago, we made the step to get into installing electronic health records [EHRs] in as many practices as we could. We did that because we needed to be in that game, not because we thought we’d have 3,500 practices on a single EHR platform. And while we’re still in the EHR business, we’ve come to accept that it’s a pluralistic system.”
Does that mean that investment in IT is really about health information exchange and interoperability? “Absolutely,” Cardoza says. “Unless you’re a medical group with one system for everybody, the reality is that in an independent system, you’re going to have a variety of EHRs. And even in the medical group world, you’ll have to be integrating with hospitals.” Ultimately, where this is headed, he says, is towards some sort of formal health information exchange (HIE). “It’s inescapable,” he says. “We’ve got about 3,500 physicians now, over a 10- or 11-county service area.”
Finally, when it comes to the broadest learnings around strategy, Cardoza says that the bottom line is that “The enabling strategy is business model alignment. It’s important to have good partners. And I’ve always said, if you want to have good partners, you need to be a good partner. So we work very hard at building relationships and creating new business models, with health plans and hospitals. And that’s a very easy thing to say and a very hard thing to do. The adversarial system is still alive and well in the American healthcare system. We’re taking that apart brick by brick. I really believe that that’s the future. We can’t do this alone.”