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.
But what about physicians in solo and very small practices? Brent Stackhouse, executive director of strategy at the New York City Department of Health and Mental Hygiene, and director of the New York City Regional Extension Center, notes that, “Here in New York City, we’re working at the REC with 9,000 doctors, and one-third operate in small practices of 10 or fewer doctors, with most of the rest practicing in community health centers and hospital outpatient departments. So our team goes out every day and works one on one with these small practice doctors helping them transition from paper to electronic, and we stay with them for years—through the achievement of meaningful use and through the achievement of NCQA patient-centered medical home (PCMH) designation [designation as a patient-centered medical home on the part of the National Committee for Quality Assurance (NCQA)].”
The key missing ingredient for small physician practices, especially solo practices, Stackhouse emphasizes, is very simple, yet very difficult to overcome: the lack of “downstream” human resources—the mid-level practitioners, case managers, and data analysts needed to execute on population health management in the solo or small-practice environment. His organization has done a pilot program that has provided outside assistance with those tasks, and it has been very successful, he reports. Long-term, however, there will need to be some kind of sustained assistance to keep such moment going. In the meantime, EHRs and health information exchange (HIE) will be vital going forward.
Below are excerpts from Mark Hagland’s recent interview with Stackhouse.
You mentioned to me that you’ve been working with many primary care physicians in New York City to achieve both meaningful use and patient-centered medical home designation from the NCQA.
Yes, over 750 physician practices in New York City have achieved that designation, and over 400 of those are level 3, the highest level. And we’re fortunate in New York state, because New York state offers a financial incentive through Medicaid. For managed Medicaid, it’s a PMPM [per member per month] incentive, and in the fee-for-service Medicaid program, it involves an additional remuneration.
What have been the biggest challenges so far for small practitioners in engaging in population health efforts?
The biggest challenge with these care management models is the lack of resources, primarily bodies: manpower. And one of the things we strive for is to get them to understand the importance of delegating their work, so that the responsibilities of care coordination are spread out across front-office and mid-level practitioners as well. But these small providers often don’t have nurses or mid-levels. And to do the following up on labs and referrals, you need additional bodies. We’ve tried to do pilots—we had a grant where we put panel managers who would one day a week go into a different doctor’s office, and they’d create a registry report in the EHR [electronic health record] who had uncontrolled diabetes who had not had a hemoglobin a1c within six months or who had uncontrolled hypertension, and then we would call those patients and ask them to come in for an appointment. It was 60 providers at 29 practices—our panel management program.
So it began with a small pilot program, to see how we could create shared resources for physicians within the community. And we hoped it could create a model for IPAs and accountable care organizations for this kind of work. Here in New York City, real estate is at such a high premium, and talent is so expensive, that it’s so hard for providers to hire additional, mid-level staff, or to even create space for an additional computer. And we’re trying to see how, through technology, we can overcome some of the obstacles, especially through the use of space. It ran for three years and ended in January 2013.
In other words, in smaller physician practices, the only way to make population health work is to push many tasks downstream from physicians to mid-levels and others, then, correct?