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Population Health in New York City: Helping Smaller MD Practices Thrive

November 8, 2013
by Mark Hagland
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Brent Stackhouse of the New York City Department of Health, shares his perspectives on population health work in smaller physician practices

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.


Brent Stackhouse

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?

Right. And physicians in small practices are small businesspeople, and these are the ones challenged the most at this point—they don’t have the resources or teams that organizations like Kaiser and Mayo and Geisinger have. And especially in New York City, we have such high rates of underserved populations, of Medicaid populations, of chronic illnesses like diabetes and CHF [congestive heart failure] and asthma, and it takes time to support these patients. And time is exactly what the physicians in small practices don’t have. And this can work, but you need more bodies. So we have billing and coding specialists on our staff who go out and work with the providers to make sure their accounts receivable are under control and that their billing and coding are optimized; because what we find is that they’re leaving a lot of money on the table, and that’s the money that will pay for the medical assistant. Right now, we have a provider in Brooklyn who wants to have her hands in everything. She has three women who sit out front in her office managing flow, and she has no medical assistants, and an enormous patient panel.

And frankly, a private Medicaid managed care organization came to us; we wanted to pilot a collaborative care management program, and they brought her to us. And they said, she has an enormous patient population and the quality metrics aren’t. And we looked at her EHR data and said, this provider isn’t doing a bad job, but they found she was in the lowest tier of quality outcomes based on their data. But we could see in the EHR that she was doing the work, but was just not submitting the claims for it. And we told them, she just isn’t sending you the information you require. So ultimately we had to set up customized templates for her to support her workflow and push some responsibility down to her staff. But ultimately, we have to help her delegate this work to a mid-level you can trust, because you’re leaving so much on the table.

And to be honest, this plan would have dropped her otherwise. Yet within a month, her documentation of smoking status went from 4 percent in June to 90 percent in August. So the technology is great, but the technology can’t get you there; it requires an extra body. So for the regional extension centers to go out and identify where the gaps are and how we can make care coordination possible—having that second set of eyes and that support, makes that job possible, because you need a team, when perhaps the office isn’t big enough to fit a team.

Tell me a bit more about the pilot program?

Certainly. At the New York City Department of Health and Mental Hygiene, we have something called the Primary Care Information Project (PCIP), and that program has initiated something called the Panel Management Program, which was created to help physicians provide continuity of care, ultimately encouraging greater patient engagement and better outcomes for New Yorkers.

After calling more than 4,000 patients, the Panel Management team at PCIP has scheduled appointments with more than 400 patients who had been falling through gaps in our medical care system. Those patients have chronic conditions, and have not been to see their personal physicians in at least six months. The conditions that these patients have included uncontrolled hypertension, diabetes and obesity, hyperlipidemia, and ischemic vascular disease. Our prevention outreach specialists (POSs) assistant 37 physicians, who together serve over 100,000 patients. In total, the POSs are traveling to 25 practices  every week, and calling targeted patients in order to schedule appointments. The POSs also foll0w up with patients about specialist referrals and risks.

The program is encouraging patients to schedule recommended office visits for preventive care, and testing whether a practice approach to chronic diseases will help high-risk patients manage their conditions. Normally, doctors see patients only when they call for an appointment. This panel approach uses EHR data to identify patients who do not receive recommended care.

What have the results been so far?

Since the program started, more patients have been coming in for appointments. The POSs speak directly with patients over the phone or leave voicemail messages encouraging them to come in. In return, patients either schedule an appointment immediately, or call back to set up appointments to

New York City is somewhat  unique, but what would your advice be for CIOs, CMIOs, CMOs, and other healthcare leaders, with regard to how to help physicians in smaller practices nationwide to proceed with population health work?

They have to identify who the trusted partner is and who truly has a relationship with the small practice provider community. And this will vary neighborhood by neighborhood. Here in New York City, there are individuals, organizations, non-profits, that providers know and trust. And it isn’t always the medical society; it’s at a much more local level. And it’s through that relationship that you’re going to start affecting change. It will be the independent physician associations, or here in New York City, ethnic provider organizations for providers with common language, etc. And here in New York City, the providers who see hepatitis, for example, have a tight-knit community. So for large integrated organizations trying to make changes in the small-practice community to facilitate care management, they’re going to have to find partners, and frankly, it will often be the regional extension centers. We helped them get implemented in EHRs, and we helped them get paid. So we’re often the trusted partner through which entities like managed care organizations, quality organizations, etc., can work, in this area. Now, that’s not necessarily true everywhere, but there are some very strong extension centers. And often, IT companies, regional medical centers, etc., are those groups.

Do you have anything to add?

I don’t think technology alone can solve the problem, but it certainly is a tool that, with the right practices, can be leveraged to help small practices maintain their practices. And even now, with that provider in Brooklyn who is completely swamped with patients, there are still tools within the EHR that can help her tremendously; the fact that she can run a registry in the EHR to find out who her uncontrolled diabetics are, for example, is huge.

So overall, you feel hopeful about all of this?

Very much so. The primary care small-practice providers in New York City are the keystone of the healthcare system, and sadly, they’re a keystone that has been sadly overlooked and depleted. So we’re trying to help them, because it’s preventive medicine that’s really going to help our community. Looking forward, we’re going to be looking at the intersection between behavioral health and physical health.

 

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?

Right. And physicians in small practices are small businesspeople, and these are the ones challenged the most at this point—they don’t have the resources or teams that organizations like Kaiser and Mayo and Geisinger have. And especially in New York City, we have such high rates of underserved populations, of Medicaid populations, of chronic illnesses like diabetes and CHF [congestive heart failure] and asthma, and it takes time to support these patients. And time is exactly what the physicians in small practices don’t have. And this can work, but you need more bodies. So we have billing and coding specialists on our staff who go out and work with the providers to make sure their accounts receivable are under control and that their billing and coding are optimized; because what we find is that they’re leaving a lot of money on the table, and that’s the money that will pay for the medical assistant. Right now, we have a provider in Brooklyn who wants to have her hands in everything. She has three women who sit out front in her office managing flow, and she has no medical assistants, and an enormous patient panel.

And frankly, a private Medicaid managed care organization came to us; we wanted to pilot a collaborative care management program, and they brought her to us. And they said, she has an enormous patient population and the quality metrics aren’t. And we looked at her EHR data and said, this provider isn’t doing a bad job, but they found she was in the lowest tier of quality outcomes based on their data. But we could see in the EHR that she was doing the work, but was just not submitting the claims for it. And we told them, she just isn’t sending you the information you require. So ultimately we had to set up customized templates for her to support her workflow and push some responsibility down to her staff. But ultimately, we have to help her delegate this work to a mid-level you can trust, because you’re leaving so much on the table.

And to be honest, this plan would have dropped her otherwise. Yet within a month, her documentation of smoking status went from 4 percent in June to 90 percent in August. So the technology is great, but the technology can’t get you there; it requires an extra body. So for the regional extension centers to go out and identify where the gaps are and how we can make care coordination possible—having that second set of eyes and that support, makes that job possible, because you need a team, when perhaps the office isn’t big enough to fit a team.

Tell me a bit more about the pilot program?

Certainly. At the New York City Department of Health and Mental Hygiene, we have something called the Primary Care Information Project (PCIP), and that program has initiated something called the Panel Management Program, which was created to help physicians provide continuity of care, ultimately encouraging greater patient engagement and better outcomes for New Yorkers.

After calling more than 4,000 patients, the Panel Management team at PCIP has scheduled appointments with more than 400 patients who had been falling through gaps in our medical care system. Those patients have chronic conditions, and have not been to see their personal physicians in at least six months. The conditions that these patients have included uncontrolled hypertension, diabetes and obesity, hyperlipidemia, and ischemic vascular disease. Our prevention outreach specialists (POSs) assistant 37 physicians, who together serve over 100,000 patients. In total, the POSs are traveling to 25 practices  every week, and calling targeted patients in order to schedule appointments. The POSs also foll0w up with patients about specialist referrals and risks.

The program is encouraging patients to schedule recommended office visits for preventive care, and testing whether a practice approach to chronic diseases will help high-risk patients manage their conditions. Normally, doctors see patients only when they call for an appointment. This panel approach uses EHR data to identify patients who do not receive recommended care.

What have the results been so far?

Since the program started, more patients have been coming in for appointments. The POSs speak directly with patients over the phone or leave voicemail messages encouraging them to come in. In return, patients either schedule an appointment immediately, or call back to set up appointments to

New York City is somewhat  unique, but what would your advice be for CIOs, CMIOs, CMOs, and other healthcare leaders, with regard to how to help physicians in smaller practices nationwide to proceed with population health work?

They have to identify who the trusted partner is and who truly has a relationship with the small practice provider community. And this will vary neighborhood by neighborhood. Here in New York City, there are individuals, organizations, non-profits, that providers know and trust. And it isn’t always the medical society; it’s at a much more local level. And it’s through that relationship that you’re going to start affecting change. It will be the independent physician associations, or here in New York City, ethnic provider organizations for providers with common language, etc. And here in New York City, the providers who see hepatitis, for example, have a tight-knit community. So for large integrated organizations trying to make changes in the small-practice community to facilitate care management, they’re going to have to find partners, and frankly, it will often be the regional extension centers. We helped them get implemented in EHRs, and we helped them get paid. So we’re often the trusted partner through which entities like managed care organizations, quality organizations, etc., can work, in this area. Now, that’s not necessarily true everywhere, but there are some very strong extension centers. And often, IT companies, regional medical centers, etc., are those groups.

Do you have anything to add?

I don’t think technology alone can solve the problem, but it certainly is a tool that, with the right practices, can be leveraged to help small practices maintain their practices. And even now, with that provider in Brooklyn who is completely swamped with patients, there are still tools within the EHR that can help her tremendously; the fact that she can run a registry in the EHR to find out who her uncontrolled diabetics are, for example, is huge.

So overall, you feel hopeful about all of this?

Very much so. The primary care small-practice providers in New York City are the keystone of the healthcare system, and sadly, they’re a keystone that has been sadly overlooked and depleted. So we’re trying to help them, because it’s preventive medicine that’s really going to help our community. Looking forward, we’re going to be looking at the intersection between behavioral health and physical health.

 

 


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