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Looking at a Recent Survey—and Patient Care Leaders’ Determination to Move Ahead on Population Health

August 8, 2017
by Mark Hagland
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A practicing physician and industry expert looks at the results of a new survey affirming providers’ determination to move forward on population health strategies

A great deal of public attention was focused this spring and summer on the U.S. Congress, where various bills worked their way through both houses of Congress that would seek to repeal, or repeal and replace, the insurance-related provisions of the Affordable Care Act (ACA). Yet even as national attention was understandably focused on that drama, the reality is that, earlier this year, it was made clear that the so-called international health system reform elements of the law were largely going to be spared any threat of repeal.

And, with regard to that, a recently published survey confirms that most leaders of U.S. patient care organizations are pushing ahead with their plans to participate fully in population health management and accountable care initiatives. Indeed, more than 80 percent of patient care organization executives responding to a survey conducted online in July by the Salt Lake City-based Health Catalyst, said that the effort to repeal and replace the ACA has not caused them to pause or otherwise change their approach to population health management. In fact, 68 percent of survey respondents reported that population health management is “very important” to their healthcare delivery strategy during the next two years, while fewer than 3 percent assign it no importance at all.

According to the survey data, 82 percent of survey takers indicated they are continuing with their PHM strategy in spite of uncertainty over the future of ACA. Four percent of respondents said their organizations were actually accelerating their PHM plans.

As our news article noted, when asked to clarify why they were accelerating their plans, survey respondents mirrored the answer of a physician leader at a large multispecialty physician group near Boston, who wrote, “Accelerating your PHM strategy has never been more important given uncertainty and expanding hurdles to achieving quality care and outcomes.”  Another 4 percent of respondents answered that they were “pausing” their PHM plans in response to the current political situation.  Ten percent of survey takers said they were undecided on the question.

Still, while enthusiasm for population health management remains high, relatively few organizations have taken on PHM contracts with payers that put them at risk of a financial loss if they fail to meet goals such as improving the health of their patient population.


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When asked how soon they expect to have more than 30 percent of their patient population covered by such risk-based contracts, 37 percent said achieving that level of risk would take between three and five years.  The next largest group put the date within the next one to two years. Fourteen percent estimated it would take six to 10 years.  Only 13 percent of respondents—the smallest share for this survey question—said their organizations have already achieved the threshold of having 30 percent of their patients covered by contracts with downside risk.

What’s more, the most common impediment to starting a PHM program or succeeding with an existing program, according to the survey data, is “financial issues” such as “getting paid for our efforts” and “balancing competing contract incentives.”  That answer, selected by 37 percent of survey takers, reflects the pressures that healthcare organizations face as they attempt to operate under the dominant fee-for-service reimbursement model while simultaneously transitioning to value-based care.


The next most significant impediment to starting or realizing success from PHM, according to the survey, is access to high-quality data and analytics (17 percent). Data access also figured into the fifth most commonly selected barrier to PHM, “risk evaluation issues” (9 percent), including “access to the right data useful to evaluate at-risk contracts.”

Meanwhile, in the context of the release of the results of the survey at the end of last month, Healthcare Informatics Editor-in-Chief Mark Hagland interviewed Amy Flaster, M.D. Dr. Flaster is a practicing internist at Brigham & Women’s Hospital in boston, an instructor at Harvard Medical School, and an assistant medical director for population health management at Partners HealthCare. She is also vice president of population health management and care management at the Salt Lake City-based HealthCatalyst. Per the terms of her interview with Healthcare Informatics, all of her comments here reflect her perspectives in her position at HealthCatalyst. Below are excerpts from the interview conducted last week.

It appears now that any repeal of the ACA in Congress appears unlikely, though in any case, internal health system reform was no longer jeopardized. Still, there was a feeling of uncertainty. But the HealthCatalyst survey certainly confirmed provider leaders’ intentions to move forward on population health, correct?

Yes, that’s right. Folks are taking a long-term approach—and the key elements of population health care providing better care in the right venue, at lower cost. And I would agree, that definitely is the takeaway as well.

In that context, where are we as an industry on the journey of 1,000 miles around population health management?

I think that we’re still early in the journey, and if you look at the survey findings, a couple of findings were at odds with each other. And so on the one hand, 68 percent said that they’re all in, and it’s a core part of their strategy, and only 3 percent aren’t assigning any importance to it, and that’s good. But when we asked survey respondents when 30 percent of their revenues would be based on risk-based contracts of any kind, that result surprised me—the largest group, 37 percent, said they planned to get to that level, in between three and five years. And the percentage that said they would reach that level in between one and two years, was 21 percent. Meanwhile,14 percent said they’d get there between 6-10 years. And 13 percent had already achieved it today; and 9 percent said they would never get there.

So the results around timeframe show that the push towards population health represents a key part of the strategy of the leaders of patient care organizations, but that folks are being smart about it. When we talk about 30 percent of your population being at risk, it sounds like a small percentage, but without creating strong infrastructure and data and other forms of preparation, that could have a hugely negative impact. So I think folks are going into risk contracting one or two contracts at a time. And that’s a very rational response. I don’t think folks are reticent to take this leap; I just think they’re taking a phased approach. And this is a multi-year journey. Care management is one important factor. But there are also parts that involve a bricks-and-mortar strategy, and building urgent care centers, and having an ED strategy. So we’re seeing that there’s a commitment to this, but they’re building their long-term strategy on this, which to me feels appropriate.

What’s your assessment of the forward evolution of data in patient care organizations, and of the physician culture, and physician willingness to move forward on population health and value-based care?

I can speak as a practicing physician collecting this data and also as someone collecting this data for HealthCatalyst. Overall, the move to value-based care is energizing to physicians, and not in theory causing burnout, because this really is an opportunity to take better care of our patients, and move away from volume. So in that way, it does reduce burnout and aligns us with the move to value-based care. But it is true that at the granular level, it has the potential to increase physician bunout because of the documentation requirements involved.

So one thing that needs to happen is to be able to help physicians in practice by enabling the tools and technologies that are able to look at and aggregate gaps in care at the system level. We also need to facilitate the ability of care managers to work on population health issues. And in some cases, the solution could be as simple as having scribes involved to help the doctor not having to be buried in their computer while being with a patient. So overall, I think population health is actually decreasing burnout, but I also think that this could be an opportunity to decrease burnout by taking some things out of the workflow of physicians.

In other words, you feel optimistic that things are moving forward at a goodly pace, around the shift into population health? You don’t see some advances being blocked or frustrated, in terms of process or technology?

I do think things are moving forward. One thing I hear in conversations with health systems is that this is moving forward at such a rapid pace, that they’re feeling stretched to implement this adequately. And as health systems are committing to new at-risk contracts, they’re not left with a ton of time to do things. But I’m hearing that folks are feeling excited, and that they’re moving at a fairly fast pace.


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Kaiser Creating Evidence-Based Complex Care Models

January 17, 2019
by David Raths, Contributing Editor
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Work aligns with recently published ‘Blueprint for Complex Care’

The National Center for Complex Health and Social Needs recently published a “Blueprint for Complex Care” to develop a collective strategy for promoting evidence-based complex care models. Recognizing that many patient issues have root causes that go beyond the medical, the Blueprint seeks to identify best practices for breaking down silos between the social care delivery system and healthcare.

Perhaps no health system has devoted as many resources to complex care as Kaiser Permanente. Its Care Management Institute, a joint endeavor between the Permanente Medical Groups and Kaiser Foundation Health Plan, has established Complex Needs as one of its national quality initiatives. It has named regional complex care leaders, created common quality measures across regions and established a complex need research arm called CORAL. (Kaiser Permanente has eight Permanente Medical Groups and regions, more than 12.2 million members, more than 22,000 physicians and 216,000 employees.)

In a Jan. 16 webinar presentation, Wendolyn Gozansky, M.D., vice president and chief quality officer, Colorado Permanente Medical Group and national leader for complex needs at the Care Management Institute, described Kaiser Permanente’s efforts and used some personal anecdotes to explain their goals.

She said Kaiser Permanenteis working on the concept of developing core competencies and tools to support a longitiudinal plan of care for patients with complex needs. “These are the folks for whom the usual care is not meeting their needs,” she said. “How do you recognize them and make sure their needs are being met?”

Gozansky gave an example from a patient she had just seen the previous wekend. This women had fallen and broken her hip. She had several chronic conditions, including significant asthma, yet she was not on an inhaled steroid.

“One concept I love from the Blueprint is that this field is about doing whatever it takes to meet the needs of the person in front of you,” she said. In speaking to the woman, she came to understand that singing in a church choir was the most important thing in her life, and the inhaler medication was making her hoarse and unable to sing.  She was fairly isolated socially except for church. “My goal was to get her rehabbed and leverage the patient-defined family that is supportive. Her goals are to sing, so we need to do what is possible to get her back to that. We have to capture that information, put it into a long-term plan of care. The goal is not to get her out of rehab but to get her singing in choir.”


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The health system has to work on care that is preference-aligned. The woman is not on a steroid inhaler but her care is preference-aligned. How does the health system assure that everyone knows they are doing the right thing?

Gozansky said the beauty of Permanente Medicine is that its setup involves an employed medical group focused on value, not volume. They can interact with health plan partners in delivery of new systems of care. “It is a virtuous cycle about value and person-centered care. This is what our complex needs team is trying to understand.”

She described the journey so far: In 2015 there were pockets of work being done across the eight Kaiser Permanente regions. In 2016 they established complex care as a national qualitiy iniative. “We knew we were not meeting these patients’ needs. We had to figure out the right way to do that.” They also realized that most of the previous research on the topic involved examples that were not in integrated systems such as Kaiser Permanente. “We had to figure it out in an integrated system,” she said.

 In 2017 they started working on cross-regional learning — for instance, taking a program from Colorado and trying it in Southern California. Then they sought to align quality measures. In 2018 they got funding to create CORAL, the complex needs research arm.  

The Care Management Institute has created a “community of practice” on complex care to break down silos within the organization and bring together research, operational and administrative executives. They also want to work with external stakeholders to make sure what they are developing is scalable, Gozansky said.

Mark Humowiecki, senior director of the National Center for Complex Health and Social Needs, also spoke during the webinar. He said one of the goals of the Blueprint was to get a clearer definition. Some people get confused about terms such as “hotspotting” and complex care, he said. He said there is a recognition that these patients’ needs are crossing traditional silos, so “there is a need to connect care for the individual but also at the system level.”

The goal, he added, is to create a complex care ecosystem by developing in each community system-level connections between social care delivery and healthcare, which in the past have operated too independently.  The five principles are that complex care is person-centered, equitable, team-based, cross-sector and data-driven. One of the Blueprint’s recommendations is to enhance and promote integrated cross-sector data infrastructures.



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NIH’s All of Us Program Teams with Fitbit for Data Collection

January 16, 2019
by Heather Landi, Associate Editor
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The All of Us Research Program, part of the National Institutes of Health (NIH), has launched the Fitbit Bring-Your-Own-Device (BYOD) project. Now, in addition to providing health information through surveys, electronic health records, and bio-samples, participants can choose to share data from their Fitbit accounts to help researchers make discoveries.

According to All of Us research program officials, the project is a key step for the program in integrating digital health technologies for data collection.

The All of Us Research Program, established by the White House in 2015, aims to advance precision medicine by studying the health data of 1 million diverse Americans over the next five years. One aim of the project is to include groups that have been historically underrepresented in research. As of September 2018, more than 110,000 people have registered with the program to begin the participant journey, and more than 60,000 have completed all elements of the core protocol.

The participants are sharing different types of information, including through surveys, access to their electronic health records and blood and urine samples. These data, stripped of obvious identifiers, will be accessible to researchers, whose findings may lead to more tailored treatments and prevention strategies in the future, according to program officials.

Digital health technologies, like mobile apps and wearable devices, can gather data outside of a hospital or clinic. This data includes information about physical activity, sleep, weight, heart rate, nutrition, and water intake, which can give researchers a more complete picture of participants’ health.” The All of Us Research Program is now gathering this data in addition to surveys, electronic health record information, physical measurements, and blood and urine samples, working to make the All of Us resource one of the largest and most diverse data sets of its kind for health research,” NIH officials said.

“Collecting real-world, real-time data through digital technologies will become a fundamental part of the program,” Eric Dishman, director of the All of Us Research Program, said in a statement. “This information, in combination with many other data types, will give us an unprecedented ability to better understand the impact of lifestyle and environment on health outcomes and, ultimately, develop better strategies for keeping people healthy in a very precise, individualized way.”

All of Us participants with any Fitbit device who wish to share Fitbit data with the program may log on to the All of Us participant portal at https://participant.joinallofus.org and visit the Sync Apps & Devices tab. Participants without Fitbit devices may also take part if they choose, by creating a free Fitbit account online and manually adding information to share with the program.

All of Us is developing additional plans to incorporate digital health technologies. A second project with Fitbit is expected to launch later in the year, NIH officials said, and this project will include providing devices to a limited number of All of Us participants who will be randomly invited to take part, to enable them to share wearable data with the program.

The All of Us research program plans to add connections to other devices and apps in the future to further expand data collection efforts and engage participants in new ways.

Related Insights For: Population Health


NorthShore to Lead “Largest Primary Care-Based Genomics Program in U.S.”

January 14, 2019
by Rajiv Leventhal, Managing Editor
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The Chicago-based NorthShore University HealthSystem and genomics technology company Color are partnering on a new initiative that will aim to deliver the power of genomics to routine primary care at population scale.

Known as "DNA10K," the initiative will engage more than 10,000 patients and will be the largest known primary care-based genomics program in the U.S., according to officials who made an announcement last week.

The approach will build on NorthShore's years of experience in genomics and actionable electronic medical records (EMR) information, while providing access to Color's clinical-grade genetic testing and whole genome sequencing to inform patients about their risk for certain hereditary conditions, according to company executives.

“The knowledge will help patients learn about their genetic makeup, including risk factors for certain disease types such as common hereditary cancers and heart diseases. This insight will help NorthShore personalize care for each patient to support improved outcomes, prevention and overall health,” officials noted.

The announcement comes on the heels of a recent pilot between NorthShore and Color that looked to unlock the benefits of genetic information in routine care.

As officials explained, in less than two months, more than 1,000 patients signed up for the Color population health program as a part of their primary care visit, an adoption rate of more than 40 percent of those eligible and significantly beating expectations of the pilot program. “This is a strong indicator of patients' interest in understanding genetic factors that can influence health and the opportunity to work with NorthShore care providers to make more informed treatment or prevention decisions,” they attested.

Overall, the DNA10K initiative supports NorthShore's efforts to improve patients' health outcomes at a population level, with genomics as a foundation for informing individualized healthcare.

Patients who take advantage of the "DNA10K" offering will provide a blood sample, which is then analyzed in Color's CLIA-certified, CAP-accredited lab, and results are returned to healthcare providers and their patients. In addition to their NorthShore primary care provider, patients will also have access to board-certified genetic counselors and clinical pharmacists from Color and NorthShore, officials explained.

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