There’s bad news and good news on the population health management front these days. The bad news is that all the forms of population health management, including accountable care organization (ACO) development, care management, patient-centered medical home (PCMH) development, and avoidable readmissions reduction work, among other types of initiatives, are turning out to be more difficult than anyone anticipated. That’s particularly true at the medical group and physician practice levels, where resource challenges, incentive alignment issues, and the lack of off-the-shelf information technologies are dogging everyone’s steps. But the good news is that the leaders of medical groups and integrated health systems are figuring out quickly where the key gaps, both process-wise and technology-wise, are, and are working to bridge those gaps.
Here’s the bottom line: medical group CEOs, CMOs, CIOs, and CMIOs, and leaders at health systems with physician groups, are coming to similar conclusions about the key learnings in this area. They include the following:
• Fundamentally, population health work of all types requires some form of reimbursement alignment and alignment of financial, organizational, and operational incentives among physicians and other participating entities, whether they are hospitals, integrated health systems, health plans, or government agencies.
• At the physician practice level, the biggest learning is on one level very simple: physicians simply cannot do it all themselves. Creating mechanisms for facilitating patient registries, performing ongoing health risk assessments for the highest-risk patients, analyzing data around readmissions, doing chronic disease patient education, evaluating the efficacy of evidence-based order sets, and a host of other tasks, have to be facilitated, whenever possible, by mid-level practitioners, office staff, or, in the case of integrated health systems and the largest medical groups, corporate-level staff members. Physicians’ time is now such a precious resource that the only way that population health management will happen and be effective is if the burden of tasks can be spread across an organization.
• In all this, healthcare information technology is an absolute must-have; but the landscape is very complex. There are simply no “off-the-shelf” solutions with which to perform all the functions required by any population health initiative, whether it is a PCMH, ACO, or chronic care management or readmissions reduction initiative. All those interviewed for this article agree: at this point in time, the best that can be hoped for is partnership with a core vendor willing to collaborate also with at least a few other vendors, to provide the solutions capable of facilitating the range of processes involved. Among the essential components, besides electronic health records (EHRs): robust data warehouses and reporting-creation capabilities; interoperability; health information exchange (HIE); and data analytics.
• At the same time, the policy landscape and the industry landscape keep changing constantly. Population health management is intersecting with healthcare reform mandates via the Affordable Care Act (ACA); with the meaningful use process under the HITECH (Health Information Technology for Economic and Clinical Health) Act; and a wide variety of private-payer initiatives. Those elements add further to the complexity around all this.
So what are the leading-edge physician organizations doing in this space? Not surprisingly, the population health-related initiatives taking place nationwide are all over the place, conceptually speaking. Among them:
• 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 works, 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 Derrington, Hill Physicians’ chief medical services officer.
• At the Cookeville, Tenn.-based Cumberland Center for Healthcare Innovation, a Medicare Shared Savings Program (MSSP) ACO formed in February 2012, Hal Chertok, D.O., president and chairman of the board of the ACO, which encompasses 30 physicians in 14 medical groups in middle Tennessee, notes that the ACO is having to bridge IT facilitation and data-driven work across 14 different EHRs, while serving a population of 11,000 Medicare beneficiaries. Chertok and his colleagues are working very closely with the folks from the Atlanta-based Clinigence, which is providing a common data platform and making it possible to harvest data and share it in participating practices, via a clinical dashboard.
• At the Houston-based Memorial Hermann Physician Network, a 2,000-physician accountable care network affiliated with the Memorial Hermann Health System, Shawn Griffin, M.D., chief quality and informatics officer, has been helping lead colleagues in his organization to bridge the gap between claims-based data from payers and EHR-derived data from his organization. In that effort, he and his colleagues have teamed up with the Hartford, Conn.-based Aetna, to launch, in January 2013, a private-payer ACO; the organization also launched a MSSP ACO in July 2012. They are collaborating with Aetna to develop and use analytics tools to bridge the claims/EHR data gap.
• At Intermountain Medical Group, a 1,000-physician organization with over 80 clinics across Utah that is affiliated with the Salt Lake City-based Intermountain Healthcare, Mark Briesacher, M.D., senior administrative medical director, has been leading his colleagues in working towards success in managing over 550,000 lives in SelectHealth, the accountable care organization that Briesacher and his colleagues refer to as a “shared accountability organization.” Briesacher and his colleagues have an ongoing initiative that is custom-building analytics solutions based on pulling data from their custom-built EHR into their self-created data warehouse.
OF INCENTIVES AND I.T. OBSTACLES
Asked where the pioneers are finding the greatest opportunities to change processes effectively, physician organization leaders are alighting on different potentialities. Ashok Rai, M.D., president and CEO of Prevea Health, a 180-physician multispecialty group based in Green Bay, Wis., says of the private-payer ACO that he and his colleagues have created in collaboration with three local hospitals, “Probably the largest insight is that there’s a lot of opportunity with the right infrastructure, to change how we traditionally practice medicine, to start to make populations healthier. In a patient-centric rather than provider-centric model, where everyone’s working to the highest level of their license, we find it a much better and more effective model in terms of preventive and primary care,” Rai says. “So we’ve seen a definite bending of the curve upward on the quality side and downward on the cost side. The biggest challenge is that with the majority of our revenue still being fee-for-service—we’ve essentially been financially disincented to make the progress we have; but it’s the right thing to do.”
Ashok Rai, M.D.
The challenge, Rai says, is in trying to effectively leverage EHRs as population health management tools. “If you look at how EHRs were designed,” he emphasizes, “they were designed to interact with the provider, not the patient, number one; and they were designed to document what was going on in the room during a patient visit; they weren’t designed to work on population health proactively. So if you’re changing your processes to say that the patient visit never ends, to care for their health, and changing your processes so that you’re trying to work with patients who haven’t come in, you end up scrambling for tools or jimmying existing tools to give you what you need.” As a result, he and his colleagues are still using manually created and maintained patient registries for the high-risk patients they’re caring for.
Intermountain’s Briesacher concurs on the challenges involved. With regard to the absence of “off-the-shelf”-type tools for population health management and analytics, he says, “You’re going to want to look at a tool set to help improve the clinician documentation workflow; for example, you’re going to want a tool set that doesn’t necessarily involve a programmer intervention. We have parts of our system that do that, and parts where we still have to add code to our code base; but that provides the flexibility that forward-looking systems would want to have.”
Briesacher immediately adds, however, that “Healthcare IT does not solve the basic question or problem. Instead, healthcare IT leaders really do have to start by focusing on the relationships of their clinic teams: do we have a strong and robust quality improvement culture? Do we have those cross-professional, interpersonal relationships? For long-term quality improvement, that’s the starting point, and what sustains you. You can throw a lot of dollars at health IT and it’s not sustainable. What informs what you should be doing with IT should be based on your key internal care processes, and mapping out those processes.”
Mark Briesacher, M.D.
In fact, Briesacher says, “Maybe even begin the process by doing it the good old-fashioned way—do some manual chart reviews and checklists. Once you’ve tested it and teams agree that a particular solution would help them do things better; then you go to the IT development team and say, let’s embed this into our processes. Otherwise, you spend a lot of time asking clinic teams to do things that don’t help them. Since every data process costs money, you have to be pretty rigorous about that upfront work; so, people and process first, and then develop IT solutions to support your improvement work.”
LONG-TERM LEARNING IN NORTHERN CALIFORNIA
If there’s anyone in the industry with a truly long-term view of all this, it’s 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. 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. 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.” The challenge, Derrington notes, is that “We manage [IT and data] 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. Unfortunately, that doesn’t necessarily work in a next initiative with HealthNet or Aetna. So it’s very slow and laborious,” she notes. “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.”
IN NEW YORK, FOCUSING ON VERY SMALL PRACTICES
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. 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 PCMH designation [designation as a patient-centered medical home on the part of the National committee for Quality Assurance].
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.
‘PEOPLE, PROCESSES, AND TECHNOLOGY’
Asked for their advice on what the leaders of physician organizations should do, all those interviewed for this article agree that what’s most important is to understand how strategic and IT requirements never exist completely separately from each other in population health. “There’s sort of this conceptual triad of people, processes, and technology,” Memorial Hermann’s Griffin says, “and we had our strengths and weaknesses, when it came to technology. You invest in promising technologies to close those gaps; and per the processes, you find ways to embed health coaches, and interventions, and alignment of your ambulatory and inpatient case managers, to facilitate medication reconciliation, etc., so you don’t have the bounce-backs you want to avoid. We’ve had to go from two care managers to 25 care managers in the past year and a half, and develop that group of people and the skill set as well, for population health management.”
When it comes to combining process change and IT facilitation, the Cumberland Center for Healthcare Innovation’s Chertok says, “I think the number-one thing is to stop doing it the way you’ve always done it. This is the time where you need to embrace change; you need to get off that hamster wheel of acute care and switch into preventive care. If it doesn’t take the physician to perform a particular task, then don’t ask the physician to do it. Use your decision support tools and your health information technology tools to their highest level of capability to allow you to perform to the best of your ability; and don’t get complacent. The goal is to continuously improve.” In the end, Chertok says, “While the MSSP is a wonderful thing, it would be shortsighted for that to be the end goal. The goal is to be a large integrated system of physicians that provides the best care for patients.”