The U.S. health system’s new transition to a population health model has resulted in healthcare systems and payers adjusting to new kinds of contracts and payment reform. Fee-for-service is being phased out and replaced with the concept of providing quality care for a population as cost-effectively as possible.
“Population health was initially created for the purposes of responding to new kinds of payment contracts,” says Neil Wagle, MD, MBA, medical director of Patient Reported Outcome Measures/Quality, Safety & Value at Partners HealthCare in Boston. Wagle also is an associate medical director for Partners’ Population Health Management.
“Instead of fee-for-service, we’re paying for taking care of a population,” Wagle adds. “That incentive in fee-for-service of doing more and more is jacking up the cost of healthcare.”
Shifting to a population health focus requires a global budget and quality metrics, Wagle says.
The Affordable Care Act (ACA) has incentivized the creation of accountable care organizations (ACOs) and other healthcare models based on population health. More than three-fifths of the U.S. population lives in a primary care service area with an ACO, although about one in five people are treated by an ACO.1
Studies also show that only 4% of healthcare spending is for encouraging healthy behaviors, even when these same behaviors account for half of an individual’s ability to stay healthy.2,3
The role of quality managers in this transition is essential, says Sreekanth Chaguturu, MD, vice president for Population Health Management at Partners HealthCare in Boston.
“Quality people are incredibly important for this because we cannot reduce cost at the expense of quality,” Chaguturu says. “We have to show that quality is being maintained or improving, and what we need to do is build out registries of quality measures.”
Quality departments should measure quality data alongside cost data, and quality best practices would be maintained through monitoring and an incentive program, he says.
Registries would make it possible to track patients, ensuring they receive 100% of recommended preventive services, he adds.
“We’d make sure patients get all of the care they need and have the highest quality chronic disease management for cardiovascular diseases, coronary artery, diabetes, hypertension, asthma, and other chronic and highly prevalent conditions,” Chaguturu says.
What is changing for quality managers is what is being measured, Wagle notes.
And from a healthcare organization’s perspective, provider incentives are shifting to both quality and cost-effectiveness.
“We’re measuring total medical expense and measuring quality in a different way,” he says. “This is extraordinarily challenging because what you’re measuring and incentivizing really matters; both are management tools.”
The old system has hospitals talking about how much revenue a department or provider is generating, and for some providers it’s difficult to change this approach and philosophy, Wagle notes.
The cornerstone of population health management is using data and evidenced-based practices to reduce total medical expense. “One strategy that has been proven in trials is focusing on the sickest patients,” Wagle says.
“They’re accounting for a disproportionately huge percentage of cost,” he says.
Quality managers can collect data to identify these target populations by collecting metrics that include specialty care data and patient-reported outcome measures (PROMs). The goal is to move metrics to clinical relevance, which would make data useful and more likely to convince providers to make desired changes, Wagle says.
“When the measures are flawed, providers — myself included — may find a way to explain away performance data, saying it’s a problem with the measure and not with them,” he explains. “As we get more clinically relevant measures, we get more buy-in from physicians.”
Measures with clinical relevance include real-time data, capturing the entire population, more sensitive and specific denominator/population inclusion, using electronic sources and claims data, and allowing for clinical exceptions, such as terminally ill patients and patients who are intolerant to therapy, he says.
Using clinically relevant measures, Partners HealthCare achieved successful outcomes in the following ways:
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within three years of its Pioneer ACO Initiative, the organization reduced spending by 2.7%, saving $21.6 million during the third year, and
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there were significant improvements in diabetes control, lipid control, colonoscopies compliance, and blood pressure control.
Other benefits included a philosophical alignment with providers, more actionable, real-time, and accurate data, which fueled competition between doctors, clinics, and hospitals, and better overall performance — even as the covered population grew.
“It takes an incredible commitment to obtain the best data,” Wagle notes.
While quality managers are limited by their health system’s electronic record’s data limitations, there are a few practical steps they can take to improve their metrics, Wagle says.
These actions include the following:
• Move to real time feedback. “Take the existing measures, as flawed as they are, and make sure they’re as close to real-time feedback as possible,” he suggests.
“Putting numbers in front of people about their individual performance will change their behavior, and it’s especially effective if you do variation reporting,” Wagle says. “Show them: ‘Here’s where you are and here’s where your colleagues are.’”
Within six months of receiving this feedback, any low-performing physician’s numbers will improve, he adds.
• Use patient-reported outcome measures. “Patient-reported outcomes measures are a huge component of how we should be measuring in the future,” Wagle says. “These measures capture a totally different aspect of care than what we’re usually measuring.”
• Answer data complaints. “Three years ago, my primary answer to complaints was, ‘You’re right — we have to change the way we’re measuring it,’” Wagle says.
Then, follow-up those words with these: “Yes, these measures are flawed, but in today’s market these are table stakes. If we can’t show that we can do these basic steps — however flawed they might be — then it’s difficult to convince the marketplace that we’re a high-quality provider,” he says.
REFERENCE
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Wyman O. ACO update: accountable care at a tipping point. Published by Leavitt Partners;April 2014.
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“F” as in fat: how obesity threatens America’s future. Bipartisan Policy Center. August 2012.
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Population health and the quality professional: future trends. National Association for Healthcare Quality. Webinar meeting host: Jessica Weglarz. Nov. 9, 2015. Available at: http://bit.ly/1RCLoC9.
SOURCES
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Sreekanth Chaguturu, MD, Vice President, Population Health Management, Partners HealthCare, Boston, MA. Telephone: (617) 278-1055. Email: [email protected].
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Neil Wagle, MD, MBA, Medical Director, Patient Reported Outcome Measures; Associate Medical Director, Population Health Management, Partners HealthCare, Boston, MA. Telephone: (781) 433-3719.
