Provider-Based Population Health

Online health risk assessments (HRAs) can be used to help make patients aware of their health problems and to help care managers stratify their patient populations by health risk. This approach complements the primary risk stratification strategy, which relies on registry reports to classify patients based on clinical data.

Using Automation to Reach Patients

Provider organizations can use an automated process to generate health risk assessment data. Patients receive an e-mail inviting them to complete an HRA. When they click on a link, it takes them to the HRA on a website. After they answer the questions, the application automatically calculates scores for their risk factors and their willingness to change their health behavior.

Care managers can use this data in a variety of ways. For example, they can identify all patients with high-risk scores. They can also stratify the population as high, medium or low risk, with the assistance of registry reports, and use that classification as the basis for appropriate interventions.

Engaging Patients to Change Behavior

Care managers may also factor in each patient’s willingness to change. For example, if a patient has high blood pressure, is overweight and is an active smoker, but is not ready to change, the care manager might consider that patient for an online education program or might send a message inviting him or her to attend a motivational program offered by the healthcare system.

Learn More

Listen to a webinar about engaging patients using care automation within an ACO environment.

On April 12, 2012, Joslin Diabetes (the world’s largest diabetes research and clinical care organization) and Phytel announced a collaboration on a landmark research initiative to compare the accuracy and predictive value of current assessment methodologies in diabetes care.

Methods of Evaluating Educational Outcomes in Diabetes Care

The study will compare four methods of evaluating educational outcomes in diabetes care:

1. Physician self-reports
2. Competency assessments based on case studies
3. Examination of a sample of patient charts
4. Data drawn from Phytel clients’ electronic registries, which cover all of a practice’s patients with diabetes

“Phytel’s expertise in population health management and its comprehensive database will enable Joslin to make valid comparisons among different methods of assessing performance and patient level outcomes relative to educational and non-educational interventions.”

– Julie Brown, CCMEP, director, Joslin Diabetes Center

Quality Initiatives Focus on Physician-Led Population Health Improvement

This is just one of many Phytel quality initiatives that are focused on physician-led population health improvement.

Other recent 2012 announcements include:

• NCQA Approved Use of Phytel Solutions to Meet Medical Home Criteria. Physician practices can receive automatic credits toward NCQA recognition if they deploy Phytel’s patient outreach and care management services.
• Phytel was announced to be on the advisory committee of the AMGA’s Chronic Care Challenge around Hypertension. The American Medical Group Foundation (AMGF) is launching a national multiyear campaign to reduce the burden of hypertension and related chronic conditions.
• Dr. Richard Hodach, Phytel’s Chief Medical Officer authored a peer-review article within HMFA entitled Automation is Key to Managing a Population’s Health. The article discussed requirements for success with population health management include a high degree of clinical data integration across the healthcare organization’s care enterprise and automated tools for engaging patients in their own care.

Whether our clients are pursuing PCMH, ACO or P4P quality initiatives, our solution and services can leverage existing EMR data to help automate and engage patients for population health management across dozens of conditions and measures – all while demonstrating financial performance! In fact, hundreds of physician groups and healthcare systems that collectively care for more than 20 million patients use Phytel’s patient outreach, care management, patient engagement, transitions of care and analytics solutions in population health management.

And Phytel, because of our focus around quality and health outcomes – is invited to become engaged in more and more projects like Joslin Diabetes.

Read our white paper Improving Compliance to Diabetes and Hypertension Protocols Using Coordinated, Proactive Outreach.

A growing number of primary group practices are taking a proactive approach to care management because they know coordinated care will be a linchpin driving impending changes in the care delivery system. Larger organizations especially are building the infrastructure they will need under new delivery and payment systems that are emerging for Medicare, Medicaid and commercial programs.

Medicare’s PGP Demonstration

Let’s look at the Medicare PGP program for example. The experiences of the 10 groups that participated in Medicare’s five-year physician group practice (PGP) demonstration show exciting examples of how these healthcare leaders took on the challenge of care coordination inside their practices and between sites of care to meet their goals.

Incentives for Innovation

The PGP pilot turned out to be a dry run for Medicare’s shared savings program for accountable care organizations (ACOs). Similar to what’s been proposed for the Medicare ACO program, the PGPs were eligible to split savings with Medicare if they met certain quality benchmarks and the savings exceeded 2 percent of expected costs.

In the demonstration project, participants could keep up to 80 percent of the savings they generated, depending on how well they did in meeting 32 quality goals, which is a powerful incentive for finding innovative and effective ways to better manage patient care.

Quality Improvements

According to the Centers for Medicare and Medicaid Services (CMS) report released in July 2011, in the fifth year of the five-year demonstration:

• All 10 groups achieved benchmark performance on at least 30 of the 32 measures.
• 7 groups achieved benchmark performance on all 32 performance measures.
• All 10 groups achieved benchmark performance on the 10 heart failure, 7 coronary artery disease measures and 2 preventive care measures.

Also for Year 5, four of the PGPs earned incentive payments based on the estimated savings in Medicare expenditures for the patient population they serve. The groups received performance payments totaling $29.4 million as their share of the $36.2 million of savings generated for the Medicare Trust Funds in performance Year 5.

Reasons for the Savings

The PGPs attributed their savings to a number of factors:

• Organizational structure
• Investments in care management and care redesign
• More intensive diagnostic coding
• Changes in market conditions

Each PGP that achieved savings used different care management strategies that may spark ideas for other primary care groups moving towards ACO models and similar population health models.

• The Dartmouth-Hitchcock Clinic in Lebanon, NH, focused on evidence-based care initiatives, including better use of care alerts, changing workflow for support staff, and using nurse case managers to work with high-risk patients.
• St. John’s Clinic in Springfield, MO, used a comprehensive patient registry, care alerts at the point of care, a case manager in the emergency department to plan transitions of care, and a care team dedicated to patients with congestive heart failure.

Conclusions

RTI International, the company that analyzed the PGP pilot for the CMS, drew these lessons from the test, many tied to the use of technology-based solutions:

• Medicare patients often have several comorbidities that need to be treated simultaneously. Therefore, group practices must address the need for complex care management that goes beyond traditional disease management for single conditions.
• Complex care management could be enhanced by combining disease-specific patient registries, or by using registries that encompass all patients.
• Planned visits can be facilitated through the use of data systems (e.g., registries and electronic health records) that analyze data and provide physicians and other clinicians with pertinent information about the patient prior to a visit. A visit planner report may, for example, provide a list of overdue tests for a patient that could be performed prior to a visit.
• Key change opportunities include increasing patient engagement, expanding care management, improving care transitions, and expanding the role of nonphysician providers.

The groups that were part of the PDP pilot demonstrated that technology, such as patient registries, plays a major role when adopting a proactive approach to care management.

What’s Next

In future blog posts, we will build on these takeaways, and talk about how the combination of technology and automation can foster even greater strides in population health.

In discussions of care coordination, one may hear it described as the process of guiding patients across care settings or managing the care of patients with chronic diseases or trying to help patients reduce unnecessary readmissions. Actually, it’s all of these things and more.

Defining Care Coordination

The Agency for Healthcare Research and Quality (AHRQ), after consulting many sources, came up with this definition:

“Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.”

“Deliberate organization of patient care” or, in simpler terms planned care … whatever its specific application, coordinated care is planned care. And “planned” means something that goes beyond a doctor’s orders or treatment plan. Planned care requires an entire care team comprised of multiple providers and team members dedicated to the delivery of quality health care to their patient population.

Components of Care Coordination

The components of care coordination, according to AHRQ, include:

• Essential care tasks and responsibilities
• Assessment of a patient’s care coordination needs
• Development of a coordinated care plan
• Identification of team members responsible for coordination
• Information exchange across care interfaces
• Interventions that support care coordination
• Monitoring and adjustment of care
• Evaluation of outcomes, including identification of care coordination issues

Coordinating All Aspects of Patient Care

As healthcare organizations form ACOs and medical homes, they will be required to effectively coordinate all aspects of care across populations and care settings.

A March 2011 Commonwealth Fund consensus report on combining these approaches to health care reform observes that care coordination will be the linchpin of this transformation:

“The effective coordination of a patient’s health care services is a key component of high-quality, efficient care. It provides value to patients, professionals and the health care system by improving the quality, appropriateness, timeliness and efficiency of decision-making and care activities, thereby affecting the experience, quality and cost of health care.”

The Role of Health IT

The consensus report also emphasizes the role of health IT in care coordination, while asserting that much of today’s existing information technology is inadequate to the purpose:

“Anchoring the electronic health record (EHR) in the traditional visit-based care delivery model limits the potential of the medical home to generate paradigm-shifting care delivery transformation and the positive outcomes it promises. Health IT requires new functional capabilities, such as multiple team member access and permissions, care management workflow support, integrated personal health records, registry functionalities, clinical decision support, measurement of quality and efficiency, and robust reporting.”

The bulk of the technologies required to achieve these goals are already available. Among the reasons they’re not being properly deployed in most cases are these:

• Electronic health records are often not designed to fully support population health management initiatives or care coordination workflows.
• Registries tend to be focused on patients with particular conditions, rather than entire populations.
• Care management workflow support is still a relatively new concept and not widespread, but one that more and more groups are embracing.
• Some provider organizations lack the infrastructure to consume new technologies and transition to new processes.

Conclusion

Technology tools are being used to improve communications across care settings, especially during transitions of care. These range from traditional point-to-point interfaces to physician and patient web portals to secure electronic messaging. Even computer faxing has its place as the industry moves from paper to electronic documentation of care. The automated stratification of patients into different risk categories is also important to groups seeking to do population health management.

The effective coordination of a patient’s health care services is a key component of high-quality, efficient care. It provides value to patients, professionals and the health care system by improving the quality, appropriateness, timeliness and efficiency of decision-making and care activities, thereby affecting the experience, quality and cost of health care.

In the book, “Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience,” Virginia Mason Medical Center (VMMC) describes its Lean journey over the course of the last decade. One of Phytel’s clients, North Shore Physicians Group (NSPG), which is part of Partners HealthCare in Boston, has engaged the services of the Virginia Mason Institute to help apply the same Lean methodology (aka the Virginia Mason Production System) at NSPG’s primary care practices.

Applying Lean to Healthcare

This book is important for any organization that is wondering how Lean applies to healthcare (after all, the origins of Lean are in the Toyota Production System). Even if your organization is already in the process of implementing Lean or a similar total quality management (TQM) methodology, it is a very engaging read. It is written in narrative form — no “how–to” or value stream maps — and it really brings the Lean principles to life.

Incorporating Population Health Management

One chapter clearly stands out for me: ”Ambulatory Care Breakthrough” was compelling because I could connect what was in the book to what I observed when I visited NSPG’s flagship clinic in Danvers, MA to start collaborating with NSPG to incorporate our care management and population health solutions into their Lean workflows.

VMMC assembled a precursor to Phytel’s Outreach and population health solutions, starting with paper medical records, computerized billing systems and new roles for medical assistants and care managers as they work with patients who schedule appointments — but it has taken almost 10 years to develop.

Care Management Using Lean

We can use their example to help clients like NSPG implement care management in a manner consistent with Lean principles. However, by leveraging technology and adopting a total population perspective, our products go even beyond what VMMC describes they have done for primary care by engaging more patients more persistently to achieve true population health management.

We are hearing more and more these days about population health management and how provider organizations are increasing their focus on it. Provider organizations understand well how to manage individual patients when they come into the office. Physicians and other care team members strive to use each visit as an opportunity to communicate with their patients about their health, preventive care and follow-up treatment, taking into account each patient’s  needs and preferences. Patients respect their provider’s knowledge of research and standards of care and trust their judgment to recommend the right care plan for them. Why the surging interest in population health?

The current visit-centric model works when providers only have to keep track of and manage the patients who schedule a visit; however, when new payment models, such as pay-for-performance and capitation require providers to keep track of and manage every patient in their panel — their patient population — provider organizations need new sources of expertise and ways to scale their services beyond the visit encounter. Many provider organizations are rightly looking for population health expertise from prestigious and successful health maintenance organizations such as Kaiser and Geisinger. Other sources for population health expertise that provider groups may not have thought of right away are self-insured employers.

As I described in the first blog in this series, self-insured employers and provider groups that seek to be accountable care organizations (ACOs) share the goals of population management — and employers have been at this for about 20 years and have figured out the best practices that the most successful employers consistently apply.

The lessons learned from employers that have implemented successful population health programs are readily applicable to physician organizations preparing to transform themselves into patient-centered medical home (PCMH) models on the road to becoming effective ACOs.  The following table maps the employer best practices to the practice-based population health (PBPH) environment to illustrate the important parallels and common strategies.

Each of these “Employer Best Practices” deserves a dedicated discussion and blog entry to explain further how leading employers have created the infrastructure they need to identify, manage and engage employees to improve their health. In fact, if your organization has already become a certified PCMH or is in the process of doing so, these employer best practices may look familiar — and that’s because the PCMH (and the ACO, by extension) is based on population health principles.

In a population management culture, providers will let their patients know they will be identifying opportunities and resources to help them to be healthier all year long, not just when they come into the office or have an acute event. And, providers will create efficient and proactive care teams to support greater numbers of patients than they can today with manual processes, disparate sources of data, and limited staff.

Now, progressive employers are increasingly looking to partner with providers who adopt the same best practices and leverage the physician-patient relationship to achieve even better results than employers could on their own.  So, provider organizations with their eyes on ACOs, should take a closer look at what employers have demonstrated thus far.

Karen Handmaker is Director of Population Health Management at Phytel.

As group practices grapple with the paradigm shift to population health and ACOs, they would do well to heed the lessons learned by large employers that have been practicing a form of population health management for years. For a self-insured corporation with thousands of employees, the patient population consists of all those employees and their dependents. To the extent that companies can prevent these people from getting sick or help them control their conditions, they can lower their healthcare spending and improve their workers’ productivity.

Interestingly, ACOs have the same motivations to embrace population health as employers do:

1. Financial Accountability. Employers, as self-insured plans are responsible for the healthcare costs of their employees and dependents; ACOs will be financially accountable for their patients through contractual arrangements with payers.
2. Risk Management. Employers and ACOs both understand that today’s unmanaged health risks can become the high cost cases of tomorrow without effective health programs in place today.
3. Member Engagement. Employers invest heavily in engagement strategies to increase employee loyalty and retention, making participation in health management programs more successful.  ACOs will adopt similar tactics to build “stickiness” with all of their assigned patients.

Many employers started down the path to total population health management with programs targeted towards employees who are already sick.  Employers have implemented these “disease management” programs over the past decade to minimize costs and improve compliance with evidence-based care standards among individuals already diagnosed with common chronic conditions such as diabetes, heart failure and asthma.  According to the National Business Group on Health (NBGH), 72 percent of big employers are investing in this $2.5 billion-a-year industry, up from 67 percent in 2008. Although the programs have been broadened to include a wider range of conditions, disease management programs still touch only those who have been diagnosed, and the most intense interventions are focused on the “sickest of the sick.” Employers have recognized that disease management programs alone do not equate to a population health approach, because these programs do nothing to prevent or mitigate the causes of chronic conditions in the first place.

Now, in addition to disease management, many companies are increasingly emphasizing wellness and health promotion, which promise to deal with what they see as the number one driver of health spending: poor health behavior by their employees and dependents. Once a relative rarity, wellness programs are now embraced by most large employers and round out total population health strategies that address health needs across the continuum of care. Nearly half of employers purchase specialty programs to alter lifestyles and health behavior, and the majority of companies offer smoking cessation and weight management programs, according to a 2010 survey by the NBGH. Thirty-nine percent of employers consider wellness programs to be their first or second most effective strategy for controlling health costs.

Companies with effective and comprehensive population management strategies have demonstrated lower health costs, higher productivity, and higher profitability.  Companies that achieve the best results use a combination of tactics to drive participation in health management programs, including financial incentives, creative marketing and automated communications, onsite health clinics and coaches, as well as online education and self-management tools.  ACOs preparing to achieve their twin goals of cost savings and high quality outcomes will be able to apply many employer strategies to their delivery model.

One advantage that ACOs may have, however, over employers is the ability to leverage the patient-physician relationship to encourage participation and positive behavior change.   Despite employers’ longstanding experience with population health, they have failed to integrate effectively with the patient’s most trusted health advisor, his or her personal physician.  In fact, progressive employers are looking to ACOs to take population health to the next level by bringing the physician to the center of the equation.

Karen Handmaker is the Director of Population Health Management at Phytel.