Population Health History, Acronyms and the Future Peter Koopman. MD FAAFP Associate Professor University of Missouri Family Medicine
Learning Goals • Understand the history of population health and pay for value. • Acknowledge Family Medicine’s contribution to that history. • Recognize the recent government rules that will move payment toward this model and away from pay for volume. • List at least two best practices to succeed in this payment system
History • Generalist Physicians have always felt connected to their community and worked for community. • In Early 1900s specialty doctors who focused on an area of the body or knowledge became more needed/popular. • 1934 American Board of Medical Specialties formed and by 1949 nineteen medical specialties had been certified. All still exist. • Through 1950s the prominence of medical specialties gained more power and prominence in health care. • Medicare became law 1965 • 1969 in part to recognize the importance of a general medical physician Family Medicine became a recognized specialty
History • Payment in 1930-50s driven by specialists and hospitals was to pay physicians based on pay for visit /procedure or volume. No recognition of health of patient or costs to system. So the more you do the more $ you got. • By 1969 at onset of our specialty, Family Medicine leaders realized payment for visits/procedures worked poorly for many Generalist Physicians. Also many in this field felt this payment process did not represent our values • Attempts to move system were unsuccessful such as RBRVS, Primary Care E+M Codes
History • Family Medicine in 1990 began to champion concept of Patient Centered Medical Home PCMH. • Data evaluated in 90s strongly showed more “Primary Care” improved health outcomes/cost. • Trials began to occur to see if health outcomes were improved and costs decreased. Some were successful. Medicare and others began small pay for value components. • Obama administration introduced the Affordable Care Act-ACA in 2009 and at least to some degree recognized the relevance of a primary care base
History • MACRA introduced bipartisan 2015 • Has a component called MIPS-Merit based Incentive Payment system that will give bonus or penalty based on health population performance starting in 2019 • Also APS-Advanced Alternative Payment Systems- Define specific goals or outcomes for conditions and involve shared risk. • Family Medicine has in last 5 years championed Triple Aim: Better Outcomes, Improved Patient Satisfaction, Reduced Costs.
Population Health Management (PHM) The Future of Healthcare Paradigm Shift Today: The Future: Reactive and Proactive and Volume-based Value-based Drivers Encourage me! Treat Educate me me! holistically!! I will pay Health Reform Population health management you! provides comprehensive Affordability Gap authoritative strategies for Triple Aim improving the systems and Weight of the Nation policies that affect health care quality, access, Reimbursement and outcomes, ultimately improving the health of an entire population Individuals are accountable for their health with the health system as their health advocate.
Achieving Success Making the “Triple Aim” Possible Engaged Communities Engaged Patients • Proactive care processes • Identified and incorporated • Identified patients patient goals • Focused on wellness • Focused on continuity and • Community resource navigator coordination Better Health • Facilitated communication for the Population channels • Improved access to care Identified Opportunities to Reduce Waste • 4 Rights • Duplication avoided • Improved coordination/transitions • Used automation to reduce resource needs • Improved screening and prevention • Aligned incentives to drive value 8
Population Health Management (PHM) Core Competencies The goal of population health is to transform care delivery practices and administrative support to deliver improved outcomes and lower costs across the continuum of care for a specified population. Success will depend on changes in care practices, business processes and cross-organizational communications, all supported by information technology. Operational Performance Member Engagement Management and BI Cross-Continuum Care Delivery and Medical / Care Accounting Management Quality Outcomes Integration and Infrastructure Management / Reporting
Population Health Process 1 2 3 4 5 DEFINE ASSESS STRATIFY ENGAGE MANAGE Population Identification Health Assessment Risk Stratification Enrollment / Engagement Strategies Management / Interventions Tailored Interventions — Care Coordination — Disease / Case Management — Health Risk Management — Health Promotion / Wellness Meeting patients where they are …physically home | school | work | shopping | in the clinic …in the way that works best for them email | text | internet | phone | video | face-to-face
YESTERDAY: CLAIMS-BASED PREDICTIVE MODELS For years, healthcare insurance companies (payers) have mined claims data for chronic patients and have built predictive models to identify high-risk patients. While this approach has seen some success, limitations far outweigh merits. Data used by payers to flag high risk patients is historical claims data — primarily costs, admissions, and diagnoses. Furthermore, regression and time series risk models are typically updated only annually.
Most physicians are highly skeptical of claims based predictive models because they have no clinical basis, and give no consideration to an individual's current state of health. Moreover, there is a complete lack of causation, "Why is a patient considered high-risk? What are the clinical reasons for the score? How do we lower the patient's risk score? How does the score measure the effectiveness of my care management program?“ http://healthcarecostmonitor.thehastingscenter.org/kimberlyswartz/projected-costs-ofchronic- diseases/ http://www.ahrq.gov/research/ria19/expendria.htm
FURTHER CONSIDERATIONS Current thinking and efforts create a disproportionate focus on existing chronic patients. A better approach is to monitor all patients, healthy and chronic, for risk of hospitalizations. Unfortunately, current claims-based predictive risk models allow no room for this approach.
VITAL PROGRESS Today, most large physician groups and medical homes already use at least a basic EHR system. CMS predicts that by 2014, more than fifty percent of all eligible medical professionals in the U.S. will use EHR. This is a transformational shift, because for the first time in history, clinical information is digitally available in real time, with reasonable availability of laboratory results and patient vital data.
CLOSED-LOOP CMP Using real-time clinical data from EHR records, health care providers now have the capacity to design a closed- loop population care management program (Figure 1). A well-designed program delivers primary care to drive higher quality, reduce costs, and deliver greater value in health care.
5 Key Best Practices • Hire Appropriately-Care Coordination, IT savvy • Introduce new processes- Hand-offs, Team based care, Patient education, Consistent management/monitoring of Chronic issues/prevention • Manage Technology and Data-Need IT support. Nurses/others need to enter data
5 Key Best Practices • Ongoing Training and Support- Scheduled and planned • Create a Sustainable Program- Start with strengths. See bonuses and support growth.
Conclusions • In large part due to Family Medicine and Primary Care our system has developed rules to pay for Population Management or value. • Although complicated it does support our specialty’s values. • Doctors offices need to remain vigilant and flexible to succeed in doing this well.
Questions to Discuss • ? Am I doing this. Do I want to? • ? What are limitations to this model? • ? Is this feasible?
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