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:Reactive andVolume-based

The Future:Proactive andValue-based

Drivers

Health Reform

Affordability Gap

Triple Aim

Weight of the Nation

Reimbursement

Encourageme!

Educateme!

Treatme

holistically!!

I will payyou!

Individuals are accountable for their health with the health system as their health advocate.

Population health management

provides comprehensive

authoritative strategies for

improving the systems and

policies that affect

health care quality, access,

and outcomes, ultimately

improving the health

of an entire population

Engaged Communities

• Proactive care processes

• Identified patients

• Focused on wellness

• Community resource navigator

Engaged Patients

• Identified and incorporated

patient goals

• Focused on continuity and

coordination

• Facilitated communication

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

Achieving SuccessMaking the “Triple Aim” Possible

Better Health for the

Population

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.

Member Engagement

Cross-Continuum Care Delivery and Medical / Care Management

Quality Outcomes Management / Reporting

Operational Performance Management and BI

Accounting

Integration and Infrastructure

ASSESS STRATIFYPopulation Identification Health Assessment Risk Stratification Enrollment / Engagement Strategies Management / Interventions

1DEFINE

2 3 4ENGAGE

5MANAGE

Tailored Interventions—

Care Coordination—

Disease / Case Management—

Health Risk Management—

Health Promotion / Wellness

Meeting patients where they are

…physicallyhome | school | work | shopping | in the clinic

…in the way that works best for thememail | text | internet | phone | video | face-to-face

Population Health Process

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?