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summer 2017 | volume 9

Achieving Success in Population Health

Management

Note to Readers

Across the first few years of the recent shift to population health, the most common questions we received centered on how to start the transition to value-based care. Since then, population health pioneers have made early gains in quality improvement and cost management by investing in “no-regret” strategies that have a positive impact in both fee-for-service and value-based care scenarios.

In today’s rapidly changing landscape, leading population health managers have capitalized on those early gains to accelerate change across their organizations. Seeking to learn from the successful pioneers, our members frequently ask us: “Why have these organizations been successful? How do they determine their focus areas? How do they measure ROI? What lessons can we learn from their experience?”

Accordingly, we’ve compiled some of the most popular posts from our blog—The Care Transformation Center—to share our latest thoughts on achieving success under population health management. In this publication, you’ll find insights for every stage of care transformation, including:

• Early targets for care transformation gains

• Answers to frequently asked questions on care management and risk assessments

• A framework to measure progress

• A CEO’s candid reflections on succeeding in population health management

For more insights, sign up for our Care Transformation Center email alerts at advisory.com/ctc.

Best regards,

Tomi OgundimuPractice ManagerPopulation Health Advisor

Dennis WeaverExecutive Vice President and Chief Medical OfficerAdvisory Board

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table of contents

4 How do you stack up on population health readiness?

6 Your top three population health questions—answered

8 Our advice for investing in population health management

10 Four referral network solutions that can have a big impact

12 Managing risk can be straightforward with these three steps

16 Three pitfalls to avoid when assessing patient risk

18 Staff for care management today, without financial regrets later

20 Who really influences a population’s health? (Hint: It’s not just providers.)

22 Prove it to your C-suite: Three tips for measuring progress on community health

24 ‘The truth is, it takes a long time’: One chief executive on successful population health management

WHO REALLY INFLUENCES A POPULATION’S HEALTH? | 20

Health systems need to work with organizations that drive health determinants in the community, while influencing individual behavior.

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A CHIEF EXECUTIVE’S POPULATION HEALTH MANAGEMENT SUCCESS | 24

How do I measure success? Population health management doesn’t lead to immediate gains. True population health management requires time and discipline for success.

POPULATION HEALTH READINESS | 4

Are you ready for population health? While there’s no such thing as a linear path to population health success, there are key milestones that allow organizations to chart their progress.

2 | Expert Perspectives

Featured Writers

This issue’s contributing experts

Within Advisory Board Consulting and Solutions, Dennis leads an enterprise-wide team focused on critical health care issues, including accountable payment, value-based care, and physician alignment models.

Dennis Weaver, MD, MBA

Executive Vice President and Chief Medical Officer

[email protected]

Tomi Ogundimu, MPH

Practice Manager

[email protected]

As the practice manager of Population Health Advisor, Tomi leads research on care management and care delivery transformation, arming decision makers with insights necessary to inform implementation initiatives.

Within Advisory Board Consulting, John leads the Clinovations team in electronic health record (EHR) implementation, EHR optimization, and population health/value-based operations efforts.

John Kontor, MD

Executive Vice President

[email protected]

As a national partner at Advisory Board, John leads a team of consultants and works with hospitals and health systems to improve their strategic direction, operational efficiency, and financial performance.

John Johnston, CPA, MHA

National Partner

[email protected]

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As the managing director for Population Health Advisor and Health Plan Advisory Council, Megan works with population health and care transformation leaders on a wide range of topics, including population health network development and patient engagement.

Megan Clark

Managing Director

[email protected]

As managing partner at Advisory Board, Eric works with the 100 largest health systems in the United States, serving as a strategic advisor to CEOs and their leadership teams.

Eric Larsen

Managing Partner

[email protected]

Hunter Sinclair, MBA

Senior Director

[email protected]

Specializing in ACOs and other payment model innovations, Hunter provides quantitative and qualitative guidance to organizations navigating the transition from volume-based to value-based health care.

As a senior consultant, Rebecca manages research for Population Health Advisor on care management redesign, primary care innovation, and community partnerships.

Rebecca Tyrrell, MS

Senior Consultant

[email protected]

As a senior consultant, Tracy manages research for Population Health Advisor on behavioral health development and telehealth strategies.

Tracy Walsh, MPH

Senior Consultant

[email protected]


DENNIS WEAVER, MD, MBA

How do you stack up on population health readiness?

Though hospital and health system leaders continue to make investments in population health management around the world, many struggle to articulate and quantify their progress. Leaders wrestle with questions like how the mix of investments matches up to their risk profile, if their strategy is right for the market, what the ROI is across efforts, or how their overall approach compares to similar organizations.

But while there’s no such thing as a linear path to value-based care success, there are iterative milestones that allow organizations to plot themselves along a spectrum.

Four stages of maturity

Recently, we surveyed leaders from over 30 health systems to help them with this exact challenge. The respondents ranged from those just getting started to those who are fully submerged in value-based care delivery. Respondents were primarily from larger, integrated delivery systems, representing urban and rural markets in 29 states.

We mapped the organizations across four broad stages of maturity, based on

an Advisory Board segmentation model that was designed using industry research on population health management. (The model has five stages, but we left out “The Skeptic” for the purpose of this discussion. From left to right below, the stages move from least advanced to most advanced.)

I’ll start by sharing one of the most obvious hallmarks of maturity—the implementation of risk-based contracts. Here’s a snapshot of what we found to be common within each stage:

THE INTENDER THE BUILDER THE ADVANCER THE COMMITTED

At-Risk Contracts

1 2.8 4.2 6.2

Lives Under At-Risk Contracts

≈35K ≈50K ≈125K ≈250K

% Patients Under Total Cost of Care Contracts

0%–20% 10%–40% 40%–50% >50%

Downside Risk? Upside onlySome

downside risk

Increasing levels of

downside risk

All had downside risk, most had

capitation

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For more on this topic, visit: advisory.com/pha

In looking at these averages, you might have the urge to place your organization into one of the four stages based on your portfolio of contracts. But to truly understand population health maturity, you have to dig a few levels deeper and also account for factors such as:

Market positioning

Care management infrastructure

IT integration

Financial management

Network adequacy

Our survey analysis and segmentation exercise was informed by all of the above factors, with the goal of pinpointing the most striking areas of strength and weakness across the board.

Four key takeaways

Collectively, we found that organizations are fairly confident in the sufficiency of their doctor networks and their ability to identify gaps in care and move the needle on quality.

However, most organizations feel weaker on things like in-network utilization and expanding care management capabilities to include behavioral health and non-clinical resources. And while organizations are mostly confident in their ability to measure traditional financial performance, many are unsure of how to build a pro forma for value-based care—which gives a full picture of the financial impact, including market share gains and efficiency improvements, for a cumulative economic projection.

We all know there’s a lot to get a handle on for success under value-based care. But overall, here’s what we found that separates the most advanced organizations from the rest:

They make investments in capabilities and network assets to match their risk profile

They have a highly-engaged doctor network with an aligned compensation model

They have strong post-acute partnerships, and also offer non-clinical patient resources

They leverage system-wide technology to analyze in-network utilization, and report on cost and quality

We recognize that organizations have different end states, with some driving towards population health leadership in their market and others preferring a more targeted strategy. Wherever you fall along the stages of maturity, the primary goal is to keep a healthy balance of risk to assets. Providers should not take on value-based care contracts without the capabilities to make them successful; alternatively, they also should not invest significantly in underlying assets while still stuck in a fee-for-service world.

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1How far along are most health systems on this journey?

To set some context, we tend to see that organizations fall within five population health profiles: the skeptic, the intender, the builder, the advancer, and the committed. The most successful health systems set a solid foundation by investing in fundamentals before advancing to the next stage. That said, there are only a handful of what we call “committed” organizations, with over half of their business in

risk-based contracting. There are also still a fair number of organizations that are skeptical of the transition.

Based on a poll of recent webconference participants, the majority of the organizations that have started down the path are in “intender” and “builder” categories—they’re testing the waters with plans to grow.

MEGAN CLARK

I recently had the opportunity to talk with two of Advisory Board’s leading experts on population health management, Dennis Weaver, MD, MBA, and Lisa Bielamowicz, MD. Here’s what they had to say on navigating the path to population health management and how organizations can measure their return on investment.

Your top three population health questions—answered

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How should I evaluate my progress?

How are organizations measuring return on investment?

There are five key areas to evaluate the milestones of the transition path:

Network: Is there a clear value proposition for staying within the system or clinically-integrated network? And how do you communicate that to patients and employers?

Care model: Is there unnecessary variation in clinical practices across providers, and therefore little control of costs or outcomes?

Technology: Do you have the tools to identify which initiatives are working, which are not, and prioritize upcoming strategies based on that data?

Strategic operations: What do you do centrally and what do you do locally?

Financial performance: How much risk are you going to take on and how quickly?

While it’s critical to measure the impact of shared savings and value-based care contracts, there are three other things every organization should look at to measure ROI in the transition: access, clinical standardization, and network integrity.

Let’s talk about patient access first. One physician network in the Northeast made a commitment to offer appointments within 24 hours, and phone visits within two hours—and they increased their panel by 20%. Expanding access by making sure patients can get in the door quickly, mapping your services with the geography of patients, and positioning yourself favorably for large employers is good no matter what your risk portfolio looks like.

The same is true for clinical variation. Many struggle with clinical variability not just across the health system but across their clinically-integrated network, and that impacts quality and efficiency in a major way. Although we’d all love to get to the 90th percentile when it comes to reducing variation, we’ve seen tremendous returns at the 50th percentile as well.

And we can’t stress how important “keepage” is and building pathways for patients to stay in the network. Even for small systems, this can have a big impact on cost, quality, and productivity.



Our advice for investing inpopulation health management

TOMI OGUNDIMU, MPH

Provider organizations getting started in their care transformation efforts have told us they are focused on population health investments in three areas: workforce, analytics, and partnership network development.

To capitalize on these investments, providers must now focus on implementation. This means answering three questions:

1. Which staff do I need on the care team to manage complex patients?

2. How can I effectively use different types of health IT to reach targeted population health goals?

3. Who can I partner with outside my organization to ensure my patients receive high-quality, low-cost care when they are not actively using the system?

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You’ve likely been focused on the care team for years. However, many organizations haven’t pushed the model far enough.

Pharmacists: Medication therapy remains a top avoidable cost opportunity for most organizations. While providers are increasingly carving out a role for pharmacists on inpatient care teams, many have yet to integrate pharmacists into the primary care team. Whether implementing a small pilot to test medication therapy management for complex patients or developing a protocol for consults with

clinical pharmacists, extending pharmacist support into primary care should be a key focus area in the future.

Medical assistants: Providers can also reconsider the role of medical assistants in care management. Providers must support select MAs through comprehensive training programs that focus on new skills in chronic disease and self-management support. Next, organizations will need to better match opportunities for professional growth and MA compensation levels to new responsibilities.

Re-envision team-based care by further expanding staff roles in primary care 1

Analytics has been a key investment to help providers prioritize patient interventions. However, as organizations implement these interventions, workflow management and telemonitoring tools will be crucial assets to improve management of at-risk populations.

Progressive population health managers implement software to support care management workflow. Such software focuses on coordinating care beyond the electronic patient record, integrating patient information from multiple data sources to

streamline documentation, and providing care managers with prompts of what next steps should be.

Remote monitoring is another prime target for health IT implementation, as several pilot programs have proven successful for preventing readmissions among very targeted high-risk patients. To scale remote monitoring in the future, you must integrate telemonitoring into an organization’s overall care management efforts, rather than pursue a disease-by-disease strategy.

Use health IT to scale coordination between and among care management teams2

Post-acute services continue to drive substantial cost variations for organizations looking to manage avoidable spending. Although providers must build a comprehensive network, partnering with and managing the transition to post-acute care must be a key care redesign initiative.

The first step is to understand local post-acute care providers’ current performance. These results can help develop a preliminary list of “preferred partners”.

Actively partner with post-acute care providers on cost, quality, and care coordination3



Four referral network solutions that can have a big impact

HUNTER SINCLAIR, MBA

Building a high-performance referral network on paper is relatively easy compared with building one that actually works in practice. I often work with organizations that have spent months or even years building a referral network that appears to have the right components on paper, but their referral volumes continue to decline.

More often than not, the problem is that these organizations have overlooked small but impactful operational issues that are necessary to get patients from Point A to Point B. In fact, our research finds that over 40% of patient outmigration is caused by operational issues in the referral process. Making just a few changes to your referral strategy can have a huge impact on the number of patients that stay in-network and on the quality of care they receive.

Here are four best practice solutions I suggest for a high-impact approach to improving referral management:

In a perfect world, your entire network would operate on one EHR—but this is rarely the case. In fact, the majority of organizations I’ve worked with over the past eight years have multiple EHRs within their network. This creates a huge communication barrier between practices, not to mention an unnecessary number of steps for the patient just to schedule their referral appointment and transfer their patient data from one practice to another.

The fix: Implement an EHR-agnostic referral workflow platform. By having a single platform that lies on top of all existing EHRs, providers can easily communicate with one another and even send clinical data along with referrals to support better care coordination.

For example, Meridian Health Partners (MHP) had a clinically integrated network of 119 practices operating on 30 different EHRs. This hindered their ability to track referral movement through the network and limited information exchange between providers. Since implementing an EHR-agnostic referrals workflow solution across all of their practices, MHP has been able to reduce referral outmigration and decrease the turnaround time needed to process referrals.

Support interoperability across EHRs to improve patient care coordination

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Accommodate patient preference to build loyalty

We've learned a lot during the era of consumerism—including that it's all about the patient. To keep patients in network and bring new ones in, you need to accommodate their preferences.

Most patients choose their provider based on convenience factors such as geography, insurance, language, and availability. When paired with a "best match" provider that accommodates these preferences, patients are more likely to keep their appointments. And further, they're more likely to come back to the system that made the referral.

The fix: Make sure your provider database includes easy-to-access information on hours, insurance, location, and other specifics for a wide range of high-value providers, practices, ancillary providers, imaging centers, labs, and post-acute providers that are both inside and outside of your primary network.

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Make it as easy as possible for community providers to refer patients to your network

I hear all the time from community providers that they are put-off from referring into large health systems because the process is complex, time-consuming, and different for each type of specialist. If they do decide to go through the process, it could be weeks or even months before the patient is seen by a specialist.

With so many unnecessary hoops to jump through, many providers choose not to refer into the larger system altogether and send their patients elsewhere—which may or may not be in the best interest of the patient.

The fix: In addition to eliminating antiquated referral processes—like faxes that are hard to track and follow-up on—make sure your organization has a streamlined workflow process in your referral platform. Key capabilities should include provider-to-provider scheduling for referral appointments and synced scheduling across physician offices.

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Track referral data to reveal where you need to make changes to your network

Tracking referral data is often the most underestimated and impactful component of a high-performing network because of the actionable insights that can be gained.

For instance, Pocono Medical Center uses their referral data to identify underserved specialties. They have been able to close critical gaps in their network by hiring new providers to expand coverage for neurology, behavioral health, pain management, and rheumatology.

The fix: If you aren't already, make sure you're capturing referral data on volume, reason for sending a referral out-of-network, data on downstream referrals, and patient no-shows to paint a complete picture of your organization’s referral network and where you have gaps that need to be addressed.

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Managing risk can be straightforward with these three steps

JOHN KONTOR, MD

Providers are under significant pressure to prepare for and participate in risk-based payment models. More and more patients will be covered by Medicare Advantage and cared for by providers participating in Medicare ACOs.

We’ll also see increased participation in Alternative Payment Models (APMs) such as CPC+. And if the current federal approach persists, providers will feel the impact of MACRA—even for their populations that aren’t at risk.

For many providers, the idea of taking on risk is scary and complicated. But in our work helping health systems across the country optimize their EHRs to better manage risk, we’ve found that managing risk can be quite straightforward if you can do three things well:

Document (and get credit for) the care already being provided to at-risk populations

Identify the unrecognized risk within your patient population through proactive care management

Hardwire chronic care management for at-risk populations

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Document (and get credit for) the care already being provided to at-risk populations

Step 1

I almost always recommend that health systems jumpstart their entire risk management strategy by focusing on improving the accuracy of their hierarchical condition categories (HCC) documentation. For those unfamiliar with HCCs, they are the mechanism used by Medicare and some commercial payers to determine patients' risk adjustment factor (RAF) scores based on their demographics and chronic conditions.

Accurate HCC capture can inflect everything from care quality to greater reimbursement. It is typically a low impact and scalable initiative to get off the ground, and health systems can use any additional revenue from HCC documentation to fund other components of their long-term risk strategy.

The best way to improve the accuracy of risk documentation is by optimizing a tool nearly all providers already use—the EHR. I'll share an example of this in action.

At one of our health system clients in the Northeast, a patient was going into pre-op for a surgery when the physician received HCC alert in the EHR. The alert informed the physician of an aneurysm the patient had years ago. Though this physician had never treated the patient for the aneurysm, and was previously unaware of it, the HCC alert enabled the physician to adjust the patient's care plan to account for the aneurysm moving forward.


Trying to manage a population's care gaps without first identifying the full burden of chronic illnesses is like checking the box without reading the fine print. You can have a million-mile view of your population's relative health and risks, but actually managing patient care over the long term will be difficult without a clear understanding of the individual patients' health challenges.

One way to identify underlying patient risk is through the Annual Wellness Visit (AWV). AWVs are visits covered by Medicare during which providers perform a health-risk assessment and discuss a

Identify the unrecognized risk within your patient population through proactive care management

Step 2

patient's preventative services for the coming year. This brings patients into the physician's office on a regular basis, where a provider can address any of the patients' chronic conditions and identify and monitor other at-risk conditions.

Once patients come in for the AWV and their conditions are identified, it's important to accurately document that risk. This is another reason I recommend health systems tackle improving documentation accuracy first, so when they proactively bring patients in for their AWV, the documentation solution is up and running.

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Mechanisms like HCC capture and AWVs are designed to be checked off on a yearly basis to support how Medicare calculates RAF scores for reimbursement. Each year's payment rates are based on the prior year's performance, and HCCs must be documented every year to contribute to total RAF.

The ultimate objective, though, is not about enhancing RAF capture. The focus is on enhancing patient care by consistently managing chronic conditions, and to truly master chronic care management, providers must use EHR-enabled HCC capture, AWV capture, and other tools to proactively identify and treat the highest risk patients within a population. That means developing an infrastructure that supports risk stratification of an entire population, and helps providers prioritize patients based on the highest risk and unmanaged burden of care.

Hardwire chronic care management for at-risk populations

Step 3

Taking a data-driven approach to monitoring and managing patients with the highest disease burden is a foreign process to many providers, but it can drive value. For example, my team builds a series of high risk targeting reports that help providers identify and treat patients who may be missing diagnoses for chronic conditions.

One of those reports specifically identifies patients who are on oxygen but don't have any recorded conditions that would justify that treatment. With the report, providers can prioritize outreach to these patients to schedule follow up visits as necessary to correctly diagnose and document care gaps.

But technology is not adequate by itself; there are never enough discrete data in the records, and natural language processing systems aren't sophisticated enough to be highly accurate. We still need clinicians to review charts, and they are a much scarcer resource. The right technology just helps us to efficiently leverage this resource to make the most of their efforts.

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Three pitfalls to avoid when assessing patient risk

TRACY WALSH, MPH

Most population health managers already know that prioritizing patients by risk is a critical component of effective care management. So why is it so difficult to segment patients into “high,” “moderate,” and “low” risk categories?

There are several risk stratification tools that hospitals use to assess patient risk, but in many cases, care managers fall prey to three common missteps when developing and selecting the questions they ask.

The term “patient risk” begs the question, “At risk for what?” Risk can mean different things to different people. The first step to improving patient risk segmentation is tying the assessment tool a specific purpose, be that avoiding preventable readmissions, mitigating unnecessary ED utilization, or reducing mortality rates.

Next, a patient risk assessment should predict patient outcomes. In many cases, the relationship between risk factors and clinical outcomes is not always clear. There are still significant gaps in the literature, particularly when it comes to information on the interactions between different risk factors.

Identifying true patient risk, especially for the moderate- to low-risk patients, requires a multidimensional assessment. Beyond severity of clinical diagnoses and symptoms, organizations should incorporate non-clinical factors into risk assessments to determine the root cause of risk. These non-clinical factors may include psychosocial or demographic indicators, like transportation access or housing stability.

To avoid this pitfall: Clarify the scope of the tool in terms of the type of risk being assessed, targeted patient populations, and desired health outcomes.

1The assessment tool isn’t accurate

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A comprehensive risk assessment tool does not necessarily ask patients about every facet of their lives. Exhaustive risk assessments are resource-intensive, may frustrate staff and patients, and often result in complicated or unwieldy outputs.

Best practice assessment tools consist of 30 questions or fewer and can easily be administered across care settings. Likewise, these tools should only include indicators that are easily observable or verifiable through discussion with the patient or caregiver. The results of the assessment should be easy for providers to interpret, and should clearly delineate participants into a particular risk category.

To avoid this pitfall: Get frontline staff involved early and often by soliciting staff input and feedback to evaluate the tool’s relevance, reliability, and ease of use.

2The assessment tool isn’t user-friendly

Identifying a patient’s risk is only the first step. To better manage patient populations, a risk assessment tool should be directly linked to targeted, evidence-based intervention. For example, a particular risk designation may be used to connect patients to existing resources, identify gaps in current practices, or inform the development of new programming.

Lastly, patient risk segmentation is not a static process. Providers should be able to track the tool’s predictability to see if it is effectively improving patient outcomes over time. Population health managers and care management teams therefore benefit from embedding performance management and quality improvement processes when applying patient assessment tools.

To avoid this pitfall: Ask the right types of questions by including clinical, demographic, and psychosocial criteria.

3The assessment tool is too broad and isn’t goal-oriented



Seek budget-neutral investments

Although we know that investing in care management is a top priority for most hospitals, the reality is there's rarely enough in the budget to cover the costs. The good news, especially for finance leaders, is that many of the top-performing programs have achieved success not by adding many more FTEs, but by transitioning existing staff to more flexible roles.

For example, one community health system is seeking to increase the number of emergency department (ED) case managers at one of its facilities. This organization recently evaluated the processes and efficiency of the centralized UR function and found

Staff for care management today, without financial regrets later

JOHN JOHNSTON, CPA, MHA

The traditional, inpatient-oriented model of case management, discharge planning, social services, and utilization review (UR) does not cut it anymore—because practically every new payment model is designed to place providers at risk for patient outcomes across the entire episode of care.

In addition to carrying inpatient-oriented resources, hospitals are now compelled to invest in new care management staff, often housed outside the hospital with a focus on coordinating care across the continuum. But accounting for productivity and ROI of a more complex staff and—more important—operationalizing these workforce “assets” in a coordinated manner pose new challenges for hospital leaders.

Hospitals can ensure that appropriate results are achieved, and sidestep some avoidable and costly hiring mistakes, by taking the following strategic steps along the care management road.

opportunities to reduce the group's staffing levels. Because these nurses already have a baseline skill set that can be easily transferred to an ED case management role, the plan is to move four nursing staff members from the centralized UR team to the ED case management function.

The health system also understood that such redeployment cannot succeed without focused and ongoing training to help staff build new competencies and skills, and the implementation of new documentation workflows, metrics, and reports to measure success.

By creating a flexible, budget-neutral workforce instead of going out on a hiring spree to staff the ED, this health system is

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demonstrating best practice from both a financial and clinical standpoint—but only as long as all previous responsibilities are properly backfilled amid any reduction in excess FTEs.

Audit the care management staffing model

Once the care management staff is in place—through redeployment or an investment in new staff—it's important to look across the acute care, post-acute care, and clinical network to ensure that staff members are positioned for optimum effectiveness.

Consider another recent example. Over the past two years, a health system in the northeast hired more than 50 new care managers to help deploy care management functions across its network. Some were housed in physician practices, some in a medical home, some in the accountable care organization, and a couple in the post-acute care division. The care managers were all recruited to fill similar positions, but a formal review of the care management program found major inconsistencies across the roles—in job descriptions, backgrounds and skills, responsibilities, and performance metrics. Furthermore, the care management models, developed at each facility, were not coordinated centrally, which resulted in conflicting methodologies and gaps in overall care management processes and objectives. It was a classic example of what happens when planning takes place at the senior executive level while execution takes place in organizational "silos."

Five essential questions confront this particular health system, and others that find themselves in the same boat:

How do we centralize both care management functional assignments and tracking of performance and productivity?

Do we have the right number of care management staff overall, and are they deployed appropriately at each site and across all facilities?

Is there an appropriate skill mix between clinical and nonclinical personnel?

Do we have an overarching care management model to control how methodologies are deployed in each area of the health system?

Do we understand how our investments are affecting management of high-risk patients and chronic conditions—and the extent to which they are helping us to avoid unnecessary readmissions?

The need for a strong, centrally managed, and continuum-wide care management structure is only becoming more pressing. To respond effectively to the demands of bundled payments, value-based purchasing, Medicare readmission penalties, and narrow networks, providers must coordinate across physician practices, medical homes, hospitals, and post-acute care providers, which will pose a challenge from a staffing standpoint.

Labor may be the biggest and most controllable cost for many hospitals, but hospital leaders will require keen insight and a deeper level of acumen to manage staff effectively as staffing priorities shift away from the acute care setting to support a more complex care management agenda.


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20 | Expert Perspectives 20 | Expert Perspectives

Who really influences a population’s health?(Hint: It’s not just providers.)

DENNIS WEAVER, MD, MBA

At its most basic, population health management means actively working to keep your community healthy. When you think about it that way, it makes you wonder, “Who or what is influencing the health of individuals in my community the most?”

To date, population health strategy has focused mainly on the role health care providers themselves play as the main influencers of health outcomes. And health care providers are certainly important. But the reality is that we are not the only ones influencing the health status of the people we serve.

In my own middle Tennessee community, we are surrounded by the savory smell of food that is deep fried and covered with gravy—delicious, but less than ideal for cardiovascular health. A short plane flight away, my colleagues in Washington, D.C., spend an average of 70 hours each year in the nation’s worst traffic, which is one of the main reasons Forbes ranked D.C. the fourth most-stressed city in the U.S.—and as we all know by now, stress is linked to a host of chronic and acute diseases.

These types of socioeconomic factors play a major role in maintaining or preventing good health, but they are all too often ignored when health systems are considering their population health management strategy. Typically, health systems see non-medical determinants of health as outside their purview. But they don’t have to be.

Partner with non-provider influencers

In our research for health system CEOs this year, we have been emphasizing the urgency of focusing on network development. Health systems need to be building a network with the scale, scope, and assets needed to realize their vision for population health and to achieve profitable growth.

Many health systems will need to partner with other types of providers—retail, ambulatory, acute, and post-acute—to accomplish this, especially if the system’s goal is to build a regional or super-regional, state-wide network. But if you really think about the basic objective of population health management, partnering with health care providers is not going to be enough.

Systems will need to engage with organizations that impact the health determinants in your community and influence individuals’ behavior when they’re between provider visits. A few examples of these organizations are religious entities promoting health behaviors, transportation companies facilitating access, the housing authority optimizing living arrangements, gyms and workout facilities, restaurants focusing on healthy living, and malls with walking programs.

What’s more, these are not entities health systems will need to own or operate, nor will the partnership arrangements require a large financial investment. But alliances can nonetheless have a big positive return.

Where to begin

Identify the lifestyle patterns and socioeconomic determinants of health status in your community: Where people eat, where they shop, what activities they engage in, and in particular, what negative lifestyle choices they are making.

Focus your evaluation on multiple sub-populations, such as children, the frail, and the elderly, and comorbidities (not just chronic illnesses), such as obesity and stress, while continuing to keep prevention at the forefront of your strategy.

Identify and enfranchise non-provider organizations that can help get people on the right track toward a healthier lifestyle.

Identify the specific patient interventions you would like to see as the outcome of partnering with each non-provider organization.

Establish a dialogue with the non-provider organizations and together design partnership arrangements that will achieve the outcomes previously set forth.

Determine how you will measure the outcomes of the partnership.

Understand the impact

Over the past five years, I have been working extensively with the Adirondack Health Institute (AHI) to improve the population’s health a vast rural area. The local providers affiliated with AHI have designed a community health program specifically around pediatric obesity. In addition to engaging pediatric and family practices, the health system partnered with schools, a local community extension center, the local university, and the YMCA.

Outside the physician practice, community partners held activities such as school fairs, community lectures, and city-wide contests. Inside the practice, providers employed a patient navigator, nutritionist, exercise physiologist, nurse case manager, community resource advocate, and counselor.

One practice measured the results by looking at the percentage of patients with a BMI of greater than 95%. The year after the program was established, the percentage of patients with a BMI of greater than 95% decreased from 16% to 14%. A second practice measured the outcomes by percentage of patients who returned to a normal BMI. That number went from 4% of patients with a normal BMI to 14% of patients with a normal BMI.

As a physician myself, I feel the weight of providers’ responsibility for population health. But that doesn’t mean that we are the only ones accountable. We need to facilitate action from others who influence our population’s health and wellness.



Prove it to your C-suite: Three tips for measuring progress on community health

REBECCA TYRRELL, MS

Health systems play a pivotal role in supporting their communities. However, these community health efforts are often seen as separate from larger strategic aims. As the industry shifts toward value-based care and holistically addressing consumers’ needs, leaders should integrate community partnerships to achieve quality, cost, and experience imperatives.

To do this effectively, leaders must apply the same rigor to community partnerships as other types of affiliation agreements. This includes identifying champions, setting expectations around commitment of resources, and defining metrics to track and measure partnerships success.

Measuring progress is the most critical and often the most challenging, so drawing on interviews with participants in the first cohort of the BUILD Health Challenge and with other member institutions, we identified three tips for getting it right.

1Define key terms upfront

A common challenge when working across organizations is managing cultural differences. Each stakeholder group—whether that’s a hospital, public health department, or community-based organization—has a very distinct culture, language, and set of processes for managing projects, data, money, and communication. That will necessitate give and take.

Start by coming to a common understanding of basic terms. “Community” may seem like a straightforward term on the surface, but there are likely multiple concepts even within a single institution (e.g., metro region, adjacent neighborhoods, specific zip codes). Clarity in definitions ensures that measures can be calculated in a way that everyone can understand.

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2Balance accessibility with meaningfulness of data

3Include a mix of process and outcome metrics

Once terms are defined, leaders must consider the accessibility of data and the time necessary to properly carry out collection and reporting. Avoid getting bogged down waiting for perfect information and instead aim for “good enough.” There are no perfect metrics or perfect methods for isolating impact in interventions with multiple partners and confounding factors.

While hospitals have robust clinical data, other partners have ready access to other helpful data points such as information on a patient’s home environment. Once stakeholders involved in the partnership are identified, discuss available data sets to determine what information is both meaningful and simple to draw from.

Demonstrating outcomes can be slow given the pace of work and long-tail of certain interventions, so ensure metrics provide helpful guideposts for progress in the interim. For example, changes in obesity prevalence may take years to observe, so to earn “credit” for the work building toward that goal, consider measuring things like the number of new users on a walking path or the percentage of individuals successfully completing a weight loss or nutritional counseling program.

Additionally, ensure that metrics that capture both community conditions, such as whether housing is affordable and healthy food options are available; as well as institutional effort, such as dollars spent and staff hired. Meaningful data facilitates ROI calculations, transparency, and accountability.



‘The truth is, it takes a long time’: One chief executive on successful population health management

This interview with Dr. Steven Safyer, President and CEO at Montefiore Health System in New York City, was conducted by Eric Larsen, Advisory Board managing partner.

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Eric Larsen

Montefiore has been an exemplar of strong population health for more than two decades, and I think you’re fairly unique in the market. Can you talk about your philosophy on population health?

Steven Safyer

You know, I think there is nobody exactly like us. But some have elements that are very similar to ours.

We’ve aspired to be like Kaiser Permanente, and I wouldn’t mind having a single commercial product, but that’s not realistic in the Bronx. We deal with 35 different intermediaries that handle commercial insurance and Medicare and Medicaid. The insurance companies weren’t exactly going to transfer their premium to us, unless there was some compelling reason, especially when they could keep 30% of their premium, or 40% in the old days.

The other side is that we have about 1,500 interns, residents, and fellows at any one time and 850 medical students. The clinical faculty at Albert Einstein College of Medicine are employed by us. So we have that academic side, but we’re unique in the sense that we sought integrated payments, and needed to build an integrated system. Otherwise we wouldn’t be able to do what they now call population health.

EricWhat are some of the key lessons you’ve learned in that population health space?

Steven

We’ve been doing population health since 1995. The truth is: it takes a long time— longer than I think politicians want to wait. In fact, it took us five years of losing money. It probably wasn’t until the early 2000s, when we were writing off the losses, that we began to have a margin in that activity.

We were compelled to manage population health because the economics of the Bronx were bad. The borough was challenged, and then the recession made it worse. We needed a sustainable model.

A lot of my colleagues now are looking to operate insurance companies. Montefiore has an application pending before the New York state Department of Financial Services that would provide us with the option to offer an insurance plan if there is a need in the market. Having an insurance license gives us the ability to adapt as we address the demands of a changing health care environment and take on additional financial accountability for our patients’ health. But I don’t feel the need to be one. I think they could play a role, but I want more money to stay in the health care delivery system going to patients so we can manage the care—actually put it to work.

We have a legal entity that takes the risk, and that doesn’t require the same amount of reserves in the state of New York as it would if I had an actual insurance company. Also, I don’t have to be marketing insurance all over. So I have all the advantages of an insurance company without those negatives.


EricCan you talk about your participation in the Pioneer ACO program? Your participating patients are older, and they are sicker, and they are more fragmented in terms of their care. And yet, you guys have figured out how to do it. How?

Steven

The reality is that to be really successful at this, you need good public policy. The state of New York has been pretty good about this. There’s been a persistent drive to move everybody into managed care. In the Bronx, the majority of Medicare recipients are in a Medicare Advantage plan, and we are responsible for 90% of those lives.

The patients who were in the Pioneer ACO were the patients whom the insurance companies didn’t want to recruit to managed care. It’s no mistake that 40% of them are dual eligible, and many of them have morbidities like mental illness, and multiple chronic problems.

There were a lot of explanations for why we did well and others didn’t. We saved up to 7% every year, which we got to split with the federal government. We focused on the sickest patients who hadn’t been in a managed care program.

We did that because of our experience and our ability to get better and better at predictive analysis and pinpoint where we should intervene. Maybe 15% of all the lives are actively managed. You have to identify the group to target for each disease or couple of diseases that you’re managing.

For example, people with end-stage congestive heart failure are going to get readmitted over and over and over again. They can’t get a transplant. But people who are earlier on in congestive heart failure, you can manage them. So we got better at picking the groups.

EricMontefiore is expanding geographically. How does that fit into the broader plan for the health system?

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Steven

There’s an easy answer to that. Everybody across the country and all the big systems in New York are aggregating and acquiring. They’re all doing it to create scale and everything that means.

One key difference between our expansion strategy and those of other systems is that I’m not trying to bring one patient here who can be cared for closer to home in a well-coordinated system.

We have 350,000 emergency department visits per year. We care for something like 900,000 people on some regular basis, of whom, in the Bronx, maybe 300,000 are prepaid. So I’m moving to have access to a bigger population because I don’t think I will ever get 100 percent of a smaller population that I care for into the capitated model, for a variety of reasons. It’s a scale issue, because for the last 100 lives I won’t have to ramp up as I had for the first 100. It’s just economics.

So we build on our experience, our capacity. We’ve prepared for it, but it’s more about populations and less about more beds. In fact, in some instances, we’ve closed the hospital beds.

For instance, we acquired Westchester Square Hospital and transformed it into the first free-standing emergency department. There were 150 beds there, and they were admitting 5,500 people per year. They will admit maybe 2,000 to 2,200 patients per year to other facilities in our system. We’re only admitting those who need to be admitted, and we’re trying to bring that population into the Pioneer ACO model so we can provide comprehensive care that addresses the medical and social needs that so many in that community face.

I strongly believe that these models will soon become the standard for why so many of us went into health care: to reduce waste, improve quality, and create stability in the cost of care.

“Maybe 15% of all of [our] lives are actively managed. You have to identify the group to target for each disease or a couple diseases that you’re managing. […] We got better at picking the groups.”

—STEVEN SAFYER



Population Health Advisor

Our research arms key population health stakeholders (executives, managers, physicians, frontline care teams) with tactical guidance to implement care delivery transformation. We provide care delivery toolkits that help providers make the case for implementation, plan out new care models, and measure return on investment.

Implementation Toolkits

Refine your approach to initiatives ranging from primary care transformation to patient engagement to telehealth and more.

Analytical Tools

Access population health resources, scorecards, ROI estimators, and benchmarks right at your fingertips.

Hot Topic Webinars

Learn the newest research in our monthly (or more frequent) webinars.

Custom Training Series

Select from 40+ topic areas to quickly orient population health stakeholders to key concepts on your work plan. Topics and pacing are customized to your organization.

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For more about membership, visit: advisory.com/pha

Additional Resources

Five Innovative Trends Driving Care Transformation: The New Benchmark for Population Health

Beyond initial opportunities to reduce avoidable cost, providers who are increasingly managing more lives under risk need to set a new standard for care transformation. This webinar explores five trends in population health innovation and frontier strategies to advance your care transformation efforts.

Population Health Intervention ROI Estimator

Organizations looking to access their investments under risk-based payment models often track changes in a population’s per member per month (PMPM) spend as their go-to metric. This tool helps you quantify the impact of PMPM changes tied to your population health interventions over a five-year term and analyze the return on investment under risk-based payment models.

Custom Training: Population Health 101 and 201

This webinar series allows members to select from 40+ topic areas to quickly orient population health stakeholders to key concepts on your population health work plan. Topics and pacing are customized to your organization, and time is allotted for Q&A with each session to help get everyone on the same page.

Population Health Manager’s Job Description Library

Download a variety of population health-related job descriptions that you can easily tailor to meet your needs. We regularly add new job descriptions to the library as the population health landscape continues to evolve.

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Population Health Analytics

Your population health success depends on risk management and care coordination. Our Population Health Analytics application combines claims data with clinical data from your EHR for a 360-degree view into cost and quality improvement opportunities across the entire continuum of care. It is designed to support every role in your population health model—starting at the executive level and driving down into operational and clinical focus areas—to help you achieve population health success.

Consulting

The stakes are high on the path to value-based care. Organizations have to find solid financial footing without dropping the ball on current revenue. Many invest in technology, staff, and contracts—components of population health management—but these pieces won’t add up to an integrated, holistic strategy. Our consulting team travels with ease across payer, physician, and patient worlds, helping you identify no-regrets investments and craft a blueprint for your transition to value.

More on Care Variation Reduction


For More Advisory Board Thought LeadershipVisit our blog at advisory.com/ctc.

To order additional hard copies of this publication, search for it by name on advisory.com.

For more information, contact Dennis Weaver at 615-760-7596 or [email protected].

Content Curator, Tomi Ogundimu

Designer, Caiti Wardlaw

LEGAL CAVEAT

Advisory Board is a division of The Advisory Board Company. Advisory Board has made efforts to verify the accuracy of the information it provides to members. This report relies on data obtained from many sources, however, and Advisory Board cannot guarantee the accuracy of the information provided or any analysis based thereon. In addition, Advisory Board is not in the business of giving legal, medical, accounting, or other professional advice, and its reports should not be construed as professional advice. In particular, members should not rely on any legal commentary in this report as a basis for action, or assume that any tactics described herein would be permitted by applicable law or appropriate for a given member’s situation. Members are advised to consult with appropriate professionals concerning legal, medical, tax, or accounting issues, before implementing any of these tactics. Neither Advisory Board nor its officers, directors, trustees, employees, and agents shall be liable for any claims, liabilities, or expenses relating to (a) any errors or omissions in this report, whether caused by Advisory Board or any of its employees or agents, or sources or other third parties, (b) any recommendation or graded ranking by Advisory Board, or (c) failure of member and its employees and agents to abide by the terms set forth herein.

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Tomi OgundimuPractice ManagerPopulation Health Advisor

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