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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.
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