TRUE POPULATION HEALTH MANAGEMENT
Requires a
collaborative strategy
between leaders in
healthcare, politics,
charity, education and
business
population admitted to the hospital viewing the 30 days prior to
the admission and 30 days afterward as the time of reference. These
hospitals look for trends discernable in their own hospital informatics system. Such hospitals are generally focused on readmission
prevention. Other hospitals look for collaboration with community
health organizations including disease specific fundraising groups.
A third type of hospital organization may work through one or more
clinical departments to do community outreach and education.
The survey demonstrated that the Population Health programs
in many American hospitals are run by middle managers who
“are fairly new to the field and their position but have extensive
experience in health care.” All of these hospitals are struggling with
finding their appropriate place for inclusion of a Population Health
program. But they do recognize that the ACA legislation is just the
gateway for more funding focused on improving the health of the
population they serve.
Physicians participating with hospital systems in integrated delivery systems may have a much greater role in managing both the
medical and the behavioral aspects of Population Health. Federal
programs such as the Medicare Shared Savings Program (MSSP)
create incentives for such physician-hospital collaborations. Typically such arrangements include an ACO or Clinically Integrated
Network (CIN) to become the legal vehicle. With the MSSP there are
three tracks based upon the degree of risk the ACO/CIN is willing
to accept. The most popular is the upside risk only. There 401 ACOs
nationally participating this upside risk only track, representing 99
percent of all participating ACOs. These managed the care of 7.3
million Medicare recipients. An ACO in this MSSP plan must lower
costs in the current year by more than two percent over the prior
14
LOUISVILLE MEDICINE
year. So if medical inflation were at five percent, to participate the
reduction in costs must come from greater coordination of efforts.
The Medicare members in each ACO are typically unaware. They
are the Medicare members who receive the plurality of their care
from one of the ACO participating physicians. Since these Medicare
beneficiaries are all fee-for-service, there is no health plan utilization management oversight. It becomes incumbent upon the ACO
participants to work to reduce utilization by their own management
of those patients. Maybe there is less giving in to patient demand
for referrals or diagnostics that the treating physician knows are
not necessary. In the past it wasn’t worth the argument with the
patient. But now physicians must use education and persuasion,
with the use of mid-level practitioners to help with these pursuits.
Once an ACO has been able to achieve greater than a two percent
reduction in medical costs for the population of Medicare beneficiaries within that ACO, then the ACO would be eligible to share
in the cost savings with CMS….but only if they have demonstrated
quality markers specified by CMS. These include measures of clinical quality, patient reported outcomes and patient satisfaction with
their care. This means to achieve any additional reimbursement the
physicians and hospitals within an ACO or CIN participating in
the MSSP must coordinate care and have information systems to
help them. This gets to the whole concept of managing the health
of a population.
The integrated health system that also owns a health plan will
then have additional resources to assist in the management of a
commercial and a Medicare or even a Medicaid population. Health
plans typically have claims systems that can capture patterns of care
for feedback to the hospitals and physicians engaged in Population