When most people think of the term “Population Health”, visions of ACOs dance in their heads. ACOs are a provider group that pulls together patients and contracts at a fixed rate per patient over a given timeframe while either maintaining or increasing quality of care, with savings typically accruing to all parties. An academic definition of pop health is: “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” While that definition may be accurate, I find it a bit nebulous, and would like to suggest the 3 Ps of pop health to simplify the definition and conversation: the Population, the Patient and the Practice. The 3 P’s provides a specific framework under which to have practical conversations around population health.
The population is the collective patient cohort that a provider has contracted with a paying entity to provide healthcare for a fixed price. In the case of CMS’s Medicare Shared Savings Program, providers receive payments based upon traditional CMS fee for service schedules, but are then incentivized to provide higher quality care through ACO33 measures, and have their populations risk-adjusted using the CMS-HCC methodology. Providers must now determine efficient and effective ways to deploy their limited care resources in order to impact clinical outcomes and overall population savings. In the case of private ACOs or health systems directly contracting with self-insured employers, the population is defined by that contract. To make this more complex, a provider’s overall population health approach may be comprised of many contracts – each with its own specific population and contract behind the care. This population complexity adds an additional element of chaos in an already chaotic system.
The paradox of population health is that in order to “move the needle” on a population, a provider must focus on the specific needs and use cases of each and every patient who is part of the population. While I will dive into the specifics and caveats of how to define an individual’s care in later posts, for now I want to establish that “the patient” is a critical component of any ACO. Each patient of a defined population has their own health issues and specific personal needs. For example, one member of a population may be a relatively healthy 68 year old woman in good shape, but has moderately high cholesterol. Her personal issues and barriers to care will be completely different than a 74 year old, wheelchair-bound diabetic with heart failure. The critical component to improving the value of healthcare and drive quality measures for a population is understanding how we can make the individual patient respond to care and meet their own needs. Delivering personalized care for each patient is critical for the long-term success of any population health model.
Here lays what I find to be the most important of the 3 Ps of pop health – practice. Yes, it’s all about the people – both on a macro (the population) and micro (the patient) side of things, but population health itself is a practice, much like medicine, and yet we do not treat it as such. Best practices and models are unique to the provider, the patient base and payers involved. What has worked at one provider may not work at another. More direct, what has worked for a rural, integrated care network will not work at an academic medical center, will not work at a large urban public hospital system. While the basics may be similar the practice and execution of the basic models will be very different However, I would argue that the learning, best practices and business models from these efforts can serve as a starting foundation for a population health effort.
At the surface, this seems to be self-evident, but I have seen providers establish fairly rigid care and financial models and too often not create a governance or technical infrastructure to embrace the practice of population health. From my time working with ONC’s Beacon Communities and CMS’s Innovation program, most of the reasons programs were not successful can be traced back to overly ambitious and complex beginnings that were rigid in approach. Successful programs were more modest in size, focused on specific measures and outcomes, and allowed for the learning and iteration on successes and small failures. From those more modest beginnings the successful programs expanded their capabilities as they learned how to assess risk, create effective population cohorts and to deploy personnel to meet the individualistic challenges faced by their populations. Most of the successful organizations were able to iterate and iterate often, which allowed providers to hone the practice of managing large, diverse populations. All of these challenges are unique to each population health effort – and may actually be different on a contract-by-contract basis for each provider. The bottom line is that population health is a practice – one that can take years to make robust and to perfect.
I will tackle each one of these 3 Ps in upcoming posts. For now, the 3 Ps act as a basic framework for conversations around the path to pop health success.