Monthly Archives: January 2016

Building a Culture of Physician Engagement in Population Health

Post by Sameer Bade, MD

Vice President of Clinical Solutions, Caradigm

In population health management, the role of physicians has evolved because the care of chronically ill patients requires a coordinated effort between members of a multi-disciplinary team. However, a team approach does not diminish the role of primary care or specialist physicians. Rather, it should engage and support physicians directly to address quality, outcomes and cost. As provider organizations seek to scale their population health and value-based care efforts, effective engagement of primary care and specialty physicians is critical.

Today, physicians are under escalating amounts of clinical, administrative, time, financial, and legal pressure to perform while their businesses are facing decreasing fee-for-service reimbursements. In increasing numbers, physicians are giving up the independence of private/small group practices and seeking employment with larger groups and health systems. This loss of autonomy coupled with administrative and regulatory pressures can lead to a decrease in physician satisfaction. We often speak about patient satisfaction but physician satisfaction is rarely addressed in a systematic fashion. Despite these pressures, most physicians rightfully view themselves as hard working, high-quality individual performers who care about patient outcomes. However, as organizations start to add the numerous requirements of value based care programs onto already over-burdened physicians, is it possible to maintain effective engagement?

Some larger physician groups and health systems are further along in their population health journey. These organizations have established patient-centered medical homes, continue to expand their multi-disciplinary care teams (nurse care managers, pharmacists, social workers, community health workers and non-clinical support staff) and are transitioning from basic registries to more sophisticated population health analytic and workflow tools. These investments have been made to both transform the care delivery process and simultaneously engage and support front line physicians and nurses. However, the majority of physician groups and health systems that I speak with are still fairly early on in their participation in value-based programs (e.g. planning to apply or in program year 1 of a Medicare Shared Savings Accountable Care Organization (ACO), grappling with the looming impact of the now mandatory  Comprehensive Care for Joint Replacement (CCJR) bundles, trying to effectively deal with the Readmissions Reduction program, participating in newly formed commercial ACOs or narrow networks, managing their own employees, etc.). In these early adopter settings, it is challenging to deeply invest in FTE’s, clinical programs, and technology.

Both physician and hospital organizations will also need to address the upcoming requirements of the 2015 Medicare and CHIP Reauthorization Act which will require participation in MIPS (Medicare Incentive Based Payment System) or APM’s (Alternative Payment Models). Not participating or performing poorly across these programs could result in a loss of 9% of reimbursement. The successful implementation of these programs is firmly dependent on the participation and performance of physicians.

In my travels and meetings with physician groups and health systems around the US, several best practices seem to be emerging around physician engagement:

Education: Frequent education on a variety of topics is critical. Physicians understand clinical care. However, concepts such as ‘benchmark’, HCC (Medicare’s Hierarchical Condition Category coding), minimum savings rate, discounting, two-sided risk, attribution, utilization management, multi-disciplinary care teams, etc. were not taught in medical school or residency. A mix of mediums such as conference calls, webinars, town halls and smaller group meetings are being employed. I’ve seen organizations with staff that travel from clinic to clinic on a rotating basis (much like a pharmaceutical rep) to provide 1:1 or small group education. Physicians need to clearly understand regulatory and industry changes, the organization’s shared goals, and the personal and professional impact of these changes.

Tools: It’s important to engage physicians with informatics tools to help them improve their performance on the metrics being measured. There are a variety of supporting capabilities which include easy to access longitudinal patient records, shared care plans, and gaps in care at the point-of-care. Physicians do not have time to log into multiple systems or read multiple reports while providing patient care. Analytics must be actionable at the point-of-care. Increasingly, physicians have an expectation that this enriched patient centric information should be available while seeing a patient or working in a patient chart. In contrast, the supporting care team may also need a population level view to help with pre-visit or day of visit planning and coordination.

Compensation: The satisfaction of being considered an efficient and high quality provider fosters engagement and can create healthy competition. However, compensation can also be a powerful adjunctive motivation. The most forward thinking organizations are not only rewarding primary care physicians and specialists, but also members of the care team when pay for performance or shared savings are achieved. Organizations are also putting a certain percentage of base and or bonus compensation at risk for actively participating and or achieving quality or targets.

Culture: Ultimately, creating the right organizational culture can accelerate achievement of meaningful physician engagement. Integrating physicians into governance is very effective as most of the top performing ACOs are organized by physician groups. Equally important is for organizations to provide the necessary multi-disciplinary team support and informatics investments. Physicians are competitive by nature, and will push each other to perform if provided a meaningful, mutually agreed upon set of goals and measures.

Measurement: In my next blog post, I will explore the importance and challenges of measuring physician performance further. I will also discuss how new analytics tools can help with measurement and support discussions between clinical leadership and individual physicians.

We have moved past the uncertainty of value based care programs initiated as part of the Affordable Care Act, and are entering the next phase of healthcare transformation anchored by the 2015 MACRA. While our transition from fee- for-service to value-based care is going to be challenging, it provides a real opportunity to decelerate the unsustainable growth in healthcare spending while improving patient outcomes. Physicians have a critical role in this transformation.

As I speak with physicians around the US, they share different and insightful perspectives on their participation in population health and value-based programs and the engagement of their colleagues. If you would like to discuss how Caradigm can help you with physician engagement, then please send a note here.


The Paradox of Population Health

Post by Brad Miller

Vice-President of Clinical Solutions, Caradigm

By and large, the healthcare industry talks about Population Health as care across populations of people. While Pop Health has evolved to drive the IHI Triple Aim across those populations, successful Pop Health efforts depend on care given on a patient-by-patient basis. From a clinical care perspective, Pop Health drives care at the Person level – the second “P” in the 3Ps of Pop Health. The paradox in Pop Health lies in that how we deliver care on an individual and personalized basis actually drives population results.

Pop Health is driven on a person-by-person basis. A patient, by definition, is a person receiving care. However, in reality, external and personal factors greatly affect how a person maintains their health and gets their healthcare. This all-encompassing understanding of the person is becoming more important to drive clinical outcomes and Pop Health successes. No longer can providers afford to view people solely as patients – providers who want to drive true global results will have to understand the patient as a person. Ironically, Pop Health has forced us as an industry to get better at data and care on a personal level.

Understanding the Patient as a Person First and foremost, personal factors like financial and family concerns play a large role in how people interact with the healthcare system. The Patient Protection and Affordable Care Act (ACA) has increased the number of covered individuals and also has created more narrow networks, high deductibles and increased healthcare utilization. High deductibles mixed with lower incomes could become a barrier to care, particularly if those individual patients need to obtain services and goods outside the clinical setting (think wheelchair ramps, dietary advice, a divorce or family death and how those factors can affect a person’s ability to get proper care). Even a family dog that a person does not want to leave alone at home during a hospitalization can prevent such a person from getting recommended preventive care. I have personally experienced these as barriers for patients, and I continue to hear those stories as I meet providers and systems across the country. All too often as providers, we are guilty of treating patients, when we really need to be treating the person. Until socio-demographic issues are better understood and addressed, they can hamper the benefits that Pop Health can provide.

A Person’s Personal “Big Data” The world of truly personalized medicine will also continue to evolve. On top of sensor data (Fitbits, Apple Watches, Bluetooth Scales, Bluetooth Glucometers), we are also seeing an explosion in genomic and proteomic data. All of this creates a more detailed, intricate and nuanced picture of a person as a patient. Collecting, analyzing and integrating this intelligence into clinical care will be one of the next large challenges healthcare faces. As an industry, healthcare may need to consider this information as a critical part of a person’s foundation that will guide personal care.

High Quality and Value Care at the Personal Level Many providers have contracted via ACNs, ACOs, MSSPs and the like to deliver care for a certain dollar value and to a quality standard. Those quality measures vary from population-by-population and contract-by-contract. Ultimately though, each person receiving care in the health system has a set of quality measures and gaps in care that need to be addressed. Put another way, there is no way for a gap in care to be closed without working at a patient level. This may seem obvious, but all too often providers talk about Pop Health and care metrics and gaps in care at a high level (i.e., how is our quality as a system?) vs. a patient-person level (i.e., how are our patients doing?).

Making it Personal Overall, understanding a person and his or her personal situation is critical to their clinical care and therefore paramount to Pop Health achieving the Triple Aim. The practice of Pop Health has a foundation in technology and data. Traditional systems like EMRs and other hospital-based technologies have not been designed to capture the full picture of a person and oftentimes these systems struggle to create a unified clinical record – a longitudinal patient record (LPR) – for a patient’s clinical information. Health systems, in the future of the risk-based model, will need to not only understand the LPR and the complete socio-demographic situation of a patient in order to drive to the desired results. I will address a vision for that technology in my next post. In the meantime, the paradox of Pop Health – that it truly is all about the individual, the person, remains of utmost importance in the current evolution of Pop Health and healthcare at large.