The industry transition to value-based payments is leading to more population health management programs, but providers are finding it’s difficult when patients lack secure housing, access to food or a way to get to appointments.
So many are now going beyond one buzz word, population health, and taking into account the role that another, social determinants of health, play in a person’s health.
“Population health management efforts are most successful when they are tied to efforts to address social determinants of health issues, since the challenges that patients face around housing, food and transportation, for example, are completely tied to their ability to engage in the healthcare system, manage their chronic conditions and stay well,” said Dr. Amy Flaster, an assistant medical director for the Center for Population Health at Partners HealthCare in Boston, told HealthCare Dive.
Flaster, also a physician at Brigham & Women’s Hospital and vice president for health management and care management at Health Catalyst, said a population health management infrastructure, such as working with community-based nurses and organizations that help at-risk people, allows health systems to address medical issues before patients wind up in the emergency room.
Leveraging an entire team within and beyond her office’s four walls, she gets help from social workers, community resource specialists, community health workers, pharmacists and nurses.
Across town at Beth Israel Deaconess Care Organization, Chief Medical Officer Dr. Sarika Aggarwal has seen PHM both from the provider and payer side. She’s led initiatives at both BIDCO and Fallon Community Health Plan.
“The key to population health is truly about taking care of patients across the care continuum,” she said. “I have not found a (population health management) program that hasn't helped the patient.”
For these programs to work, they need invested partners on all sides — payers, providers and communities.
Still, ROI is difficult to prove. Potential cuts to Medicaid and an apparent lack of interest in population health at the federal government level could also stand in the way of organizations looking to go down that road.
Social determinants of health
Providers can't ignore tackling social determinants of health in many communities.
Boston Medical Center, for example, treats a large at-risk patient population.
“They’re trying to look at patients more holistically,” said Rosemarie Day, who runs consulting firm Day Health Strategies, noting examples like physicians writing prescriptions for food and then sending the patient to the hospital's own food pantry.
Another factor: Patients with mental health challenges may have a harder time caring for themselves, especially when they have co-morbidities, Day noted.
Some state Medicaid programs, health plans and providers are starting value-based payments for behavioral health services. Arizona, Maine, New York, Pennsylvania and Tennessee have all created Medicaid managed care organizations with value-based payments that target behavioral health.
“If you can manage mental health issues, you actually have a big opportunity to reduce medical cost spend,” said Day, who served as chief operating officer for Massachusetts’ Medicaid program and deputy director and chief operating officer at the state's Health Connector.
Three legs of a stool
Population health programs can be considered as a three-legged stool, made up of a provider side, the payer side and community programs. Providers serve on the front line with patients, Payers use analytics to coordinate care and provide value-based payments and community programs help patients outside the physician’s office.
Payer involvement is crucial, offering claims data to match patients with the most appropriate interventions and providing contract incentives to providers.
Of course, physicians are tasked with treating patients the same regardless of the payment model, but alternative payment models can provide the extra funding to help compensate for that care coordination.
“The creation of ACOs and other alternative payment models are directly changing how health systems think about delivery care for their patients,” Flaster said.
Community programs provide services that patients can’t get during a physician visit. Community organizations help people find food and housing and resolve transportation issues for appointments.
Are they worth it?
So providers say the programs can help improve patient health and tackle social determinants.
But the big questions are: Can they save money in the long run? Are they worth it?
Aetna Chairman and CEO Mark Bertolini has touted the goals of the company’s foundation, which invests in population health projects that aim to reduce chronic diseases, provide walkable neighborhoods and improve quality of life.
An Aetna Foundation-financed study found that investments in certain areas did result in better health outcomes. For example, getting residents active is connected to decreased diabetes and cardiovascular disease; and cutting smoking rates reduced asthma and improved mental health. The study additionally found areas with the highest unemployment rates are also the unhealthiest, which goes back to social determinants of health.
With this in mind, Aetna’s Healthiest Cities and Counties Challenge provides $10,000 grants to 50 communities or organizations. Programs promote healthy foods, increase mental wellness and seek ways to decrease prison reentry. The programs that show an improvement are eligible for more funding — as much as $500,000.
A Health Affairs report recently highlighted a Colorado program called Bridges to Care, involving an emergency department and the community to promote primary care. The Center for Medicare and Medicaid Innovations funded the program through a grant.
The program offers medical, behavioral health and social care coordination services, such care coordinators, health coaches, behavioral health specialists and community health workers.
Six months after Bridges to Care intervention, there was a 28% reduction in ED visits and 114% more visits to primary care physicians compared to patients in the control group.
Digging further, the researchers found that patients with mental health co-morbidities had 30% fewer ED visits and 30% fewer hospitalizations — and 123% more primary care visits compared to the control group.
However, PHM programs aren't always cost-effective, despite their success with patients. Aggarwal gave the example of a program that offered home visits to the more costly patients with comorbidities. She said the program was successful with patients and staff, but ultimately it was too expensive.
So instead, Beth Israel spun off the cost-effective parts of the program into one for pharmacists and disease management. Improving a patient's medication management can result in improved outcomes quickly.
In that case, BIDCO initially connected patients with out-of-control diabetes to pharmacists, who provided recommendations to providers. Aggarwal said 40% of patients involved saw a significant decrease in their A1C levels.
Beth Israel then expanded the effort to health coaches and added similar chronic obstructive pulmonary disease and depression programs, with hopes to move into other chronic illnesses.
Despite signs of success, the hurdles are many: Potential pushback from leadership, funding crunches and the difficulty in measuring what's working are among the big ones.
The first piece of PHM is creating a cross-disciplinary team. Each stakeholder needs to set aside territorial hangups. Respect is needed for each stakeholder no matter their background or whether they have a medical degree. “Getting a team to truly come together and flourish to reach that ideal of a patient-centered medical center is not easy to do,” Day said.
Leaders of these efforts must become “a champion of change,” she said.
“Generally, you can throw a lot of money (at population health), but if they’re not led well and they’re poorly executed, you don’t get the results you want,” she said.
They require planning, outreach to other stakeholders and physician buy-in. Health system leaders need to communicate with providers and fully explain the programs.
“You need to engage them and put in the right incentives. A lot of my work is spent with providers in our system. That is important to the core of the population health,” Aggarwal said.
Flaster said one way to get physician buy-in is through data. Physicians will buy into the program if they can see it will lead to better care.
Aggarwal said modifying patient behavior and achieving a positive ROI isn't always easy. Programs may take 18 to 24 months to show a significant impact. And one can never be sure which part of the intervention was successful.
Plus, the care teams need to coordinate to eliminate duplications in post-acute care. Aggarwal gave the example of a discharged patient who may receive calls from multiple stakeholders. The patient becomes frustrated by the multiple calls and stops answering the phone. That doesn't help the quality of care and is a waste of resources.
Instead, population health requires continual dialogue among the stakeholders to limit duplications.
Future of population health
Population health programs are expected to expand as payment incentives become more aligned with value rather than volume. Aggarwal said infrastructure, data, financial incentives and administrative pieces will all become better aligned, as well as the model to identify patients who would most likely benefit from the programs.
Day believes that states and the private sector will continue to innovate. Oregon and New York both have Medicaid ACOs and Massachusetts’ Medicaid program called MassHealth will soon start its own managed care ACO. Massachusetts was the first state in the nation in October 2016 to create a payment model that added SDH variables to medical diagnoses, age and sex.
Seventeen healthcare organizations are taking part in the Massachusetts ACOs, including Partners HealthCare, BIDCO and Lahey Health on the provider side and Tufts Health Public Plans, Fallon Community Health Plan and Neighborhood Health Plan on the payer side.
Starting March 1, the ACOs will be financially accountable for cost, quality and member experience for more than 850,000 MassHealth members. The program includes investments in primary care and community support services.
The federal government is providing $1.8 billion to restructure MassHealth via a five-year 1115 Medicaid waiver. ACOs will receive more than $100 million in new investments this year to support the change to value-based care.
Day said having states try these kinds of initiatives in Medicaid is a positive — as long as the federal government doesn't cut Medicaid funding. Day doesn't think the current administration will undermine population health, but also doesn't think it will be a priority either.
“I don’t feel too optimistic at the moment about the national level,” she said.