Population Health Turned Inward

Employee Health Successes

In 2011, the healthcare field’s movement to population health and value-based delivery models was still very much in its infancy, as described in a November/December Healthcare Executive article that year. In a winter 2016 interview for Leadership magazine, David Nash, MD, dean, Jefferson College of Population Health, Philadelphia, gave the industry a “C” grade for its efforts in managing the health of its own employee populations, which many experts consider to be a good starting point for effective population health management. 

"Sharing across organizations is what really has potential when you’re going through an industry evolution the magnitude of this."

- Stephanie S. McCutcheon, FACHE, Health Employer Exchange

Where does the field stand in 2019?  

Though there have been some significant developments in the past five to seven years, it seems the healthcare field’s journey to population health and value-based care is still a work in progress. The healthcare leaders and providers focusing on these initiatives and paving the way for others continue to work on what is needed to make one of the industry’s biggest transformations. And as with most journeys, there have been lessons learned, successes to celebrate and paths forward revealed. 

Stephanie S. McCutcheon, FACHE, CEO, Health Employer Exchange, Baltimore, describes this process as a long journey—not a swift solution—and that progress is being made, with many healthcare executives still recognizing the importance of moving to value-based care.

“I think our field has really stood up,” she says. “Leaders in the field didn’t just say, ‘Oh, I’m not so worried about this. It will all work its way out.’ I think many said, ‘We must take on the leadership role and lead the evolution of it.’”

Nash, who also is The Raymond C. and Doris N. Grandon Professor of Health Policy at Jefferson College of Population Health, says the industry too is making progress on this journey. He finds similarities between today’s population health and value-based care transition and how the landscape changed after the publication of the Institute of Medicine’s To Err Is Human: Building a Safer Health System. 

“I think more than ever, we’re starting to pay attention to issues that we never did before, especially the social determinants of health,” Nash says. “It is now socially acceptable to have these conversations. It reminds me when in 1999 To Err Is Human was first published, and all of a sudden talking about medical error was more acceptable.”

Emerging Success Factors: Value Readiness in 2019
Since 2011, several factors have come to light about what will be required for the healthcare field to take on population health management and value-based care successfully. First and foremost, McCutcheon says, is recognizing that taking initial steps on these initiatives is more important than perfecting them. In other words, don’t let fear immobilize an organizational initiative from getting started. 

While experts agree most organizations in the field should be looking at value-based care and population health and at least considering how they can make moves into this arena, McCutcheon advises that all organizations adopt these types of changes at an appropriate pace. That is one of the most important lessons that has emerged since several health systems came together in 2012 to form the Health Employer Exchange.

The participating health systems—all self-insured—have developed and adapted a Value-Based Care Model and an Innovation/Transformation Approach & Methodology that they have replicated and scaled during the past six years across the participating health systems in which they used their employees as the “population” to be cared for and managed. Since HEE was founded, the group has developed 12 principles to reduce health plan and workers’ compensation costs and increase employee/enrollee satisfaction. Every six months, the health systems in HEE came together to share the principles they had adopted and enhanced—as not all work for all organizations—so others could learn from them and potentially deploy them across their organizations.

Replication of different care models (or “principles,” as HEE calls them) has emerged as a success factor in the move to value and population health. “I really respect these organizations for standing up and saying, ‘Can I do this faster and more effectively if I use the principles as adapted by another organization?’ Sharing across organizations is what really has potential when you’re going through an industry evolution the magnitude of this,” McCutcheon says.

"Many of the health systems and small hospitals, particularly rural hospitals, are really operating on thin margins, and that makes it a difficult time to walk away from potential revenue or income. We’re trying to forge ahead with bold moves that we hope make that journey easier for others."

- Mikelle Moore, Intermountain Healthcare

Another important success factor in the move to value has been mindful selection of a population on which to focus. Experts agree that focusing on a population with which the organization already has some risk arrangement is a wise move. The health systems in the Health Employer Exchange chose their self-insured population—their employees—to implement their programs. This choice, McCutcheon says, works because the employer, the health system in this case, already assumes full risk for the population. Patients who are on Medicare Advantage plans—arrangements that for healthcare providers generally include a significant amount of risk but also substantial cost-savings opportunities—are another group organizations can consider when starting value-based care initiatives, according to McCutcheon.

Realigning Incentives While Reimagining Care
Salt Lake City-based Intermountain Healthcare has set out to transform care delivery at some of its primary care clinics. Called the Reimagined Primary Care Clinics, the model offers the organization’s primary care, family medicine and internal medicine physicians a different way to practice, according to Mikelle Moore, senior vice president/chief community health officer, Intermountain Healthcare, and an ACHE Member. 

Several clinics within the integrated not-for-profit system—which has 22 hospitals, more than 185 clinics and a medical group with more than 1,500 multispecialty doctors and caregivers—are now participating in the model, in which physicians can choose between what Moore calls a “quasi-fee-for-service model”—physicians are compensated based on the traditional fee-for-service method but also based on their performance metrics related to quality, patient satisfaction and clinical practice improvement—and a panel-based employment model in which physicians are compensated based on their performance within a team-based care approach. 

The fact that physicians can choose between the two models has helped quell physician uncertainty. “When we started talking about the new model and the option for a different structure and compensation, at first there was fear that physicians didn’t want to be forced to change into the new model,” Moore says. “We very quickly said, ‘Well we don’t need to force it. Let’s just operate those models side-by-side and allow physicians to self-select.’ We can even produce information about what compensation would have looked like under a different model to help inform dscision making and create transparency.” 

Feedback from participating physicians has been tremendously positive, says Moore. Intermountain currently has six physicians and three advance practice clinicians in the model and plans to have 20 more providers by June 1 (at press time) and 40 total providers by the end of the year. “We have more demand than we have bandwidth to do the conversion, and I think that speaks for itself,” she says. “The physicians are saying they really enjoy practicing this way.”

New Players on the Care Team
Milwaukee-based Froedtert & the Medical College of Wisconsin, a regional health network comprising five hospitals, an academic medical center, more than 1,700 physicians and nearly 40 health centers and clinics, is one organization embracing the journey to value-based care and population health through the strategic use of care coordinators. These team members are an extension of the doctors and nurses leading the care teams and have been instrumental in managing care transitions.

“If a patient visits the ED or is discharged from the hospital, they’re in a transitions of care category, and we help manage those patients so that we can hopefully reduce readmissions, reduce ED visits, help them get their medicines right and improve their health,” says Jonathon Truwit, MD, enterprise CMO of the health network.

Using care coordinators is done in conjunction with other population-health focused initiatives such as isolating patients with chronic conditions to better manage their care, according to Truwit. An array of digital solutions also feature prominently in these efforts at Froedtert & the Medical College of Wisconsin.

Care teams have incorporated a digital tool designed to help patients with diabetes manage hemoglobin A1C. The tool is used in combination with four months of patient education sessions. Following the educational component of the program and for six months after, the tool helps patients maintain glucose control. Truwit notes that programs like these help improve the health of the patient population while keeping overall costs down for the health network.

Paving the Way for Others
The replication and learning from others, which is at the heart of McCutcheon’s Health Employer Exchange, ultimately will help move the industry farther away from fee-for-service and closer to value-based care. The systems in the HEE are considering an annual colloquium to share results and lessons learned from their work in improving care and reducing costs. 

Intermountain’s Moore acknowledges it is the larger systems that must be the ones to lead the way in the pursuit of and transformation to value, especially in a financially stressed industry like healthcare.

“At Intermountain we recognize that many of the health systems and small hospitals, particularly rural hospitals, are really operating on thin margins, and that makes it a difficult time to walk away from potential revenue or income,” she says. “We’re trying to forge ahead with bold moves that we hope make that journey easier for others.” 

And that “C” grade Jefferson College of Population Health’s Nash gave the industry back in 2016? Today he says it’s more like a “B” or “B-plus.”

“We have made progress, especially in the last three years,” he says. “Ten years ago, when we opened this school, there wasn’t even a textbook for what we were doing. Now there are 12 or 14 schools and universities that call themselves population health, and there are a score of medical school departments of population health.”

In addition to making progress, the field’s attitude also has evolved over the last few years, with many now acknowledging this is the right direction. 

“I think it’s going to pay off if we all make this leap,” Moore says. “It’s going to be the right thing for patients, it’s going to be the right thing for our communities, and it will work out for health systems in the long run.”

Jessica D. Squazzo is a Chicago-area-based writer and editor.


A CEO To-Do List for Managing Population Health

Effectively managing population health and value-based care initiatives will require strategic and innovative leadership. David Nash, MD, dean, Jefferson College of Population Health, Philadelphia, provides a to-do list for CEOs—six strategies for better managing population health.

  1. Begin population health management with an employee population. “We know that employee health and wellness is so central to productivity,” says Nash.
  2. Keep the well “well.” “Keeping the healthy people healthy is a powerful social motivator,” Nash says.
  3. Train leaders for value-based care. Leaders will need guidance for this transformation.
  4. Use patient registries. “I still think that’s important,” Nash says. “The registry enables you to benchmark your performance.”
  5. Partner with managed care plans. Every major organization is looking for provider partners, according to Nash.
  6. Fund physician leadership training. “We can never get enough of this,” Nash says. “That should always be on the list.”