Making the transition to population health: Healthcare leaders share challenges, opportunities and a roadmap for success

As the healthcare landscape evolves, provider organizations are expanding their focus beyond individual patient care and looking toward managing the health of populations. The goal of population health is clear: improve the quality and effectiveness of care while controlling costs for a defined group of people. However, as Megan Clark of the Advisory Board notes, "the transition path couldn't be murkier."

To help provide some clarity, athenahealth brought together 79 executives from 72 accountable care organizations, health systems, provider organizations or consulting firms for a series of roundtable discussions to find out what it takes to successfully transition to a population health model of care. They examined obstacles and opportunities their organizations face and identified promising strategies for navigating the transition process. "Managing population health is a challenging concept," says Anil Keswani, MD, corporate vice president of Ambulatory Care and Population Health Management at San Diego-based Scripps Health. "It involves a set of strategies and capabilities that many of us are still wrestling with at this point."

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Throughout the discussions, athenahealth used Amy Edmonson's leadership triangle framework to help leaders focus on aligning three crucial elements of their organizations — Vision, Culture and Operations — to drive and sustain future success in population health.

Identifying obstacles
Vision refers to clarity about where an organization is strategically headed and what value it seeks to add in its community or market. Many healthcare leaders struggle with vision because they see the population health model of care as very different from the prevailing focus on individual patient care. In fact, only 15 percent of leaders polled during our roundtable discussions strongly agreed their organizations were well aligned around a shared vision of population health. In some cases, executives reported feeling pressure from payers to enter population health management before they were ready, or are entering the fray simply to keep up with competitors. Few, if any organizations seem to have defined a clear and compelling value proposition or a way of measuring and validating the benefits a population health focus brings to their organization or community.

As a result, many leaders worry about moving too quickly on population health. They are concerned that focusing on population health will undermine revenue — that is, a healthier population will require fewer hospitalizations and procedures. Additionally, leaders report that providers are reluctant to enter into risk-based contracts, fearing they may be unfairly penalized on already low profit margins.

The greatest cultural challenge for healthcare leaders is realigning an organization's focus away from acute, episodic care and toward a team-based, collaborative model for sustaining wellness across a population. First and foremost, this shift requires buy-in from physicians. Although many leaders point out that many physicians want to be involved in population health efforts, they are often too busy taking care of sick patients to take on new roles. In addition, specialists are still struggling to find their place in population health efforts.

Health system leaders also question how their organizations can appropriately engage patients, families and communities in the population health model. How, for example, do they encourage patients at high risk for emergency services or hospitalization to make positive behavior changes? Population health is impacted by a complex array of factors that include socioeconomic status, ethnicity and the ability to access care. "We underappreciate the degree to which the patient — the customer, if you will — is in the driver's seat in terms of what really happens to their health and wellbeing," says Brian Goldstein, MD, executive vice president and COO, Chapel Hill-based UNC Hospitals. "Population health is the aggregation of the health of each individual, and each individual is autonomous."

Healthcare leaders also face operational challenges they must overcome as they continue to develop and experiment with population health. They agree that delivering meaningful, usable data at the point of care is the most significant barrier to industry- wide adoption of population health management. The key term is "usable data," says Poonam Alaigh, MD, an internal consultant with Atlantic ACO Strategy at Morristown, N.J.-based Atlantic Health System. "Sometimes there's so much information that you can't get any directional signal. And groups can interpret that information to their advantage, versus having a unified approach and gaining an unbiased understanding of what that information means."

Provider organizations struggle with aggregating data across their systems, making it actionable, and having the tools to scale the data to the level that's needed for population health. Physicians simply don't have access to the right information at the point of care — from costs to complete patient histories — to inform their treatment decisions. Leaders stressed the need to create a more seamless process for moving patients through the care system, moving away from the fee-for-service model that has health systems functioning as competing silos of care and toward a team-centric approach to coordinating care.

Finally, leaders expressed uncertainty about the best organizational structure for population health models. Some leaders felt strongly that healthcare providers should be payers, and others felt just as strongly that they shouldn't be. Many agreed that there would be a blurring of the lines between insurers, providers and hospitals as organizations figure out how to effectively band together and scale up.

A roadmap for population health
Organizations face significant challengesas they move toward managing the healthof populations. But as our discussions progressed,healthcare leaders identified keystrategies that could make the road to populationhealth less bumpy. 

1. Prioritize high-value interventions
Wondering where to start? Many leaders recommend focusing on high-risk groups. These include both medically underserved populations who have more limited access to care, as well as patients with multiple chronic conditions, who are associated with a high percentage of healthcare expenditures. "True population health is about understanding the disparities in your community. If you look at the management of cost, it's about managing the high risk of super-utilizers. This is the top 5 percent of healthcare utilizers, or the top 10 percent who are about to join their ranks," says Scott Reiner, president and CEO of Roseville, Calif.-based Adventist Health.

High-risk populations are the most responsive to prevention and expense management strategies. They are also common in the fee-for-service world, and leaders point out that managing their care can prove to be an effective "bridge" in migrating to risk-based models of care. "Our approach is to try to reduce the cost of taking care of people with complex illnesses, or where there's the most opportunity to cut cost," says Dr. Goldstein, "and then concurrently, and hopefully incrementally, add populations of the healthy majority who sometimes need episodic care."

Along with high-risk populations, organizations should focus on the rising risk group, those patients with identifiable and preventable health risks who have not yet become high utilizers of care. Effectively managing these populations requires that leaders consider how health is impacted by economic, mental health and other psychosocial factors — an approach more common in public health. "We need to collect social determinants of health data and set the patient in the context of their life. It may not change the intervention, but it may change how and where that intervention is implemented," says Elizabeth Majestic, Vice President of Population Health at Cottage Health.

2. Build a fully integrated system
Leaders agreed that a population health model most likely to succeed under risk is fully integrated; a system with diversified revenue streams and strong regional partnerships and affiliations with community groups, payers, and other providers. Organizations will need to embrace alignment and share patient data among a network of medical and community groups that serve a given population.

Leaders also agree that organizations have to shed their fee-for-service culture and embrace a team-based mentality that has providers working together to meet the needs of a community. "We have to move away from this model that serves self-interest," says Larry Mullins, CEO of Corvallis, Ore.-based Samaritan Health Services. "Whether they are hospital interests, physicians' interests, or ambulatory surgery interests, that doesn't work when you're getting into population health. You're talking about allocating a finite amount of resources for a defined population and you really can't have one player trying to dominate out of self-interest."

Leaders agreed that they still have work to do on identifying compensation models that make the most sense and motivate providers to be part of a well-integrated care team.

3. Develop a population health workforce
One of the most important leadership priorities is to engage and support physicians and staff on the front lines of care delivery as they take on new roles and responsibilities within the organization.

The roundtable participants all agreed physicians must be allowed to focus on providing high-quality, efficient care for their patients and not be asked to spend more time on administrative work. Organizations can have staff assume such tasks such as data entry, maintaining EMRs or patient outreach and monitoring. Many leaders believe that specially- trained 'population health managers' will emerge as crucial supports to primary care physicians, much like certified medical assistants or the care coordinator in the medical home model. "The population health piece is not a conversation with the provider," says Tom Kloos, MD, president and CEO of Summit, N.J.-based Optimus Healthcare Partners, vice president of Atlantic Health System, president of the Atlantic ACO and executive director of MSO Services. "We try to leverage the clinical coordinator that's identified within each PCP office. They're the ones who do the outreach. They're the ones who assess the population that the practice serves."

Organizations that want to move into the population health space will require both leaders and staff to develop new skill sets. Some are actively promoting the redesign of medical school training; others envision new roles for staff to lead population health efforts and create relevant support systems for physicians and patients.

4. Design data systems to support population health
In order to be effective in population health, organizations need effective ongoing data aggregation across their populations. Some healthcare IT vendors are providing data aggregation as a service, using the cloud to bring together a patient's clinical, financial and demographic data to provide a complete picture of care. Integrating disparate EMR and claims data enables organizations to better address care gaps and manage care across the patient population.

Organizations also need clinical and financial data in real time across the enterprise. Having "situational awareness" at the moment of care gives organizations the transparency needed to control costs and better coordinate care. "Our primary care doctors hear over and over again 'you're the gatekeeper. You're the one who controls the costs on down the line,'" says Anna Loengard, MD, CMO of Honolulu-based The Queens Clinically Integrated Network, Queen's Health Systems. "If they could have a single EMR where they could see a patient- centered view of that patient's care, and also know the cost of care for various referrals down the line, that that would take us a long way."

5. Moving care beyond the doctor's office
Population health leaders should maximize a multi-channel approach to managing patients, including traditional patient visits, but expand expanding use of online, mobile and telemedicine options. Leaders understand that to really succeed under risk or value-based contracts, organizations will ultimately need to better engage patients and impact their behavior in the time outside of the typical 15-minute office-based encounter. "There are lots of people that want more from their primary care doctor," says Bill Winkenwerder, MD, chairman of Winkenwerder Strategies. "They want that interaction, they want to be guided, and they want it now. Most practices are not set up for that. There needs to be a new layer where you can just either call or go onto the web, have an app on your phone, and within 30 to 60 seconds, you're talking to a doctor."

This kind of immediacy requires exploring such enhanced operational capabilities as open access scheduling, user-friendly patient portals, secure text messaging, care management mobile apps, and live and automated messaging. To really impact population health, organizations must move their outreach and patient engagement more aggressively into the ever-growing digital space. "You want your population to be able to access the care services they need through the mechanism that works for them," says John Hitt, Chief Medical Quality Officer at Minneapolis-based Hennepin County Health System. 

Going forward, healthcare delivery systems will need strong leadership to navigate the "murky" transition to population health. Many organizations are so fragmented that the most important job for leaders will be advancing a vision, building consensus and effectively communicating evolving priorities — before they get into tackling the nuts and bolts of delivering care.

The future is not about surviving or thriving in a risk contract or simply taking on new methods of reimbursement. That's a small goal. If healthcare leaders want a big, audacious goal, they should be rethinking how to manage entire populations and create care delivery mechanisms to support this new approach. The changes will require the development of new capabilities, and new strategies, but they will be beneficial.

We can't cross the chasm into population health with a series of small, isolated steps. We are at the cliff's edge and it is time to build the bridge — even if there is significant ambiguity about what rewards await at the other side.

This article originally appeared on athenaInsight. com.

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