Why provider-driven care is best equipped for population health management

Effective population health management is a critical aspect of hospitals' and health systems' efforts in transitioning from volume- to value-based models of care in which reimbursement becomes more and more closely related to outcomes, readmissions and other quality indicators. When facing such a paramount paradigm shift, who is best suited to lead?

[The following content is sponsored by xG Health Solutions.]

Earl Steinberg, MD, CEO of xG Health Solutions, a care delivery improvement company powered by innovations and learnings from Danville, Pa.-based Geisinger Health System, makes the case for provider-driven population care management. While many physician practices are beginning to reengineer their practices to better handle population health management, providers have not always led this initiative.

Historically, health plans were the ones that provided population health management with their own case managers, health coaches and call centers. Payers have certain assets and capabilities that are valuable for population health management, according to Dr. Steinberg.

First, payers have claims data, which allows them to construct a picture of all billable utilization of a patient regardless of which provider was involved in a particular encounter. In comparison, EMR data is limited to the data generated at a particular provider site — it is not comprehensive in that it does not include the treatments or services a patient obtains outside of a particular provider. Health plans also have analytic expertise, allowing them to use data to identify patients who would most benefit from some type of care management intervention, according to Dr. Steinberg.

Additionally, health plans have an abundance of nurses who use sophisticated telephony that enable them to reach out to patients efficiently.

However, the exclusive use of health plans to handle population care management is inadequate in several substantial ways, emphasizes Earl Steinberg, MD, MPP.

"There is a significant lag in the availability of data relative to an encounter that a claim is generated for," says Dr. Steinberg. "The lag could be months, so information is often outdated. Or, something could happen and would not be reflected in the claim until much later on."

In addition to issues of timeliness, health plans alone lack the clinical data that electronic health records offer to inform future interventions.

Finally, health plan-led care management typically uses separate software for utilization management, disease management and case management, making integration and coordination with provider-driven care management difficult, if not impossible.

What makes provider-driven care management preferable to health plan-driven management?

There are several attributes of provider-driven care that make it effective for leading population health improvement.

Close relationships with patients and among providers

According to Dr. Steinberg, provider-driven care necessitates nurses and case managers to be physically present in the office, which enables them to establish much closer relationships with patients than could be done over the phone.

"By being embedded in the practice, it is possible for the nurse to arrange to have a patient come in for certain types of service and obviate the need for the patient to go to the emergency room," says Dr. Steinberg.

Provider-driven care also allows case managers to form close relationships with the physicians and the office as a whole, which leads to enhanced coordination — instead of waiting for the doctors to call them, the case managers can just knock on their doors.

Team-based care improves operational efficiency

One of the founding principles of xG Health is recognizing the value and efficiency of team-based care that operates within provider-driven population care management.

"At xG Health, we strongly believe in a team-based care approach in which every member operates at the top of their license or skill set," says Dr. Steinberg.

According to Jeffrey Davis, MD, Senior Medical Director at xG Health, substantial portions of physicians' time today is spent on activities that can be automated or delegated to other team members, which ultimately reduces the amount of time they can spend with patients

For example, in an effective team-based care approach, case managers are assigned to monitor the sickest patients and perform many of the tasks for these patients, allowing physicians to focus on what they are trained to do — making complex medical decisions and building patient relationships.

According to Dr. Davis, it is essential for the case manager — usually a registered nurse — to be embedded in the practice. In this role, the case manager not only helps manage the highest risk and complex patients but does it in a much more collaborative and coordinated way because he or she works right alongside the physician and the rest of the team at the practice site.

What must providers do to become effective population care managers?

Providers must learn and acquire certain essential capabilities to effectively manage population health.

Key capabilities for provider-driven care management

First, providers need to do everything that is good about health plan-driven care management. "They need to become agile and able to analyze and interpret claims data so they can understand both the view of the population and of the patient," says Dr. Steinberg.

Physicians must also learn to use this data in conjunction with clinical EMR data, according to Dr. Steinberg. If physician practices don't have the manpower to achieve this data extraction and analysis, they must broaden their team.

Monitoring this data and using it to proactively deliver early interventions to patients and identify ways to prevent patients from needing to come into the office for visits is an integral component of provider-driven care management, as opposed to having everything focused on in-office encounters, according to Dr. Steinberg.

Additionally, Dr. Davis notes that a significant behavioral shift will be necessary for fee-for-service providers if they wish to implement successful population health management programs.

In a fee-for-service world, physicians are reimbursed on the amount of services they provide to individual patients, independent of outcomes or possible complications. In a value-based approach, physicians will be responsible for managing the health of defined populations as opposed to individual patients during in-office encounters; and, as such, they will become accountable for both the quality outcomes and the total cost of care of that defined population.

Implicit in this transition from a volume to value-based world where providers will be assuming more accountability for both the quality and cost of cost for a defined population is also the taking on of financial risk for the care and outcomes of that population. This is a huge change for physicians.

The transition poses obstacles for providers

According to Dr. Davis, the process of shifting from volume- to value-based care models poses several key challenges. First, the transition will require physicians to operate in teams and give up some of their individual autonomy in that process. The professionals at xG Health firmly believe in physicians-directed teams, but all members have an equal voice. A key part of this team-based work includes monthly meetings focused around reviewing data to help inform clinicians on how well they are doing on a regular basis.

"Most physicians aren't used to meeting like this, but these meetings are important and focus on care management processes and transitions of care," says Dr. Davis. "Physicians will now be responsible for patients after they go home." If a patient is readmitted, in a value-based system this could impact how the physicians involved in his or her care are reimbursed.

The team-based approach is designed to alleviate burdensome, nonclinical work physicians currently perform, but developing an effective team takes time and commitment. According to Dr. Davis, every member of the team must be accountable for providing highest quality care possible in a patient-centered manner. In addition, the clinical care teams have to learn to use EHRs not just as a representation of old paper records, but redesign them to reflect not only how physicians think and act, but how to provide the most efficient care to the population they are accountable for.

Another important process that providers must understand is the use of technology to engage patients — such as online portals or devices that measure vitals. These tools enable physicians to collect information from patients in between and in advance of visits, providing patients with the opportunity to play a much more active role in their care. "Patient involvement and engagement is being increasingly recognized as an extremely important element in achieving improved outcomes — the complimentary side of successful provider-driven care is highly engaged and informed patients," says Dr. Davis.

While there is efficiency and convenience for patients, physicians and administrators in leveraging such information, the key component is that there must be someone on the receiving end in the doctor's office who is recording and acting on this data, according to Dr. Steinberg.

Strong physician leadership is key

To achieve all of these changes, physicians must be receptive to the various requirements of effectively managing population health under a value-driven system. One of these requirements is transitioning away from a care delivery “system” in which different facets operate in silos to one focused on integration and evidenced-based medicine.

Many physicians tend to resist change, but they must move away from this and become change agents, according to Dr. Davis. Specifically, physicians must not only develop their own leaders but also acknowledge the need to bring in trusted experts and partners who can assist in the large-scale changes that are occurring within the world of medicine.

According to Dr. Davis, more physicians today are actively seeking leadership positions.

"There are more physicians who are stepping up to the plate with a vision because they understand medicine is more than providing good care one patient at a time, but also about how the care system should be organized and implemented to achieve the goals of the triple aim," says Dr. Davis. "It's slow, but it's happening."

Investing in formal training and giving physicians management experience is a crucial aspect of preparing physicians to become leaders in the new models of health care delivery.

What models of provider-driven care exist?

According to Dr. Davis, provider-driven care management systems exist across a spectrum. The most successful of these are tightly integrated organizations that own most of the elements across the whole continuum of care.

"Examples of those organizations include the Geisinger Health System, the Mayo Clinic and Kaiser Permanente — highly integrated delivery systems with strong physician leadership and highly developed physician cultures with a focus on high quality care and outcome measurement" says Dr. Davis.

Another model of provider driven care is embodied in accountable care organizations, which require provider groups/hospitals to enhance care coordination and take clinical and financial accountability for a large population. ACOs ensure patients — especially the chronically ill — receive the right care while avoiding the duplication of services and preventing medical errors.

A third model that is being implemented within primary care and multispecialty groups is the deployment of patient-centered medical homes which highlight the role of primary care providers in providing highly coordinated, team-based care for a defined population.

Each of these platforms are examples of newer delivery models which require significant clinical re-engineering in order to deliver efficient, high quality care to populations and that require strong physician leadership to succeed.

Role of the payer

When it comes to negotiating payers' involvement in provider-driven care management systems, the more collaboration, the better, because providers treat patients covered by multiple payers, they must have the capability to coordinate with case managers from each.

"The best option in population health management is not an either-or between the provider and payer," says Dr. Steinberg. "The payer ought to be providing claims data to the provider, and if the payer has case managers, they should make an effort to get the case managers integrated in the physician's office."

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