Operation Population Health: Cultural and Process Changes Facing Hospitals Today


Although the concept of population health has taken hold on the healthcare industry in the past few years, it is nonetheless easy for it to remain just that: a concept.

The following content is sponsored by xG Health Solutions.

Although the concept of population health has taken hold on the healthcare industry in the past few years, it is nonetheless easy for it to remain just that: a concept.

Change doesn't come easy in hospitals and health systems, but this is even more the case when a change is systemic and far-reaching — precisely the intention of population health. Hospital leaders may struggle in breaking down population health from high-minded, intangible concepts to actionable processes.

Earl Steinberg, MD, CEO of Columbia, Md.-based xG Health Solutions and executive vice president of innovation and dissemination at Danville, Pa.-based Geisinger Health System, says population health brings along a tandem of challenges. One is strategic, the other operational.  

"Population health turns the business model for hospitals upside down," he says. "Hospitals historically focused on putting heads in beds and providing services that generate income. In population health, they're incentivized to keep people out of the hospital and only provide services that are clearly necessary. That represents a complete change in their business model. Once they've embraced that change, then operational challenges come into play."   

The strategic challenges
Janet Tomcavage, RN, chief of population health for xG Health Solutions and chief administrative officer for Geisinger Health Plan, says healthcare delivery organizations have never been very good at thinking about a population's needs.

"We've been good at taking care of one patient at a time," she says. "Now we're asking healthcare delivery organizations to step back and take accountability across the whole spectrum of care, the whole spectrum of health — from birth, childhood, adulthood to end-of-life care. That's not a place healthcare, traditionally, has been."

Health systems must adopt a new mindset under population health, one that is not necessarily incremental in nature. Although hospitals may still largely operate under a fee-for-service pay structure, they are increasingly expected to behave as though they are reimbursed under a pay-for-value model. This means there is much less business as usual.

xG Health Solutions experts say the organizations most successful in adopting population health behaviors are those with senior leaders deeply committed to the change. The workforce of a hospital or health system may know they need to change their business model, and many even want to do so. But this intent is meaningless without champions in the C-suite.

"We find the organizations most successful in moving forward in the transformation process are those with the most senior leaders who believe that the organization needs to change, from the CEO to CFO to chief clinical officer," says Ms. Tomcavage. "I think organizations know they need to change, and many times they want to. However, senior leaders often don't feel a sense of urgency or don't have a strategy for transitioning from volume to value. Both are critical, and organizations that will be most successful have both from the start. Then they empower the people at the next level to implement the strategy."

Even if a hospital has a well-adjusted workforce and change-friendly culture, the concept of population health and all it entails can prove overwhelming. People must remap their view of what the healthcare system is supposed to do and develop new capabilities. To mitigate exhaustion and cynicism, leaders must mindfully communicate the implications of population health to drive engagement, understanding and morale. Given the "rookie" nature of population health — hospitals are still very much learning from one another via trial and error — it is also beneficial to make the transformation as collaborative as possible.  

"There's an old saying," says Dr. Steinberg. "'If you want someone with you on the landing, you want them there for the takeoff.' Involving people and getting their fingerprints on the design of a solution is more effective than shoving it down their throats," he says. For instance, if physicians are missing from the table when population health decisions are made — such as those involving evidence-based protocols or care redesign — hospital leaders may have a difficult time gaining their engagement going forward.

The operational challenges
Once a hospital's workforce embraces the changes required in population health, the work really begins. The operational challenges involved in this transformation are aplenty.

For instance, hospitals need to master and employ entirely new sets of population health-related data analytics, such as clinical and financial analyses of insurance claims and electronic medical record data. They also need to take on responsibility not only for the inpatient component of an episode of care, but also for the broader continuum. This requires hospitals and leaders to consider other parts of the delivery system, such as home health, post-acute facilities and various ambulatory care settings, all of which are important to transitions of care.

Hospitals embracing population health also need to slash unwarranted variation in care, a task many have not focused on in the past, says Dr. Steinberg. This doesn't mean hospitals and physicians were negligent. Rather, unwarranted variation is a byproduct of the autonomous nature of medicine and the traditionally fragmented healthcare system.

"Doctors would pretty much deliver the care they wanted, and that resulted in variation in almost every aspect of care," he says. Now, hospital and physician leaders must identify these variations and root them out in a way that improves outcomes and reduces costs. Leaders must think about variation not only at a physician-level, but also in terms of facility and regional variation. The lens needs to widen.

These challenges are interrelated, and healthcare organizations won't succeed if only some behaviors change. For instance, a primary care physician may take on accountability for a population. But if the health system really needs the physician to drive down the total cost of care and improve quality outcomes, the PCP will need to be accountable for what happens to that patient in the nursing home or under the watch of a specialist, as well as for primary care.

"While they may not provide the care, they still need to keep the patient in the line of sight and remain accountable for what other parts of the organization may do to that patient," says Ms. Tomcavage. "They need to call up the hospitalist and say, 'Here's what's been going on with this patient.' It also means PCPs need to steer patients to specialists who really are higher value."  

Another challenge isn't specific to physicians. Rather, it involves hospitals' and health systems' non-physician workforce, which has an incredibly important role in the dynamics of population health. "There is a lot of workflow redesign that needs to happen in the acute arena and physician practice site," says Meg Horgan, RN, senior vice president of advisory services for xG Health Solutions.

Part of this modern-day, population health workflow involves staff caring for patients even after they've left the hospital or physician office. The work of care managers or other staff is seemingly infinite. Pre-appointment planning, medication reconciliation and discharge management can prevent and eliminate barriers that derailed patients' care continuums in the past. Solving these problems, such as lack of transportation to an appointment, is exciting and has great potential to improve a population's health — but it also requires changes to how hospitals and health systems have traditionally functioned.

How long will it take?  
Part of what might make population health daunting is the uncertainty around how long this transformation should, or could, take. It is difficult to master large-scale organizational, even industrywide, change without a sense of pace. Dr. Steinberg says he thinks at least one thing will light a fire under hospitals.

"I think the amount of time any of these things take depends on the speed with which the payment system changes," he says. "The more changes that occur in how a health system gets paid, the faster any of these required changes will occur. Some things are doable within a one-year period. Others will take five or more years. The timeline depends in part on how many different things you attack at one time."

More Articles on Population Health:
5 Myths Surrounding the Business of Population Health Management
What Organizations do Hospitals Partner With for Population Health?
Health System C-Suiters, Meet the Chief Population Health Officer


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