Your population health efforts should focus on primary care first

The focus of population health efforts to date have been risk identification and stratification. Those two capabilities are, indeed, critical to improving the health of your populations. But they are only one part of a much bigger puzzle, and it’s time for healthcare executives to focus on the big picture.

It’s not hard to imagine why we’ve spent so much time on the analytics. While data integration remains a challenge, it’s a lot easier to extract data from numerous sources for analytics than it is to create true interoperability among clinical applications. And analytics are a fairly clean project, with little of the messy human and cultural changes that are at the heart of the rest of the puzzle. So analytics are a good place to start.

Inevitably, though, healthcare executives are going to have to face these messy human and cultural changes, as well as the barriers to the free flow of information. Because once you identify the gaps, you have to close the gaps. And that requires facing these challenges head-on

The first step is to understand why the gaps exist. The analytics for that are more problematic and require a lot of socioeconomic data that is harder to get and harder to integrate than clinical and claims data. But it will be necessary.

One example of an organization that is attempting to do this combines the clinical and claims data with socioeconomic data to identify the hidden risks in a population. A western Massachusetts integrated health system includes in their risk algorithms factors such as distance from a patient’s home to a primary care provider and availability of transportation and family support. Their thinking is that if you live too far from a clinic or don’t have transportation or family support, you are less likely to get regular care. If you are at risk for diabetes or another chronic condition, those facts are red flags, because you aren’t likely to get the help and support you need to avoid that condition.

This is just one example of the kind of challenges we face in population health. It’s going to be as much about social support as it is about medical intervention. Income, location, health literacy, family support and a dozen other factors will have far more power over outcomes than anything that happens in the exam room.

For healthcare executives who have spent their careers focusing on procedures and inpatient care, that’s a big change. It’s going to take some creative problem-solving to figure out how to influence the patient’s environment in ways that will really make a difference.

Technology is part of the answer, but attitude is just as important
In last month’s column I wrote about high-value primary care providers, those who got stellar outcomes with only about half the per-capita healthcare expense as other practices. These primary care teams (and they are teams, not just physicians) exhibit significant cultural differences from other practices, starting with a laser-like focus on patient needs that go beyond diagnoses and medications. When they invest in technology, they choose carefully. If it can help them provide better care at a lower cost, they invest. If not, they don’t.

Notably, all of these practices make sure their physicians have mobile access to the electronic health records of their patients. That means a physician on call will have all the information needed to help a patient and to make good care decisions. Mobile access is one piece of technology that should be de rigueur for primary care (and for specialty practices, too).

But the cultural differences between these high-value primary care providers and other practices go way beyond good use of technology. They start with the attitude and belief that when people need help with their health, they shouldn’t have to wait until it is convenient for the provider. To quote the study that identified these practices, “Patients have a sense that their care team is ‘always available,’ and that they will be able to reach someone who knows them and can help them quickly whenever necessary.”

To accomplish this, they set business hours that reflect the reality of patients’ lives, not the 9-5 world most practices inhabit. These providers offer same-day appointments, accommodate walk-ins and extend office hours to include evenings and weekends.  Physicians take their own after-hours calls most of the time, making use of mobile access to the EHR to ensure all knowledge of each patient’s condition is available for decision-making.

These practices also treat people as individuals, adjusting treatment intensity to patient need. Often those who are the sickest got that way because they didn’t have access to the support they need. So to improve their outcomes, you have to give them that support.

In these high-value practices, if you are “high-risk” you get more help, including a care manager, longer office visits, frequent phone checks by staff and even house calls if needed. This is an area where technology can make a big difference. Telehealth and remote monitoring have proven to be very useful in providing, at an affordable cost, the extra care needed by people with chronic conditions.

Transportation is also a barrier for many patients, and some healthcare systems are partnering with Uber to get patients to checkups. While the cost may not always be covered I’m willing to bet the data will quickly show the payoff from this will justify the expense of providing the transportation.

But telehealth, remote monitoring and even free rides with Uber won’t make a lasting difference unless they are part of a culture that cares more about patient convenience than provider convenience.  And too many primary care practices are still provider-focused.

Changing the status quo
So how do you begin the cultural change that will transform care? You start by understanding what changes are needed to improve care, then finding all the ways the needed changes will make things better for physicians. Indeed, the physicians in these practices have an enviable quality of life. Because they practice as a part of a team, they aren’t distracted and overwhelmed by the tedious detail of medical care. Instead, they get to focus on the things that matter, the things they trained to do. They are intimately involved in diagnosis and treatment decisions, but they aren’t deeply involved in all the other details of care and the business of the practice. They have staff who focus on those tasks, and they have advanced practice nurses and physician assistants who take care of the stuff that doesn’t require their level of expertise. As the study authors note, “these small-scale, mainstream primary care exemplars enjoy a competitive income” as well as high job satisfaction and a good quality of work life.

If you are a CEO of a healthcare provider organization or a health plan, you need to carry this message to physicians. It is always better to show than tell, especially if the tale you're telling contradicts existing cultural norms. Start, perhaps, by choosing physicians who are inclined to make changes for the better and send them to visit these practices and shadow their colleagues. These physicians could then become advocates in your community for high-value care.

You also use data. Most physicians are competitive by nature (they wouldn’t have gotten into medical school if they weren’t) and are eager to outperform their colleagues. If you provide them the data on their outcomes and costs and how that compares to these high-value practices, you’ll get their attention. It’s not the only thing you need to do, but it is a good tactic for starting the conversation. With the help of those physicians who have seen this style of practice in action, you can then guide your community of physicians to find answers that work for them.

You also need to support their efforts in tangible ways. For health plans, that means reimbursing primary care physicians for all the care they give, not just procedures, and doing so at a generous rate. You may spend more on primary care physician payments, but you’ll ultimately spend less on overall care.

For hospitals and health systems, you need to offer easy access to technology such as mobile access to EHRs and telehealth, and you need to make sure data flows unrestricted within your system. If a patient is seen in one of your facilities, make sure the patient's primary care physician knows about it immediately and gets all the data from that visit. 

High-value primary care is critical to your survival
Your health system or health plan won’t survive if you don’t nurture high-value primary care. That may seem like a bold statement, but the system is losing its ability to sustain high costs and poor outcomes. To stay profitable and competitive, you have to become a high-value organization, and you can’t do that without high-value primary care physicians. The patient experience and patient loyalty start with them and how they do business. Any attempt to change the system that doesn’t recognize that fact is unlikely to succeed.

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