Population Health – The Myths and Realities of Achieving

a Healthy CommunityLancaster General Hospital

November 17, 2011

Steven Peskin, MD, MBA, FACPEVP and Chief Medical Officer, MediMedia

Associate Clinical Professor of Medicine, UMDNJ

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Major Issues with the US Healthcare System

• Poor and uneven access to medical care, especially for the uninsured

• Escalating costs and volume of services

• No link between cost and quality

• Excessive administrative costs

• Dysfunctional payment system

• United States is lagging internationally in health outcomes

Real Reform: Real Leadership

1. The missing link is links!

2. Comparative outcomes are all relevant and visible to patients.

3. Many treat, few prevent.

4. Create a culture of health.

Real Reform: Real Leadership

Current Approach

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Focus on current medical problem

Primary care physicians

Care based on periodic visit

Short visits with little information

Decisions by clinical autonomy

Information restricted

One size fits all

Patient a passive participant

New Approach

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Focus on all risks

Cooperative team of providers

Continuous healing relationships

Emphasis on education & coaching

Evidence-based decisions

Electronic information flows freely

Care customized to needs & values

Patient/family active participants

The Concept of Population Health Management

• PHM programs are a set of interventions designed to maintain and improve people’s health across the full continuum of care–from low-risk, healthy individuals to high-risk individuals with

one or more chronic conditions. • Populations targeted by PHM are often delineated by

health benefit source rather than geography. However, some proponents argue that because improving population health is a national goal, a target population can also be identified broadly, as in “all citizens of the United States,” as well as narrowly, as in “all people who call Dr. Jones their doctor” (Berwick et al. 2008).

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Conceptual PMH Framework

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The Conceptual Framework

Population health is person-centered; organizational interventions are tailored to the individual and community resources are targeted to individuals. Individuals are evaluated to identify their place on a continuum of health risks, from no or low risk to high risk. Specific interventions, such as health promotion and wellness, risk management, care coordination/advocacy, and disease/case management, are targeted to people based on where they fall on the continuum of risk/care.

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Aspects of PHM Cont’d

•Patient self-management education

•Focus on health behavior and lifestyle changes

• Interoperable electronic health records

•Electronic registries

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2011 Lancaster, PA Snapshot

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2011 Snapshot comparison of Lancaster County vs. the MOST HEALTHY (CHESTER) and the LEAST HEALTHY County (Philadelphia) County in PA when comparing Health Factors

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2011 Snapshot comparison of Lancaster County vs. the MOST HEALTHY (UNION) and the LEAST HEALTHY County (Philadelphia) County in PA when comparing Health Outcomes

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Population health engagement – menu of options

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Population Programs

Screenings

Referrals

Target Programs

• Telephonic Health Coaching addressing lifestyle and chronic conditions

• Mail based programs• Onsite programs

• Worksite• Physician’s Office• Hospital• Other Clinical Facility• At Home• Lab option

• Communications• E-messaging • Online Programs• Campaigns

• Warm transfers/ HA• Health Plans• Employers• Physician’s • Other Providers

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The Three Pillars of Engagement

Source - Staywell Health Management 2011

Obstacles to PHM

In the U.S., the biggest barriers to population health management are:• Fragmentation of care delivery• Misaligned financial incentives • Lack of managed care knowledge• Insufficient use of health information technology

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Three Pillars of PHM

• To execute on the promise of PHM, physicians and their care teams must strengthen their relationships with patients in a variety of ways, including making sure they come in for needed preventive and chronic care. Care teams, which include physicians, midlevel practitioners, medical assistants, and nurse educators, must optimize the services they provide to patients during office visits. And as a coordinated team, they must extend their reach beyond the four walls of the office to provide a continuous healing relationship. The appropriate IT tools can facilitate achievement of all three goals while lessening the burden on practices.

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The Beginnings of Change

•Over the past 15 or 20 years, approaches such as pay for performance and disease management have had a limited effect on quality improvement.

•More promising models have emerged in the past few years. These include:

– Patient-centered medical home (PCMH)

– Accountable care organization (ACO).

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Patient Centered Medical Homes

• While much progress is being made on the PCMH, practices that try to become medical homes can encounter obstacles.

– Small primary-care practices may lack the time and the resources to transform themselves and acquire the necessary information technology (Nutting, Miller, et al.).

– They may find it difficult to gain the cooperation of specialists and hospitals.

– Physicians may not receive adequate financial support from payers for coordinating care (Landon, Gill,et al.).

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Accountable Care Organizations

• ACOs consist of hospitals and physicians that take collective responsibility for the cost and quality of care for all patients in their population.

• ACOs may be single business entities, such as a group-model HMO or an integrated delivery system. But they could also involve an “extended medical staff” or a contracting network that includes a healthcare system.

• Core of ACO’s may be medical homes

• ? The future of population health management

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The Promise of Population Health Management: Crucial Role of Automation

• What is also needed for successful PHM is an electronic infrastructure that performs much of the routine, time- and labor-intensive work in the background for physicians and their staffs. Tools exist but are underused.

• Technology is not a substitute for the physician-patient relationship. But to the extent that automation tools are used to strengthen that relationship, technology can help drive population health management.

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• In order to be able to effectively manage all aspects of health from wellness to complex care, healthcare organizations must assess the entire population, taking advantage of online or web-based programs.

• Patients can then be stratified into various stages across the spectrum of health. – Those who are well need to stay well by getting preventive tests completed

– Those who have health risks need to change their health behaviors so they don’t develop the conditions they’re at risk for

– Those who have chronic conditions need to prevent further complications by closing care gaps and also working on health behaviors.

• Technology can be very helpful in assessing and stratifying patients and targeting interventions to the right people. The automation of the processes provides a more efficient and effective way to do population health management.

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The Promise of Population Health Management: Crucial Role of Automation