I have the opportunity to travel around the country, interacting with health plans and provider systems as they work out new payment models and new systems of care delivery, and I see an intense interest in these new models coupled with many theories on their pathway to success.
Weighed against the medical literature, three things are apparent:
- Most of the theories on improvement focus on processes that may have small relevance to outcomes.
- Most of the interventions at play are in very early stages and are very incremental.
- Interventions most likely to be linked to big outcomes are culturally challenging and being held at bay for the moment.
A major impact on outcomes requires bold action.
One provider system, struggling to find time for primary care physicians (PCPs) to engage in new models of care, changed their compensation system from volume (RVUs) to value (salary base plus variable contingent on quality). I watched 40% of their primary care office visits evaporate.
I’ve seen independent primary care clinicians, frustrated by the limits of disease management, adopt a patient engagement/self-management support model that works across all conditions and is especially beneficial to those with multiple conditions, resulting in reduced unnecessary ED visits and hospitalizations, improved patient experience scores and better clinical outcomes.
And I see health plans taking a bold step when they move from volume to value-based contracting.
While many provider systems are eager to engage in these new models, they usually struggle with the changes necessary to achieve breakthrough success, which are to move compensation from volume to value and implement system-wide population health management.
The hallmarks of system-wide population health management explain why it has such a profound impact on health outcomes:
- System-wide population health management works with people who may not be coming in to see their PCP, but may be seeing specialists from outside the network.
- System-wide population health management moves beyond the framework of “compliance” to address multiple determinants of health and wellness.
- System-wide population health management requires tools and resources that are not currently found in medical office practices (notwithstanding EMR vendor hype) and are rare, even for most ACOs.
Not all provider systems or health plans will survive this sea change. Some health plans are betting on future relevance by investing in plan-level population health management. But too often population health management is a new label on the old product of case/disease management. Good population health management is fundamentally different.
Plan-level population health will be a good bet if plans figure out how to integrate this work with and provide support to struggling primary care practices, if the care delivery focuses on people and not only a handful of conditions, and if the measurement emphasizes outcomes over processes.
Where this ends up is anyone’s guess, but the current state of U.S. health care makes a case for continued relevance of any group – health plan or provider system – that is (1) willing to invest in the tools and resources to support system-wide population health management, (2) willing to see beyond the incrementalism inherent in the predominant process-driven theories of change, and (3) willing to invest in the long-haul hard work of bold culture change.
L. Gordon Moore, MD, Senior Medical Director for Populations and Payment Solutions at 3M Health Information Systems.