Pressure Points This is the second in a series of special issues taking a closer look at the factors shaping modern medicine.

From Intervention to Prevention:
Demystifying Population Health Management

caring for patientAmerica’s health care system is broken.

Costs have ballooned, now closing in on 17.9 percent of our gross national product (roughly, this means that for every $6 spent, $1 goes to purchase health products or services). And though we spend almost twice as much, per-person, as any other nation – saddling future generations with crushing debt, making us less competitive in a global marketplace – we’re hard-pressed to prove we’re any healthier.

Fortunately, that’s changing. Eager to make sure future investments bear real fruit, federal government is driving dramatic transformations.

“Political and health care leaders have long understood that the most humane, sustainable way to manage medical costs is to help people avoid the need for expensive services altogether, intercepting problems before they escalate,” said URMC CEO Bradford Berk, M.D., Ph.D. “But the way health care is both delivered and financed has to change dramatically first to even make that idea work.”

Enter Population Management

So how do we switch gears from thinking of health care as a series of isolated, reactive, crisis-type encounters, to a big-picture approach that anticipates needs and improves outcomes — especially amongst the highest-risk patients? (Individuals with chronic conditions, after all, consume the single largest portion of our national health care tab – close to 70 percent of all expenditures, thanks to times spent in emergency departments and hospital beds).

The idea is to adopt a system focused on proactively keeping people well – not only because it’s the ethical thing to do, but because it makes fiscal sense. Healthier people tend to need costly care less often. Take the experience of Pennsylvania-based Geisinger health system; after adopting a “medical home” approach to primary care that invests heavily in prevention, leaders there saw overall hospital admissions drop off 20 percent. Per-patient care costs were trimmed 7 percent.

Instead of simply seeing patients as they call for “sick” appointments, Geisinger and other health reform leaders are preaching “population management” – a doctrine that involves scanning large group of patients and asking, “What are the pressing health needs of this population, and how can we best satisfy or even preempt those?”

population graphicWhat defines these “populations” might be general shared conditions, such as diabetes or congestive heart failure, or more specific details, such as needing hip replacement or open-heart surgery, explains Steve Goldstein, CEO of Strong Memorial and Highland hospitals. Members might also be diverse; take a group of workers employed by the same organization, like our university.

“Essentially, a population is any community in which you are going to focus on improving outcomes, quality and cost,” he said. “The interventions you design to manage its care will be unique to the needs of the population itself.”

To expertly manage such populations, health systems must build a broad portfolio of organizations and disciplines, stretching from preventive programs to primary care practices, outpatient, acute, and post-acute facilities to community-based services like home care. These providers must freely share information – and accountability for proactively managing patients’ care.

IT-Powered Medical Homes

At the heart of population health management lays the patient-centered medical home (PCMH).

At first blush, it might resemble a primary care office, but look closer; you’ll see an unprecedented proactive, team approach to care. Coordinated by a patient’s own physician, nurses and data coordinators, care in the Medical Home model stresses prevention, early intervention and close partnerships with patients to tightly manage chronic conditions. Medical homes are absolutely critical in making the leap from intervening when there’s a problem to preventing the problem in the first place.

“The patient-centered medical home breaks the back of spiraling costs by creating a mechanism to take care of high risk and chronically ill patients,” Goldstein said. “That’s why payors are focused on creating medical homes for Medicaid patients that carefully manage those with chronic conditions so that they don’t end up in the ED, moving from crisis to crisis.”

The National Committee for Quality Assurance has certified all 21 practices in URMC’s Primary Care Network as the highest level patient-centered medical homes, thanks to concerted changes in the way these practices are organized, staffed, and supported by information technology (like eRecord).

“The managed care of the 80’s and 90’s failed because we lacked the technology infrastructure needed to really analyze practices and more strategically deploy limited resources – staff, time, money,” said Betty Rabinowitz, M.D., Medical Director of URMC’s Center for Primary Care.

“But in the era of electronic medical records, we do. Doctors are developing the tools to look across their patient population, sort and group patients by common traits, make informed choices about where dollars and energy are best spent, and then measure their progressin real time.”

To demonstrate, Rabinowitz flashes up a computer screen with a clean, color-coded set of simple graphs that chart a single practice across several measures – a dashboard of sorts.

“This bar chart shows me how many patients have been seen in the last 30, 60, or 90 days – even those that haven’t been seen here in two years or more,” she said.

With the click of a mouse, she delves deeper within the delinquent patient pool to see how many have diabetes, and further, which subset has diabetes that may be uncontrolled. The same intelligence is available for groups of patients with other conditions – information the practices refer to as “disease registries.”

Within the medical home, data coordinators generate and pore over such registries, interpreting data for physicians and care management nurses who are then responsible for making sure patients receive appropriate preventive care, comply with health plans, and don’t slide downhill. Care managers are registered nurses with sufficient time and training to work with patients on improving nutrition, channeling motivation, or simply connecting to community resources. (See related article for a glimpse into how care managers help patients stay healthy.)

Thanks to today’s IT capability to track clinical measures across a practice over time (eventually, these sorts of tools will need to be shared more broadly, charting clinical measures overan entire network over time), patients and their physicians will be able to tell, empirically, whether or not population health management is actually working. New national benchmarks give further direction, clarifying quality goals and giving medical homes concrete standards to strive for. For instance, the National Committee for Quality Assurance establishes explicit criteria for medical homes it certifies – goals such as no more than 15 percent of a practice’s patients should have uncontrolled diabetes.

“Doctors can then compare their practice’s performance, and see how well they’re helping patients be better stewards of their own health,” Rabinowitz said. “That’s where population management really starts to come alive."

Changing How Money Flows

Although the medical home may be its fundamental building block, true population management happens across a broad network of doctors and organizations that provide a continuum of care – stretching from patients’ own homes, to medical homes, hospitals and nursing homes, to rehabilitation centers, and more. This spectrum offers systems the flexibility to move patients to the most medically appropriate and cost-effective setting.


Yet today’s fee-for-service reimbursement models still pay individual players for services rendered, creating a fractured system that, frankly, incents providers to see more patients. To support population management, more flexible financing models are needed. They must empower provider networks to choose where in the system they need to direct dollars to achieve the best possible outcomes.

This turns modern-day medicine on its head. Suddenly, the bulk of the risk shifts from payors to networked providers. Armed with a fixed tab to provide care to a given population, health networks that invest wisely stand to earn money; but wrong choices are costly. They can lead to losses that must be borne by the network itself.

The good news? If networks avoid hospitalizations, the cost-savings, theoretically, can be reinvested in prevention and other ways of keeping patients well – and so the cycle continues.

Implications for Hospitals

While helping patients avoid ED visits and hospitalizations makes smart medical and economic sense, it has undeniable implications for hospitals and those who work within them.

“Historically, hospitals have thrown down the gauntlet, saying, ‘we’re here, so use us’,” Goldstein said. “The fee-for-service reimbursement system set up a dynamic in which the more care we provided, the more we got paid. That’s why providers began marketing to increase utilization and margins.”

But now, with the imperative to cut costs, the federal government has launched population management demonstration projects that are designed to provide what people need, not what providers want to sell them.

In this scenario, he says, hospitals are going to have to work with physicians to be sure that they are providing the right services that make the population as healthy as possible.

“We stand to avoid health crises. We’re allowing the patient to participate in his or her own health,” he said. “Really, it’s a common sense way to think about health care.”

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