A Practical Approach to Implementing a Population Health Management Program

Share

By Michael Solomon

Whenever I engage in discussion with health care executives or clinicians about strategies and programs for population health management (PHM), we have to step back and invest the time to get everyone on the same page as to what this broad and widely interpreted term truly means. Not surprising, the notion of population health management is referred to as squishy, and informal surveys suggest clinicians may not know what PHM means to them.

This lack of clarity in definition and scope is a growing problem, because the migration to value-based care and payment models that we’ve been witnessing for several years is accelerating. Yes, there may be a pause by some healthcare systems and payers in moving forward on value-based initiatives until the Trump Administration’s health policies become clearer for the reasons articulated in a recent article posted here. However, we are reminded by executives of key non-government health organizations that payment reform is a bipartisan priority. Regardless of the future of the Affordable Care Act, the Medicare Access and CHIP Reauthorization Act (MACRA) alternative payment model is a driver for continuing down the path of population health management. For additional insights on MACRA, read our recent blog, “Top 10 Takeaways from the MACRA Final Rule.

Making the transition to an environment where payments are outcomes-based requires significant investments in infrastructure and programs to manage the health of patient populations. All stakeholders in health care are affected, including health care systems, payers, and pharmaceutical companies. But, before informed decisions can be made about strategies and investments in this new world, collaborating organizations need to work together toward a common view of population health management that has clear and aligned goals and well-defined boundaries.

Here I will propose a starting point – a general framework that is straightforward and is scoped to be within the “wheelhouse” of a health care delivery organization that is collaborating with payers or pharmaceutical companies to implement population health programs. This framework can serve as the vehicle for developing well-defined, sharply focused programs to target specific patient populations and are managed toward measurable goals.

First, we need to carve out of the broad concept of total population health management those aspects that can be influenced by health care providers. In its most comprehensive form, total population health encompasses management of socioeconomic and environmental factors in addition to clinical and health behavior indicators affecting a defined population’s health status. While this is certainly the long game, Dr. Donald Berwick, President Emeritus of the Institute for Healthcare Improvement and healthcare visionary cautions that the U.S. healthcare system isn’t close to where it needs to be to address the multiple determinants of a population’s health. What can be influenced are the clinical indicators of health and health behaviors of certain patient populations – especially groups diagnosed with certain chronic conditions or at high risk of developing a chronic disease in the near future.

With that narrower band of determinants in place, a goal of population health management programs gaining broad acceptance – and based on the IHI’s Triple Aim – looks achievable: to (1) improve the health of a particular patient population, (2) improve the quality and safety of care delivered to this defined group, while (3) reducing costs. Evaluating progress towards this goal is based on outcome measures already broadly adopted by health care providers (e.g., % patients with blood pressure under control, rate of adverse drug events, emergency department visits). In a value-based world, a payer, pharmaceutical company, and healthcare system can find alignment between this goal and each of their respective strategic interests.

Last, we need a framework to design population health programs to achieve this goal for a specific patient population and set of outcomes i.e., performance indicators. This framework has four components: (1) target population, (2) risk factors, (3) interventions, and (4) key measures. Two examples of actual, clearly defined and scoped, and arguably successful population health programs illustrate this design framework: congestive health failure program at Essentia Health and  vaccination program sponsored by Merck:

image-of-programs-for-phm-post-161031

With this approach to population health management, stakeholders can come together and implement sharply focused programs, and driven by measurable near- and long-term result targets.

I will return to this blog soon to share a business case for pharmaceutical company collaboration with health care systems on population health programs.

Share

5 Ways the Trump Presidency May Impact ONC

Share

By Tony Schueth

In a post on November 14, we laid out our view of the implications of an unexpected Trump victory on healthcare, in general, and health information technology (health IT), specifically (click here). The Office of the National Coordinator for Health IT (ONC) has a profound impact on health IT. Here are five ways the Trump presidency may impact ONC:

  1. President-elect Trump has more than 4,000 political appointee positions to fill, and has started doing so. The National Coordinator for Health IT (ONC) and his/her chief of staff are among that tranche. We don’t expect that Mr. Trump or the transition team will see these roles as a particularly high priority and, if we were advising him, we’d agree. First, he’ll have to name the Secretary of Health and Human Services (HHS) who will, in turn, probably fill the National Coordinator role with someone who sees the role of ONC the same way as the president and secretary. The interim director will be the current deputy, Jon White, MD. A federal employee, Dr. White is among the classiest and smartest leaders in HHS. Furthermore, he gets our world.  He has been at ONC for 2 years and was previously the health IT portfolio lead at the Agency for Healthcare Research and Quality (AHRQ) since 2004. At AHRQ, he was the project officer for the 2006 electronic prescribing (ePrescribing) pilots and 2009 ePrior Authorization expert panel, which is how we got to know him. In our view, ONC is in very good interim hands.
  2. The Office of the National Coordinator for Health IT (ONC) was created in 2004 under a Republican administration (George W. Bush), and expanded during the tenure of a Democratic president (Barack Obama). This is just one piece of evidence that both parties view health IT as being part of the solution – not the problem – given our unsustainable healthcare cost increases and the fact that we rank 11th worldwide in the relative overall quality of our health care. Now, we understand that the word “establishment” was prominent in the election, something Presidents Bush and Obama would be the poster children for and President-elect Trump ran against. But health IT may be too far in the weeds for Mr. Trump to have formed an opinion; almost anyone from health IT who would be worthy of the post of National Coordinator would see health IT and electronic health records (EHRs) as part of the solution.
  3. That said, there are different ways that ONC could operate under a Trump administration. The   Bush era budgets were very lean. The original request in 2004 was for roughly $50 million and a couple dozen staff. Six months later, the budget got zeroed out due to congressional spending cuts; HHS Secretary Thompson had to shuffle administrative money to keep the lights on. The budget was eventually restored to $61 million and 23 FTEs in FY 2007. Under President Obama and the 2009 American Recovery and Reinvestment Act, the budget grew to roughly $60 million in 2013 and 171 FTEs to $92 million in 2016 and 200 FTEs. While that’s an insignificant amount to the Federal government, President Trump may not see the need for that big of a budget or that many people. Now, we understand that under Affordable Care Act, the department was “codified,” meaning they won’t have to justify the budget every year. That said, Congress controls the purse-strings, and they could provide a much lower funding.
  4. A wise man once said that people who look at the same facts with a different set of core beliefs will come to vastly different set of conclusions. There is consensus that we can’t sustain the growth in healthcare spending and the fact is that we do not rank in the top 10 on the world stage as far as the overall quality of our health care system. There are some questions about President-elect Trump’s core beliefs, but he said in debates that he’s interested in the federal government getting out of the way for private industry and Republicans have generally and recently preferred regulations be handled on a state level. To be sure, health IT is complicated with many-to-many transactions galore and some stakeholders being ready before others. The federal government can ensure that stakeholders are ready simultaneously, thereby reducing inertia or abandonment and spurring progress. We would think that ONC will be viewed as playing an important role; it just may not be as big as what it’s been.
  5. ONC can be a convener, certifier, thought leader and influencer of federal and state regulations. The size of staff and budget needed for such roles can be debated; however, ONC’s influence on health IT is profound–especially in relation to what we have already pointed out is a drop in the bucket in terms of federal spending. ONC has some staff from industry, but many more that don’t have such experience. We hope they can attract more of the former, and encourage them to continue to partner with outside organizations and subject matter experts to ensure that they have the expertise to put their goals and objectives into a proper context.

To be sure, we have yet to be invited to Trump Towers, so these are just some thoughts based on experience, not insights into a process. But we will keep our ears to the ground, letting our readers know when changes have been made at ONC. And, in subsequent blog posts, we will explore other possible areas of change in health IT impacting our clients.

Share

Reading the Tea Leaves: What Lies Ahead for Health IT in the Trump Administration?

Share

By Tony Schueth, CEO

The voters have spoken and there will be a new administration in roughly two months. What does this mean for health information technology (health IT)? Point-of-Care Partners (POCP) convened its senior consultants and took a look at the tea leaves. Here’s our preliminary take on at the short-term impacts.

At the federal level:

  • Legislation. There are three laws that could be impacted by the change in administration.

Affordable Care Act (ACA). President-elect Donald Trump was vocal about wanting to repeal and replace parts of this law during his campaign. We believe he will make good on this promise. Early reports indicate this could happen quickly. Making modifications to ACA is likely to occupy a lot of time and energy by the Congress and his administration this coming spring. Replacement legislation could have cascading effects on health IT, such as requiring changes to the health care infrastructure emphasizing interoperability, connectivity and information exchange. Moving millions of patients off and on various public and private insurance plans also creates demand for health IT and a new patient identifier (for a primer on this issue, see our article in the November issue of HIT Perspectives). It also is possible that the Center for Medicare and Medicaid Innovation will be in the crosshairs. If it survives, it may no longer be an agent of change.

Medicare and CHIP Reauthorization Act (MACRA). The new administration will continue implementation of the health IT provisions contained in the Merit-Based Incentive Payment System (MIPS), which is one of two Medicare payment tracks authorized under MACRA (for more detail, see our blog). The health IT part of MIPS accounts for a quarter of physicians’ scores for Medicare payments under this track. Details were spelled out in a recent final rule, which we do not expect will be revisited in the near future. However, President-elect Trump has promised to reduce government regulations, and this new rule is long and complicated. It is possible that once stakeholders have had a chance to digest this regulation and size up the new administration, there could be movement for something different down the line.

21st Century Cures Act. We should not overlook this bipartisan legislation, which has been a work in progress for more than a year (not to mention 19 separate amendments in the Senate). Senate Majority Leader Mitch McConnell and House Speaker Paul Ryan recently announced that final touches were being made to the legislation and they expect to have it on President Barack Obama’s desk by the end of the year. He presumably will sign it because it’s a bipartisan effort and seemingly has “motherhood and apple pie” provisions (although advocates have concerns about some of them). If signed, the Trump administration will have to implement it.

Most people are familiar with this proposed law because it would provide additional funding to the National Institutes of Health and streamline requirements for drug approval by the Food and Drug Administration. Of interest to health IT junkies is Section 3001, Interoperability. According to a summary, these provisions would “refocus national efforts on making systems interoperable and holding individuals responsible for blocking or otherwise inhibiting the flow of patient information throughout our health care system.” How these provisions would mesh with efforts under way by the Office of the National Coordinator for Health IT (ONC) concerning information blocking have yet to be determined.

  • Appointments. President-elect Trump did not say much about health IT during his campaign, but we know that as a chief executive officer he will want to surround himself with top-notch people. As a result, there are several key appointments that could impact health IT.

The first is secretary of the Department of Health and Human Services (HHS), for which Dr. Ben Carson is rumored to be under consideration. We don’t know Dr. Carson’s experience or level of interest in health IT. However, because of HHS’ regulation of health IT and its use in research, quality and payment, the secretary will be involved. The incoming secretary will also need to rely heavily on the new administrator of the Centers for Medicare and Medicaid Services (CMS) and the head of the ONC. This is where the rubber hits the road when it comes to health IT. The CMS will continue its work on standards for Medicare Part D and implementing MIPS’ health IT provisions. We expect the ONC to continue its certification of health IT as required under MIPS. It also is likely to remain the focal point of interoperability, including addressing information blocking, as expressed in a recent report to Congress. That said, it is unclear whether this issue will be of interest to the Trump administration.

We also should not overlook the head of the Centers for Disease Control and Prevention (CDC). Don’t forget that the CDC has been involved in health IT, including monitoring progress toward adoption of electronic health records and issuing a 10-year interoperability plan. Will the agency continue to have a say in health IT in the Trump administration or will it return to its traditional focus on health promotion and disease prevention?

Two transition advisors could have some very influential thoughts as to who might fill these HHS jobs and what their portfolios might be. The first is Newt Gingrich. While he is expected to fill an as yet unspecified role in the administration, Gingrich nonetheless knows quite a bit about health IT. He was heavily involved in health IT circa 2005; his organization, the Center for Health Transformation, authored the book Paper Kills, which was among the first publications to promote the need for and benefits of health IT. The second is Mike Leavitt, former governor of Utah who then served as HHS secretary from 2005 to 2009. In the latter capacity, he oversaw a considerable number of groundbreaking efforts and policies related to health IT, including those related to electronic prescribing under Medicare Part D.

Another potential appointment of interest, although in the longer term, is head of the Veterans Administration (VA). If the VA privatizes some facets of veterans’ care, there will be new and considerable demand for health IT infrastructure and connectivity — as well as the need for a national patient identifier and work on more accurately enabling health IT to connect patients to their records across the health care system.

  • Payment systems. We personally believe the move toward value-based care is necessary to reduce costs and improve quality. We wonder if the new administration will continue the government’s role in promoting value-based reimbursement as well as sponsor demonstration programs and pilots for affordable care organizations and patient-centered medical homes, for example. Or will that that be left to the private sector? If so, it could be some time before the private payers step in. We think President-elect Trump might be interested in the issue as a businessman, a purchaser of health insurance for his company and a proponent of the free market system.
  • Fighting the drug epidemic. The Trump administration will be facing the epidemic of opioid abuse and heroin overdoses, which have shown no signs of abating. We expect states will continue to enact legislation requiring use of electronic prescribing of controlled substances (EPCS) and prescription drug monitoring programs (PDMPs). It is possible the ONC will be asked to step up its role in promoting PDMP interoperability and EPCS.

At the industry level, we see several things happening in relation to health IT. For example:

  • Short-term Inertia. Not surprisingly, the industry will shift into neutral until the dust settles on what the Trump administration will require in the way of health IT and how it will be implemented. Companies will likely slow development as well as put certain agendas on hold, such as population health. These will affect health IT vendors and software developers.
  • Revisit budgeting. We believe payers, facilities and other health care entities will be revisiting management of their revenue cycles and costs in light of the change in administration. It’s very possible that many will go into freeze mode in terms of capital and nondiscretionary spending for several months, if not all of 2017, because of uncertainty and the need to review and revise strategies. This will have a ripple effect on acquisition and replacement of health IT and related infrastructure.
  • Slowdown in mergers and acquisitions (M&A). Until the election, the health IT market had begun to consolidate. Now that there’s a new administration, we expect that consolidation to ratchet down, if not come to a screeching halt, until a clearer picture emerges as to where things will be going. In addition, we expect health systems, which have been investing a lot of money in value-based care and the acquisition of hospitals, to pull back on M&A. As a result, they will put off investments in health IT and infrastructure systemwide or fold new acquisitions into what they already have.

All in all, we believe health IT to be an integral part of the solution, not part of the problem (although we admit there are, well, opportunities for improvement). The keys will be actors, agents and timing. POCP is closely monitoring the transition. Stay tuned for future blogs as developments unfold.

Share