A focused and automated approach to population health management

Positioning provider groups for success as Medicare accountable care organizations (ACOs), or similar models (“ACO-like”) for commercial and Medicaid populations, requires significant  practice transformation and a total embrace of population health management (PHM).  More to the point, to be “accountable” for populations of patients, provider groups and their care teams will need the help of automated technology and “lean” processes to anticipate and act upon patient needs -- not only when they come into the office, but between encounters as well.

Unlike today’s volume-driven reimbursement system that pays individual providers and facilities for each service delivered, ACOs will pay an organization of providers and facilities a flat fee to cover total costs for a defined population of at least 5,000 people.  ACO payment models are designed to achieve the Institute for Healthcare Improvement’s “Triple Aim” of improving population health, improving each patient’s care experience, and reducing or controlling the cost of care.

PHM, a systematic approach to ensuring that patients receive appropriate preventive, chronic and transitional care to avoid the need for costly care, is fundamental to the Triple Aim objectives.

Implementing PHM starts at the top of a provider-led organization, with committed leadership and vision to create a new practice model that is powered by aligned processes, incentives and technologies for providers as well as patients.  The following six topics are essential for PHM and will help your organization build a roadmap to become a successful ACO.

  1. Leadership and teamwork. Big endeavors require buy-in and championing from physicians and the entire leadership team. Furthermore, the ACO should be a collective effort and foster a team approach, where input from all levels of the organization, from the chief medical officer to the front desk staff, is sought and encouraged. To ensure success, identify leaders at each level within the organization and provide the proper channels for involvement  and training.
  2. Change management. Many different organizations and people will need to change the ways they do business and work together to achieve ACO goals. Be sure to create a formal plan for addressing the human side of managing change. Don’t underestimate this step -- it may require as much planning as the technology, clinical and workflow changes.
  3. Culture of accountability. All members of the organization must embrace and understand that everyone is accountable for improving the care of patients and reducing avoidable costs. Make a formal case for the ACO -- don’t assume everyone within the organization understands the motivation and value for the change. Create a clear structure to guide decision-making and accountability.
  4. IT infrastructure. ACOs will require physicians to manage not just the 30 or so patients they see each day, but patient panels upwards of 2,500 assigned to each physician. Providers will need a proactive approach to preventive, chronic and acute care for all patients, both during and between encounters with the healthcare system. None of this is possible without an IT infrastructure that includes the ability to collect, store and manage data to identify gaps in care, follow patients across sites of care, monitor and stratify patients based on risk, and produce actionable reports for each physician panel.
  5. Measuring outcomes. ACOs require the ability to measure clinical results, costs and patient experience population-wide. These metrics mirror the Triple Aim objectives and are used as the basis for quality and financial reporting -- both internally and externally to payers and other outside entities. Such data analysis is an integral part of PHM and requires specially designed business intelligence applications that must be considered early on in the process.
  6. Patient engagement. The most powerful motivator for empowering patients to better manage their health is the physician-patient relationship. Studies show that patient engagement can improve health outcomes and avoid preventable deaths. Due to the large patient panels ACOs will require physicians and their care teams to manage, a balance between human interventions and automation tools will be essential to stay informed and in contact with patients  before they need more costly interventions.

The ACO model signifies a dramatic shift in strategy for practicing medicine and requires physicians and healthcare organizations to begin planning now if they are to achieve success. These steps, including a technology-driven PHM infrastructure, can ensure that physicians are able to make the transition to accountable care and realize the Triple Aim.

Richard Hodach, MD, is chief medical officer at Phytel.