Governance Advice for Hospital Boards: Population Health

"For 60 or 90 days of post-discharge care?"

Writing in the April 26 issue of JAMA, Michael Jillinek of Lahey Health has some important advice for healthcare organization boards of directors.

As income shifts from fee-for-service to global payments, the insurance risk transfers that underlie much of "population health" are an important threat to these enterprises' viability.

After a compact and well-written summary of the growth of population health, he offers six suggestions for these boards:

1. Plan on having "forthright discussions" about the difficult tradeoffs between still-remunerative fee-for-service activities (such as high-dollar imaging, lucrative surgical services) and having to invest in the Triple Aim (care coordination personnel, improving quality measures for persons with chronic illness).

The Population Health Blog suspects most boards will ask why they can't have both the FFS cake and the global payment icing. If that's the case, these boards need to plan on having forthright and very lengthy discussions. It's organizationally difficult to have one mission on the 4th floor of the hospital and another in the emergency room.

2. If the organization's employees are enrolled in a "self-insured" health plan, bring them into a population health program sooner rather than later.

Not only is this an important opportunity for a board to understand the revenue versus savings versus expenses involved in driving the clinical and care experience outcomes of population health, its only right to take this for a personal test drive before subjecting your patients to it.

3. Look for common ground between old fee for service and new global payment arrangements.  The author suggests reducing readmissions is a good start.

The PHB suggests boards ask their management teams to also pursue the care coordination "chronic care management" payments offered by CMS.

4. Start demanding population health metrics from your management team, "such as details of total medical expenditures."

More details on the work of measurement can be found here.  The PHB has also humbly suggests here that health organizations should be prepared to invest significant resources - and discipline - into the process.

5. Invest in primary care, care coordination teamwork and pursue "population health pilot programs."

Since the PHB believes well-intentioned CMS' programs are star-crossed (see here and here), it suggests working with local commercial insurers for starters.  As it reviews resources like this, they seem to have a better track record. 

6.  Ask your management team to be open population health contracting.

Hear hear, says the PHB.  But it also cautions that the board needs to have individuals with the kind of industry knowledge necessary to provide oversight of these contracts.  

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Value Creation for Healthcare Apps - or - Avoiding the Mistakes of "Meaningful Use"

Meaningful Use is debated

Any health care provider who hasn't been sealed in a Faraday cage for the last five years is likely aware of "Meaningful Use 3" or "MU3." Briefly, thanks to the American Recovery and Reinvestment Act (ARRA) of 2009, CMS can impose incentive payments to promote the adoption and "meaningful use" of electronic health records (EHRs).  Meaningful Use or MU has since become its own government program.  MU1 and MU2 are well underway, and CMS is preparing for the third phase, or MU3.
 
But a phunny thing happened on the way to this phase phorum. While insiders have saluted the good intentions behind the latest requirements, there's a lot of bad and even more ugly. It's telling when even the prestigious New England Journal publishes a highly critical perspective like this. It seems that skepticism over the fit of MU with the realities of clinical practices is being misinterpreted in some quarters as technophobic non-cooperation.

And so it goes.

Fortunately, for the Population Health Blog, its psychological EHR scars have long healed.  It, like a lot of other colleagues, has moved to a market of (for example) electronic care solutions that are not local and PC-based,  but are mobile and cloud-based.  And the good news is that - so far - there is no ARRA statute intended to enable a well-intentioned lawyer from uttering those Nine Most Terrifying Words just when the health app ecosystem is reaching critical mass.

But that doesn't mean that we can't learn from the EHR-MU Wars.  To wit:
 
1) Learn from mistakes; for example, better, not more, information technology begets more patient safety.

2) It's ultimately all about user value creation: for example, resist linking the technology to billings/revenue and link it to care/satisfaction.

3) Design with the end-user in mind: for example, release no product unless the intended user has shown that it can fit in their (provider) work flows or their (patient) home setting

4) Align the time frames: keep in mind that the short-term time technology horizon of 2-3 years to may not align with the 5 or more years it takes to "bend the curve" for a insurance risk-bearing organization

5) Resist the allure of government help: while incumbent companies may believe federal legislation may turbocharge their business models, the MU suggests that the downsides are considerable.

CMS and Health Reform: More of the Same

Unmentioned.....

Whoa, with breathless media coverage like this (dramatically change! ambitious!) you'd think that the Feds had just announced something important about health reform. 

After reading the CMS press release, a CMS blog post and this article in the New England Journal, the Population Health Blog has concluded that it's more of the same. 

As the PHB understands it, Medicare's January 26 announcement is that it will build on three ongoing reforms:

1. Financial incentives to expand "alternative payment" methodologies to 30% of all reimbursement by 2016 and to 50% by 2018.  These include accountable care organization arrangements, monthly fees to Patient Centered Medical Homes and use of bundled payments.  In addition, 85% of fee-for-service payments that are still in place will be linked to quality by 2015, with an increase to 90% by 2018.

2. Promoting "provider integration." That apparently means a new forum called the Transforming Clinical Practice Initiative, with a first yet-to-be-planned meeting in March of 2015.  In addition, CMS will continue to rely on its Partnership for Patients and the Patient Centered Outcomes Research Institute.

3. Information technology (IT) including more promotion of electronic records, meaningful use, interoperability and universal information technology standards.

[Yawn]

The cynical PHB is not impressed. The Obama Administration was using, is using and will continue to use faux announcements to advance its reforms.  What's more, when it reads the CMS pabulum, it's riddled with the same top-down mainframe rhetoric on realigning care, moving from volume to value, accountability, alternative payment models, serving populations, building a better system, increasing coordination, convening meetings, promoting information technology etc. There are no new details here.

The PHB will share three insights, however:

1. CMS, Ms. Burwell and their White House handlers lost an opportunity to reach out to the Republicans about the sustainable growth rate and leveraging that to build on multiple areas of agreement to jumpstart bipartisan reform.  Doing so could have accelerated the forward momentum of value-quality-cost-based reforms beyond the 2016 elections.

2. That being said, health care providers need to increase their familiarity with the opportunities as well as perils of payment reform as well as the very real barriers to fixed payment schemes.

3. The announcements are a reminder how CMS is still fixated on the EHR, while the real innovation is occurring in handhelds and their associated applications.  The PHB figures that its not about the providers and their desktop electronic records, but about patients and their smart phones. As these devices continue to grow in speed, power and sophistication, providers who figure out how to use the iPlatform to leverage self-care, communication and decision support will thrive.....

With or without Medicare's incentives, promotion or IT policies.

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