Accountable Care Organizations Can Improve Population Health If They Use The Correct Definition

The right definition was there all along!

Writing in the March 20 issue of JAMA, Drs. Douglas Noble and Lawrence Casalino say that supporters of Accountable Care Organizations (ACOs) are all muddled over "population health."

The Disease Management Care Blog says the article is what is muddled and that the readers of JAMA deserve better.

According to the authors, after the Affordable Care Act launched the Medicare Accountable Care Organizations (ACOs), their stated purpose has morphed from Health-System Ver. 2.0 controlling the chronic care costs of their assigned patients to Health System Ver. 3.0 collaboratively addressing "population health" for an entire geography. 

Between the here of "improving chronic care" and the there of "population health," Drs Noble and Casalino believe ACOs are going to have to confront the additional burdens of preventive care, social services, public health, housing, education, poverty and nutrition. That makes the authors wonder if the term "population health" in the context of ACOs is unclear. If so, that lack of clarity could ultimately lead naive politicians, policymakers, academics and patients to be disappointed when ACOs start reporting outcomes that are limited to chronic conditions.

In short, they don't believe ACOs, as currently configured, are up to the new task.  That's because ACOs would need to collaborate with social service organizations, be responsible for a geographically defined service area and improve long term public health outcomes.  According to the authors' subtitle, the answer to the question "should they try" is "no."

The Disease Management humbly disagrees.  That's because Drs Noble and Casalino, the editors of JAMA and the manuscript's peer reviewers seem to be ignorant of the the correct definition of population health. It's right there on the Care Continuum Alliance's web site, in this longstanding page that describes the "population health model of care."  When the DMCB did a simple Google search on "population health definition," it had little difficulty finding the link.

The CCA helpfully describes population health as:

a delivery model characterized as a physician-guided health care delivery system designed to develop and engage informed and activated patients over time to address both illness and long term health.

Was that so hard?

And how is that accomplished?  According to the CCA, the ingredients to that make for population health include:

• Population identification strategies and processes;

• Comprehensive needs assessments that assess physical, psychological, economic, and environmental needs;

• Proactive health promotion programs that increase awareness of the health risks associated with certain personal behaviors and lifestyles;

• Patient-centric health management goals and education which may include primary prevention, behavior modification programs, and support for concordance between the patient and the primary care provider;

• Self-management interventions aimed at influencing the targeted population to make behavioral changes;

• Routine reporting and feedback loops which may include communications with patient, physicians, health plan and ancillary providers;

• Evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall population health

Accordingly, if an CMS-contracted ACO can identify its assigned Medicare population, perform needs assessments, promote awareness of health risks, offer education as well as support, increase self management, use data feedback and evaluate outcomes, it's offering "population health."  By using that playbook, an ACO will capitalizing on the experience of a community of population health service providers that have been doing precisely this for over a decade.

This vision is far more compact than the overreaching, misinformed and muddled definition of "population health" offered in JAMA.  It is also, if ACOs invest in the right resources and partnerships, well within reach.

The DMCB's answer to the question "Should they try?" is "yes."

Have Good News to Tell About Your Care Coordination Initiative? Share It At the Care Continuum Alliance Annual Meeting!

The Disease Management Care Blog feels your pain. 

You help lead a unique and innovative care coordination initiative.  Your program has some preliminary data that strongly suggests quality has increased while costs have remained neutral or gone down.  Patients are satisfied.  Docs are happy.  You even have a patient anecdote or two.

But something's missing.

While your institution's marketing department has been supportive, you believe that the customers you want to serve are tired of glossy brochures, breathless press releases and chatty sales reps.  Your customer meetings are fun, but you can't tell if the positive feedback is the result of real insight or that second glass of wine. 

On the other hand, the prospect of publishing your findings in some scientific journal is too dreary to contemplate. 

You know some more meaningful is at stake.  You want to share your good news and get some feedback.

Here's your solution: the Care Continuum Alliance Annual Conference.  Hundreds of individuals just like you - individuals who give a damn about patients, are excited about making a difference and want to make a living doing it - will be available to give feedback.  Who knows, some of them may talk partnerships.  Others will resent your competition, confirming that you are on the right track.

The CCA Call for Proposals can be found here.  You have until March 6 to submit.

Does Hiring A "Care Coordinator" Assure Care Coordination?

Apparently not.

That's the Disease Management Care Blog's main take-away after reading the Care Continuum Alliance's "Population Health Management in Physician Practice: A Call to Action."

The CCA commissioned a survey that asked 105 primary care physician leaders about the implementation of population health-based care coordination in their clinics. The clinics were from all regions of the U.S. and ranged in size from 5 to 95 physicians (a total of 1,916 physicians with a mean of 18).  To be included in the survey, they had to be planning or had already implemented patient-centered care initiatives, many of which were modeled after the medical home. 93% already had an electronic record and10% reported being part of an Accountable Care Organization (ACO).
 
First the good news.

Over and beyond hiring non-physician providers (96% had at least one nurse practitioner and 70% had a physician assistant), 91% reported that they had hired a "care coordinator."  What's more,  85% said that population health was conceptually important in their practices and the majority 55% rated this as either a "4" or "5" on 1 to 5 scale.

But the bad news is that less than half were familiar enough with the concept to fully implement it in clinical practice.  The number one challenge in this area was the difficulty in making sure that roles and responsibilities of the care coordinators were appropriately defined. 

It should be noted that the practices surveyed in this report were not typical of primary care,  where experience with care coordination is even lower.  This was a elite group of innovators on the cutting edge of primary care who had committed precious resources and already were hiring care coordinators. Yet even these select clinics risk being operationally stymied by not knowing how to effectively implement it in their practice settings. 

The CCA report appropriately concludes with a call for education, tools and support to help physicians fully implement this in their clinics.  The DMCB wholeheartedly agrees.  Based on this report, hiring care coordinators is certainly necessary but isn't sufficient to attain high quality population health.

We still have our work cut out for us.

What You May - or May Not - See at the Care Continuum Alliance's Forum12 Annual Meeting in Atlanta

Along with many readers, the Disease Management Care Blog is looking forward to the Care Continuum Alliance's annual meeting, Forum12, two months from now in Atlanta. Not only will the DMCB get to make new friendships, the plenary presentations and smaller educational sessions are great way to learn how to apply the theoretical underpinnings of wellness, prevention and care management to the real world.

To help attendees better prepare for the meeting, the DMCB is pleased to offer this Lettermanesque "Top Ten" of things you may, or may not, see at the Forum12:

10. Someone genuflects upon hearing the term "CMS Innovation Center."

9. Only healthful fruit is served at one of the meeting breaks; in response, attendees riot.

8. A DMCB YouTube video is embedded in session PowerPoint (hey, it's happened).

7. Three quarters of the attendees sitting in on a session are from the presenting faculty's company.

6. Someone shows up at an early morning pre-meeting yoga class dressed in business attire, thinking it was a presentation on the return on investment from an employee yoga program.

5. The term "engagement" is used 20 times by a presenter in the course of ten minutes.

4. One faculty member hits a "presenter's trifecta": 1) arrival flight lands on time 1/2 hour prior to the presentation, 2) he or she finds the meeting room within minutes and 3) catches the departure flight 1/2 hour after the end of the presentation.

3. The imposing booming disembodied voice asking you to take your seat at a plenary session is that of a female. With attitude.

2. The competition between the exhibitors for your attention becomes so intense, one offers free beer. Others follow suit.

1. The DMCB spouse "crowdsurfs" one of the plenary sessions.

How To Provide Care for the Medicare-Medicare Duals: The Population Health Management Playbook

The Care Continuum Alliance (CCA) has come out with an important report on how to improve the care of the 9 million persons who are "dual eligible."  These individuals are among the most economically vulnerable and sickest Americans.  They simultaneously qualify for both Medicare and Medicaid and their health care costs are staggering.

The CCA recommendations for the care of duals on a regional or state basis should not be unfamiliar to regular readers of the Disease Management Care Blog: collect the necessary data, risk-stratify the individuals, maximize coordinated care for those at greatest risk, work with the docs, measure outcomes, lather, rinse repeat.

No knowledge base on disease and population health management and dual eligibles is complete without this download.  Check it out and you'll learn that....

Data on this population should be centralized, comprehensive and interconnected: This means pooling insurance claims, electronic records, labs and pharmacy and making the data available in health information exchanges.  How else will program planners understand the dual's needs, plan programs, foster communication among providers and evaluate outcomes?

The population should be risk stratified.  Health risk assessments are a good option because these persons may drift in and out of dual eligibility.  Incentives should be offered to increase the likelihood that the HRA surveys will be completed.

Professional care planning should be used to to best "position" patients in a coordinated, patient centered and streamlined manner.  This coordination should include providers, pharmacy, behavioral health and long term care to maximize mental health support, rehab, end-of-life care, additional counseling needs and referral to community-based programs.

Provider incentives should use all possible options including capitation, shared savings and bonus payments.  Training and tools should be made available.

Goals for the dual population should be defined and there should be measurement of progress toward those goals.

The Care Continuum Alliance Webinar Series on ACOs: Not To Be Missed

The internet can make me smarter?!

Feigning modesty once again, the Disease Management Care Blog is very pleased by the strong audience strong speaker ratings for the ACO webinar "Realizing the Potential: Assessment and Stratification Tools for Accountable Care Populations"  that it co-presented back on July 28.  You can find out more about what you missed by accessing a recording, plus finding out more about the follow-on presentations here. 

Note that the second webinar of the series is happening today at 1:30 EST and that it's not too late to register.  The speakers are eHealth Initiative CEO Jennifer Covich Bordenick and the extremely smart Emory University and Thomson Reuters researcher Ron Goetzel.  They'll be tackling measurement, reporting and finding solutions when it comes to optimizing outcomes for ACO populations.  Click here so you can see whether an ACO is a good idea and how your competition may be appoaching this important topic.

Added bonus: If you're a practicing doc or a hospital administrator, the good news is that you may qualify for free access to the webinar plus DMCB recorded presentation!  Is that a good deal or what?

This high octane ACO learning series culminates in two half day special sessions that are part of the Care Continuum Alliance Forum 11. Confirmed speakers represent a broad variety of prominent stakeholders, including The Lewin Group, Centers for Medicare and Medicaid Services, National Committee for Quality Assurance, TransforMED, TowerBrook Capital Partners, Park Nicollet Health Services, MedAssurant and others.

Time To Share Your Good News

Thousands of Disease Management Care Blog readers have come to recognize that it's possible to launch robust population-based care management programs and simultaneously study and manage the outcomes. That methodology also means that you can also share your results with your colleagues at scientific and industry meetings.

Case in point: the Care Continuum Alliance annual meeting called Forum11. There is still time to submit an abstract. Not only will you and your company get the recognition you so richly deserve, but it will be a great excuse to network and learn at a great meeting. You may even get to see the DMCB in person!