Patient Engagement

A Requiem for Population Health?

Article · March 21, 2018

Some pundits are already sounding the death knell for value-based care, a vital tool in the pursuit of a healthier population. Granted, it is difficult to maintain a balanced, evidence-based perspective in the face of unprecedented negativity, fear, and the omnipresence of “fake news.” But, like most of my colleagues in the health policy and population health communities, I prefer to begin with a close look at the evidence.

It is true that early outcomes of health care reforms have been mixed; however, there appears to be sustained momentum in the direction of value-based care (VBC). Some initiatives are achieving positive savings and quality outcomes, while others are producing mixed results. For example, the Hospital Readmission Reduction Program has been successful in improving care coordination between hospitals and alternate care settings, thereby reducing overall costs. Other value-based programs, such as the primary care medical home (also known as the patient-centered medical home) and accountable care organizations (ACOs), are successfully reducing duplicative services and unnecessary hospitalizations without directly cutting costs.

Benefits usually accrue with length of experience, and VBC is no exception. It should come as no surprise that the greatest successes are being achieved by pioneering VBC programs (e.g., Intermountain Medical Group and Mayo Clinic) that have spent years in the trenches, developing clinically integrated networks and/or working with physician practices to establish global payment contracts.

A majority of the nation’s ACOs reduced Medicare spending in the first 3 years, and 82% also improved the quality of care they provided, based on data from the Centers for Medicare and Medicaid Services on 33 individual quality measures. In fact, ACOs outperformed fee-for-service providers in 81% of the quality measures. While recognizing that some policy changes may be warranted, the Office of Inspector General recently concluded that ACOs show promise in reducing spending and improving quality.

Although the new Administration has given mixed signals regarding mandatory programs such as the Episode Payment Models, there appears to be support for the voluntary Bundled Payments for Care Improvement Initiative. Also of note, the Physician-Focused Payment Model Technical Advisory Committee (PTAC, a generally overlooked entity created by the Medicare Access and CHIP Reauthorization Act), continues to evaluate and recommend collaboratively developed alternate payment models to the Health and Human Services (HHS) Secretary. The ACS-Brandeis Advanced Alternative Payment Model was among the first two models approved by the committee for pilot testing at its April 2017 meeting. The PTAC sent its formal recommendation to the HHS Secretary, and the American College of Surgeons–Brandeis Episodes of Care model that is making its way through the committee has been recommended for pilot testing.

Proof of Life

In one important respect, the Patient Protection and Affordable Care Act is a misnomer; it is all about access to care and not about cost control. In effect, we are paying a great deal of attention to the tail rather than the entire beast. The issue is not the politics — the red, blue, or purple color currently assigned to each state — it is the system itself.

We continue to spend 18% of our Gross Domestic Product on health care; yet, from the American citizen’s perspective, the outcomes of that care are not commensurate with the expenditure. Case in point: Medical error is still the third leading cause of death in this country. What the U.S. health system needs is a booster shot to help it combat rampant inefficiency and ineffectiveness.

It is far too soon to pronounce the patient (i.e., health reform) dead. The evidence of its transformative effect is abundant:

  • We have already entered a new era of medical practice in which more than half of all U.S. physicians deliver patient care as employees rather than as private practitioners. There are arguments pro and con for this trend, but one undeniable plus is that physician employees tend to be amenable to working within nationally endorsed professional guidelines. This bodes well for improved quality of care and positive patient outcomes.
  • Totally transparent information is now available to anyone with an electronic device. With an app and a click, anyone can search for performance scores on individual physicians, hospitals, and nursing homes. As the volume of quality-related information expands, Americans will continue to become wiser consumers of health care services.
  • Another important consideration that is beneath the radar of most Americans is the transformation of medical education.

What the nation needs now is a determined shift in attention from “alternative facts” to the health care evolution that is already underway. The Administration’s efforts to dismantle the Agency for Healthcare Research and Quality (AHRQ) amount to a self-inflicted shot to the foot. AHRQ is the entity that promotes and funds research into the tools we need to solve the system’s problems, and we must work together to assure its survival.

Surviving and Thriving

Looking to the not so distant future, new structures and relationships within the health care industry are likely to materialize; for example, national-level for-profit managed care organizations may emerge and become better aligned with their physician networks.

In the wake of failed national merger attempts, pent-up energy may be channeled into new frameworks and associations; for example, in the spring of 2017, a consortium of Chief Executive Officers from Kaiser Permanente, Medtronic, Novartis, and international representatives called for consensus around an approach that embraces patient-centered, outcome-focused care. In a report titled, “Value in Healthcare: Laying the Foundation for Health-System Transformation,” the consortium coalesced around core principles that are in lock-step with population health: measuring outcomes and costs, focusing on specific populations, and customizing interventions for those populations.

In light of the facts, population health is not only alive but thriving. I hope that readers will join with its many proponents to work toward ensuring that VBC becomes the norm — enhancing health outcomes, reining in rising health care costs, and placing patients firmly at the center of care.

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