I attended a Population Health conference this summer where a number of representatives from large health systems and physician organizations convened to discuss common challenges. Many of my healthcare colleagues assume that anything that carries the label “Population Health” must relate to health disparities and food deserts. While we do address these topics, the vast majority of sessions and conversations had one underlying theme: lowering the total cost of care.
In rebuttal to any charges that our group is far too corporate to be considered a fair example of Population Health advocates, even the Institute for Healthcare Improvement addresses the importance of managing costs with the third part of the Triple Aim stated as “reducing the per capita cost of health care”.
Whether it is from Medicare or commercial ACOs, the Efficiency metric in CMS’s Value-Based Purchasing program, or the continued push from commercial payors for bundled payment programs, health systems and provider groups are beset by demands regarding cost. Unfortunately, at this conference, and in most groups trying to meet the demands of Population Health, one key stakeholder group is often absent: Specialists.
If cardiologists, spine surgeons, and hospitalists cannot become engaged with Population Health principles, moving the cost needle will be very challenging, if not impossible. I believe there are ways, however, to engage specialists in providing efficient care.
Access to Data: Commercial insurance payors have provided Primary Care Physicians with cost data for their attributed patients for years. Moreover, most primary care physicians are enrolled in risk contracts with penalties and potential bonuses with quality and cost-of-care tied in. Specialists, unfortunately (or fortunately, depending on whom you ask), have been immune to the cost of the care they provide. While groups like Propublica have released Medicare payment data, what would be valuable to specialists is how their quality and costs compare to their peer groups who manage the same conditions. For example, what is the average cost between two gastroenterologists for a patient with inflammatory bowel disease. Sharing this data with specialists can lead to some tough questions about best practices, clinical variation, and, appropriateness criteria.
The need to develop appropriateness criteria: When talking to several orthopedic surgeons about a new bundled payment program for joint replacements, one senior surgeon opined, “Well, this is all well and good, but what do we do about the 82-year-old woman with a bad heart and severe arthritis?” His comment has stuck with me because it points to the lack of guidance many practitioners have when it comes to deciding which patients should receive treatment and which patients should not. Defined by Brooks and colleagues at the RAND corporation, a procedure or treatment is considered appropriate if the expected health benefit of the treatment exceeds the expected adverse consequences by a wide enough margin that the intervention is worth doing.
Unlike clinical guidelines, which may recommend a therapy for certain pathology (joint replacement for severe arthritis), appropriateness criteria incorporate patient-specific variables (diabetes, heart disease, obesity, etc.) and the “appropriateness” is defined by an expert panel. Specialty societies and colleges should endeavor to establish appropriateness criteria for their members to help curtail care that may both be wasteful and potentially harmful to their patients.
Teaching the residents: When I was a surgical intern (during the first term of the George W. Bush administration), I recall my first day on the Trauma service. I was given a list of patients by the graduating intern and the order to do the discharges first—especially the one going to the SNF, as it would require the most paperwork. I did as I was told and sent the patient to this magical place called ‘SNF.’ It took me a couple of months to muster up the courage to inquire what the acronym stood for. I have become well acquainted with Skilled Nursing Facilities in my short career in Population Health as I have looked at reducing post-acute care expenditures, but, sadly, the interns whom I speak to now have just as foggy of a notion of why it is important to know where our patients go after they leave the hospital. Most teaching institutions are tertiary- and quaternary-facilities that focus on developing new therapies and techniques in addition to training residents on what constitutes standard of care. It may be easy to forgive academic physicians for not having the time, quite frankly, to educate on Population Health. Unfortunately, if training programs do not start stressing this aspect of medicine, specialists will remain in the dark.
I will be admonished by some for spending an inordinate amount of time on medical costs in an essay about Population Health, and I would be the first to state that quality of care should never be sacrificed when accounting for the cost of care. However, as patients continue to face increasing out-of-pocket costs for the care they receive, it is one more reason to make sure that their dollars are being used judiciously.
Vikram Reddy, MD is an Associate Director of Population Health for the Henry Ford Health System.