Understanding the social determinants of health and how they impact population health

A patient’s health status can be impacted by many factors, including genetics, eating habits, and physical activity (or lack thereof). There are a number of other factors that can affect a patient’s health as well, which cannot necessarily be treated with medications or traditional care plans. Social determinants of health are, according to the World Health Organization (WHO), “the conditions in which people are born, grow, live, work and age.”

For patients, social determinants of health, “circumstances (that) are shaped by the distribution of money, power and resources,” can influence their food choices and even whether they have access to quality healthcare. Social determinants include “intangible factors such as political, socioeconomic, and cultural constructs, as well as place-based conditions including accessible healthcare and education systems, safe environmental conditions, well-designed neighborhoods, and availability of healthful food.”

For healthcare providers, social determinants of health affect decisions made for population health management. The physician must take into consideration whether patients can afford to eat healthy foods, fill their prescriptions, and follow other plans of care that may be out of their range either financially or logistically. True value-based care can involve collaborating with community organizations and social service agencies to gauge needs and provide appropriate care based on the patient population’s circumstances.

The “complex interactions and feedback loops” of social determinants of health, as described in a recent article in NEJM Catalyst, include “poor health or lack of education (that) can impact employment opportunities which in turn constrain income. Low income reduces access to healthcare and nutritious food and increases hardship. Hardship causes stress which in turn promotes unhealthy coping mechanisms such as substance abuse and overeating of unhealthy foods.”

Value-based care for these populations will depend on the physician understanding the social determinants of health for the patient group, including the economic environment, employment opportunities, access to safe drinking water, and availability of quality food choices. Maintaining detailed patient data in electronic health records (EHRs) can help the physician track and manage the population health of patients who are impacted by these social determinants of health.

Healthcare professionals have available significant “data and research which indicates that the social determinants of health have a higher impact on population health than healthcare and that a higher ratio of social service spending versus healthcare spending results in improved population health.”

Roy Steiner
October 29, 2018


Accountable care organizations (ACOs) to know

The growth of Accountable Care Organizations (ACOs), those groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients, is evident in the fact that there are now 649 ACOs across the country. Becker’s Hospital Review recently compiled a list of 144 of those ACOs, “to highlight ACOs across the country and examine the opportunities for improving quality care and care coordination.”

Some of the ACOs on the list were established as long ago as 2008; some were just formed in January 2018. Some are based in large cities, while others are in small towns. A few of the ACOs to know, selected randomly from the Becker’s Hospital Review list, include:

ThedaCare ACO (Appleton, Wis.).  First established in partnership with Green Bay, Wis.-based Bellin Health in 2008, ThedaCare was selected for the CMS Pioneer ACO program in 2012. In three years, the ACO was responsible for nearly $14 million in savings for the federal government. ThedaCare ACO then became a Next Generation ACO to take on risk.

Heritage California ACO (Northridge, Calif.). CMS selected Heritage California ACO to participate in the Pioneer ACO Model in 2012. Heritage California ACO transitioned to the Next Generation ACO Model in 2016 to continue providing value-based care.

Kootenai Accountable Care (Coeur D’Alene, Idaho). The Kootenai Care Network is a clinically integrated network that includes Coeur D’Alene, Idaho-based Kootenai Clinic’s 200 providers as well as independent providers. Kootenai Accountable Care is a Track 1 participant in the Medicare Shared Savings Program.

LifeBridge Health ACO (Baltimore). LifeBridge Health ACO includes 594 participants and covers 19,000 lives. The ACO includes more than 160 primary care providers and more than 400 specialists. LifeBridge Health ACO participates in the Medicare Shared Savings Program and achieved quality scores of 100 percent in 2015.

NewHealth Collaborative (Akron, Ohio). NewHealth Collaborative is in its seventh year of operation. The Track 1 Medicare Shared Savings Program ACO includes 250 primary care physicians supported by 650 member and affiliate specialist physicians. The clinician-led ACO reported $3 million in shared savings for the 2015 performance year and distributed 63 percent of the savings to ACO participants.

UnityPoint Accountable Care (West Des Moines). The ACO is part of the CMS Next Generation ACO Model and reported $10.5 million in shared savings for the 2016 performance year. UnityPoint Accountable Care distributed 100 percent of the savings to ACO participants.

Signature Partners (Falls Church, Va.). Signature Partners is an ACO serving patients in Northern Virginia. As a collaborative of more than 1,700 physicians, the organization aims to use the clinically integrated network and EHR technology to better coordinate care.

Rio Grande Valley Health Alliance (McAllen, Texas). Seventeen primary care physicians make up Rio Grande Valley Health Alliance. The ACO is a Track 3 participant in the Medicare Shared Savings Program and reported $6.2 million in shared savings for the 2016 performance year.

Roy Steiner
October 10, 2018


Advice on the management of complex patients

Primary care physicians who care for complex patients are often challenged with managing their care appropriately. Caring for complex patients involves the need to coordinate with specialty providers, to control the redundancy of tests, reduce the number of avoidable hospital admissions, and to curb costs for the patient and the provider. According to a study report published in the Rand Health Quarterly, “a relatively small proportion of complex patients … incur most of the nation’s health care costs” in the US.

The report, recognizing the challenges faced by primary care physicians in treating complex patients, states that “innovative uses of analytics and health information technology (HIT) may address these challenges.” Analytics, using various types of data, “may help create better risk stratification approaches that more effectively target patients for interventions.” HIT tools “may facilitate communication and improve timely decision making.”

Dr. Clive Fields, president of the Village Family Practice and co-founder/chief medical officer at VillageMD, writes in Physicians Practice that managing complex patients involves thought and planning on the part of the primary care physician. Dr. Fields also cites the need to take advantage of patient data collection and analytics, stating that the successful management of complex patients “involves implementing best practices, using data to identify opportunities for improvement, measuring outcomes, and creating a cycle of continuous improvement.”

Dr. Fields offers some additional advice on complex patient care. Primary care physicians should clearly understand their role in the care of complex patients. When multiple providers are treating the patient, as is usually the case, the primary care provider should take the lead in coordinating that care.

Primary care physicians should also know their patients well to better manage their care. They should be able to answer three questions, Dr. Fields suggests:

  •         Who are my complex patients?
  •         What illnesses and complications do they have?
  •         Where have they been in the healthcare system?

The answers can be easily attained by getting to know the patients more thoroughly as individuals and as part of a population group. Answers can also be found in the data contained in the patients’ electronic health records (EHRs), enabling primary care providers to coordinate and manage the care of their complex patients more efficiently and more effectively.

Roy Steiner
October 8, 2018


How is care quality measured?

Quality is not as easily measured as quantity. Terms like value-based care and quality care are increasingly used by healthcare providers as well as the Centers for Medicare & Medicaid Services (CMS) and even private healthcare payers. Measuring this care has become an integral part of the reimbursement and incentive system, particularly in the case of Medicare, but the question of how to measure quality care may not be clearly resolved for many providers.

CMS has launched a new Meaningful Measures Initiative to help define quality measures for healthcare providers. The Meaningful Measures areas are each linked to specific CMS strategic goals and, in fact, “serve as the connectors between CMS strategic goals and individual measures/initiatives that demonstrate how high quality outcomes for [CMS] beneficiaries are being achieved.”

Nineteen Meaningful Measure areas include such measures as Alcohol Use Screening, Use of Opioids at High Dosage, and Influenza Immunization Received for Current Flu Season, aligning with the CMS goal to Promote Effective Prevention and Treatment of Chronic Disease, for example. These areas have been divided into six quality categories as part of the Meaningful Measures Initiative:

  1.       Promote Effective Communication and Coordination of Care
  2.       Strengthen Person and Family Engagement as Partners in their Care
  3.       Promote Effective Prevention & Treatment of Chronic Disease
  4.       Work with Communities to Promote Best Practices of Healthy Living
  5.       Make Care Affordable
  6.       Make Care Safer by Reducing Harm Caused in the Delivery of Care

In addition, six cross-cutting criteria are applied to any Meaningful Measure area:

  1.       Eliminating disparities
  2.       Tracking to measurable outcomes and impact
  3.       Safeguarding public health
  4.       Achieving cost savings
  5.       Improving access for rural communities
  6.       Reducing burden

While quality can be a subjective term, particularly when it comes to measuring healthcare quality, CMS emphasizes that its new Meaningful Measure Areas are “concrete quality topics, which reflect core issues that are most vital to high quality care and better patient outcomes.”

Roy Steiner
October 8, 2018


Coordination of care v care case management

A patient’s care must be managed appropriately to avoid unnecessary or duplicative tests, to ensure the patient’s medications are not contraindicated, and to improve the patient’s overall health outcomes. Two activities play key roles in the patient’s care: coordination of care and care case management. They may sound very similar but are actually quite different.

Coordination of care is achieved when the primary care physician collaborates with other healthcare providers, such as specialty physicians, to ensure that all are working together for the patient’s good. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines coordination of care as “bringing together various providers and information systems to coordinate health services, patient needs, and information to help better achieve the goals of treatment and care.” SAMHSA adds that coordination of care “increases efficiency and improves clinical outcomes and patient satisfaction with care.”

The New England Journal of Medicine (NEJM) Catalyst explains that there are several elements involved in successful coordination of care:

  • Easy access to a range of health care services and providers
  • Good communications and effective care plan transitions between providers
  • A focus on the total health care needs of the patient
  • Clear and simple information that patients can understand.

Care case management is a more episodic approach. It could involve accessing a patient’s electronic health records (EHRs) between visits to ensure tests and medications are appropriate. Care case management can also involve determining if and why a patient is not following the provider’s instructions for ongoing care. In such a situation, the provider would identify factors affecting the patient’s desire and ability to engage in the healthcare program prescribed by the provider and work with the patient to overcome potential barriers.

The eHealth Initiative and Foundation (eHI) clarifies that “a comprehensive, value-based case management system should allow healthcare institutions to … construct a longitudinal record of care, including care that the patient may have received from other providers and organizations, … improve patient safety by avoiding contraindicated prescription medications, and … track in-system progress, so providers can better evaluate quality indicators and the effectiveness of treatments for both individuals and broad populations.”

Care case management can encompass coordination of care activities. Likewise, coordination of care is often included as part of the patient’s care case management strategy.

Prabhat Dhar
October 1, 2018


What is an accountable care organization?

Accountable care organizations (ACOs) were developed as a way to emphasize accountability among healthcare providers, moving away from the fee-per-visit model and toward value-based care. First coined in 2006, the term was used by Dr. Elliott Fisher during a meeting with the Medicare Payment Advisory Committee (MedPAC), in which he and others “argued that in order to significantly improve quality and costs, accountability for a patient’s care should be shared among all providers along the health care continuum.”

The Centers for Medicare & Medicaid Services (CMS) Innovation Center defines an ACO as a group of “doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve.” ACOs also involve shared responsibility for the cost of healthcare. Through various CMS programs, independent physicians who participate in ACOs are able to potentially share in the savings of that cost with Medicare.

CMS Innovation further explains that “when an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.” Establishing strong partnerships with other physicians within the ACO and coordinating services can result in increased savings for all.

ACO programs within Medicare include:

  • Medicare Shared Savings Program (cms.gov) – For fee-for-service beneficiaries
  • ACO Investment Model – For Medicare Shared Savings Program ACOs to test pre-paid savings in rural and underserved areas
  • Advance Payment ACO Model – For certain eligible providers already in or interested in the Medicare Shared Savings Program
  • Comprehensive ESRD Care Initiative – For beneficiaries receiving dialysis services
  • Next Generation ACO Model – For ACOs experienced in managing care for populations of patients
  • Pioneer ACO Model – Health care organizations and providers already experienced in coordinating care for patients across care settings

ACOs are growing in number since they were first established after the Affordable Care Act of 2010 was put into place. There are now ACOs in all 50 states.

Prabhat Dhar
October 1, 2018


MSSP 2017 ACO results released

The Centers for Medicare & Medicaid Services (CMS) Medicare Shared Savings Program (MSSP) is offered to healthcare providers as “an opportunity to create a new type of health care entity, an Accountable Care Organization (ACO).” The program is voluntary and is designed to enable “providers to come together as an ACO to give coordinated, high quality care to their Medicare patients.” MSSP offers several tracks for ACOs to “assume various levels of risk” with the potential to share in the cost savings.

CMS recently released data for 472 ACOs participating in MSSP and caring for 9 million beneficiaries in 2017. Generally, the results were positive. More than half of the ACOs saved money and a third earned sharing savings. Both figures were increases from the 2016 participation results.

The National Association of ACOs (NAACO) released a summary of key data points found in the CMS MSSP report:

  • $1.1 billion in gross savings
  • Gross savings were generated by 60 percent of ACOs
  • $800 million in shared savings bonuses paid to ACOs
  • 34 percent of ACOs earned shared savings bonuses
  • $314 million in net savings to Medicare (after accounting for bonuses paid to ACOs)
  • A mean quality score of 90.5 percent for ACOs under pay-for-performance measurement

The net savings to Medicare of $314 million consisted of $291 million from those ACOs participating in Shared Savings only (Track 1) and $23 million from those ACOs participating in Shared Savings/Losses (Track 2 and 3).

While the results were positive for ACOs for 2017, new CMS proposals may “deter new entrants to the Medicare ACO program,” according to NAACO. While ACOs now have up to six years to prepare for taking financial risks while in the MSSP, a proposed rule would shorten the time in a shared savings only model to two years. In addition, CMS has proposed cutting the amount of shared savings in half, from 50 percent to 25 percent for shared savings only ACOs.

Prabhat Dhar
September 25, 2018


Tips for finding the best population health management solution

Population health is a relatively new concept but is growing in popularity and importance, with the move toward value-based care. Population health management essentially means tracking the healthcare data in a specific population of patients, being accountable for the health outcomes of that defined population, and providing positive outcomes at the lowest possible cost.

Population health management requires a set of tools that enables the independent physician’s practice to be efficient and organized enough to manage the patient data and provide those positive outcomes. Sometimes that means outsourcing the management tasks to a population health management company.

Health IT Analytics offers several tips for finding the best population health management solution, emphasizing that “understanding patterns of risk and acting proactively to avoid expensive health events are crucial for success in a value-based world.” Tips include:

Create a goal-oriented roadmap. The goal for population health management will be different for each independent physician, depending on the physician and the patient population. Accessing data from electronic health records (EHRs) can help the provider in identifying the specific goals for the practice and for the patient population.

Map population health goals to specific health IT capabilities. Population health management solutions, either standalone or as part of an EHR, must enable one or more of the following capabilities:

  • Data aggregation
  • Data analytics
  • Reporting and visualization
  • Care management and care coordination
  • Patient engagement

Identify vendor-customer partnership values. When choosing a population health management vendor, the independent physician should consider a number of factors that will impact the relationship. Research at the beginning to ensure the values mesh will improve the success of the partnership long-term. The provider should investigate the vendor’s operations in terms of:

  • Sales and contracting
  • Implementation and training
  • Upgrades and optimization
  • Customer service and support
  • Dispute resolution

Ask for peer recommendations. Population health management is gaining in importance as independent providers become more focused on value-based care. When investigating potential health management solutions, it’s always a good idea to learn from those who have gone before and to seek out their lessons learned from their vendor experiences.

Prabhat Dhar
September 24, 2018


5 tips on closing care gaps

Collaboration and electronic health record (EHR) interoperability are key factors in closing the care gap that exists among healthcare providers. Sharing information, in real-time, about a patient’s diagnosis and treatment plan can be crucial to a quality outcome for that patient. A recent report, Closing Gaps in Care through Health Data Exchange, points out that providers “are unable to efficiently identify patients in need of healthcare services or deliver services according to evidence-based guidelines in a timely manner.”

The report is the result of mixed methods qualitative research conducted by the Louis W. Sullivan Institute for Healthcare Innovation, in close collaboration with GE Healthcare. It “provides an overview of current approaches, best practices, emerging opportunities and barriers to identifying, preventing and closing gaps in care through data exchange via health information technologies.”

Emphasizing the need to close care gaps, which are defined as “the discrepancy between evidence-based recommendations or best practices and the care that is actually delivered,” the Sullivan Institute report points out the following five tips:

  1. Greater education and communication are needed to raise awareness among stakeholders, particularly providers, about the value of identifying and closing gaps in care.
  2. Gaps in care can threaten the performance of healthcare organizations.
  3. Gaps in care programs have had a positive impact and seem to produce a high return on investment.
  4. Consensus is needed to develop and standardize quality measures and methodologies for information exchange among health plans, providers and patients in an actionable manner. The report also stipulated that additional key technical barriers to exchanging gaps in care information include the provenance, quality, completeness, timeliness, transparency and accuracy of data.
  5. Addressing gaps in care is a critical issue for stakeholders that grows in importance as value-based care efforts mature and health insurance coverage access and care increase.

Prabhat Dhar
September 18, 2018


The importance of organizational alignment

A group of healthcare providers was recently asked, as part of a larger survey, for their top two reasons that alignment is important to a healthcare organization. Better patient outcomes and organizational stability were overwhelmingly the top responses. The survey was conducted of NEJM Catalyst Insights Council members – “a qualified group of U.S.-based clinical leaders, clinicians, and executives who are directly involved in health care delivery.”

Participants in the survey differed somewhat as to their top reasons, although “all segments of the Insights Council agree that organizational alignment is most important to achieve better patient quality outcomes.” The percentage of those saying that the top reason for alignment is organizational stability in a dynamic, changing health care marketplace were: clinical leaders (65%), executives (60%), and clinicians (48%).

Perhaps not surprisingly, more clinicians participating in the survey (26%) than those executives participating (14%) also said that organizational alignment is important for satisfaction among frontline clinicians.

When asked what is meant by the term “organizational alignment,” more than half (57%) of the clinical leaders and executives participating in the survey said that alignment is “the organization’s mission, vision, and goals…supported by governance, strategy, and incentives.” Just over a third (37%) of the participating clinicians chose this definition. Clinicians (17%) were more likely than executives (9%) and clinical leaders (7%) to say that alignment is achieved when “all functions of the organization are directed toward patient care.”

Almost all of those participating in the survey (99%) said that alignment is necessary for key stakeholders within the healthcare organizations. However, only 63% of the Council members reported that this alignment exists within their own organizations, identifying the gap as being highest among frontline clinicians and top executives such as the CEO.

The survey was conducted of 655 NEJM Catalyst Insights Council members.

Prabhat Dhar
September 10, 2018