As health care reform takes hold, hospitals are being entrusted with keeping the healthful healthy and carefully managing the chronically ill across all settings, from hospital to home. Population health is the key in this new reality — parsing patients into different groups, analyzing data and targeting interventions.

Health care markets around the country are moving at varying speeds toward this new model, says Brian Silverstein, M.D., president of consulting firm HC Wisdom. That may depend on how aggressively employers manage health care costs, insurers’ willingness to experiment with new models, and the level of competition in a market.

Health care organizations large and small are realigning themselves toward managing the health of patient populations. Advocate Health Care — with its 10 acute hospitals — has entered into $3.5 billion in contracts with various payers, based on the quality of care, rather than number of visits. The Downers Grove, Ill., system is educating its employees about population health, aligning around common measurements, refocusing primary care and coordinating service across the system.

Though smaller, 300-bed Greater Baltimore Medical Center, too, is repositioning itself as a community health system. Chief Executive Officer John Chessare, M.D., says that’s meant aligning loosely affiliated physician practices, and embracing advanced primary care to better coordinate all of a patient’s encounters with the health system. “The smaller you are, the easier it is to get started,” Chessare says. “Most small hospitals also have a relatively small medical staff and a smaller population of individuals that they’re trying to cover. So, the real change is trying to get everyone on board with the vision, and rowing in the same direction.” 

4 steps on the path to population health

There are four steps that hospitals should take on their journey to treating the health of populations, says Joseph Damore, vice president of population health management at consulting firm Premier Inc. Where hospitals are along that path, and where they should be, varies from market to market. Damore believes most are in the middle, developing their initial plan or starting to implement it. Damore says health care is in the third wave of interest in population health, and momentum is picking up. “Most organizations have now come to the conclusion that this is not going away, and it doesn’t matter politically, whether Democrats or Republicans are elected. We’re still going to move in this direction across America.”

Preparatory

  • Educating employees about population health
  • Assessing the organization’s needs
  • Performing a gap analysis to see what’s missing
  • Developing an operational plan

Transformational

  • Building up a primary care network
  • Instituting patient-centered medical homes
  • Integrating clinically with care sites across the spectrum
  • Managing care of individuals
  • Developing networks
  • Utilizing health informatics

Implementation

  • Defining populations
  • Pursuing new payment models
  • Partnering with insurers

Expansion

After hospitals tackle one initial population in a pilot, Damore says they often expand the concept to other payer groups, such as:

  • Their own employee health plan members
  • The commercially insured
  • Medicare and Medicaid members
  • Employers via direct contracting
  • The uninsured

Building an infrastructure

Advocate Health Care established nine steps in building its organizational structure to pursue population health, says Michael Englehart, M.D., president of Advocate Physician Partners. He emphasized staying transparent with physicians along the way and setting realistic expectations for how long the process will take. “Any investment you make is going to take a period of time. You have to be realistic about how quickly it will bend the curve or you’ll start to see the impact. But it doesn’t mean that you take a blind eye and keep going down a path. We’re very metrics-driven, but we have to be realistic.”

1 | Reaching a board and executive decision and aligning the organization

“You can’t step into this model without the support of the board, and the executive team has to subscribe to it, whether you’re going big bang or starting with a small shared savings contract. This is expectations-setting. It’s not a straight line. There will be bumps. There will be setbacks. There will be lessons learned.”

2 | Implementation and structure

“We had a running start because all of the people, intellectual capital and some of the technology were already in place. But after that, a traditional physician-hospital organization might not be able to pull off shared savings because it doesn’t have bench strength; it doesn’t have the technology and experience. And so, you can’t underestimate the financial needs. It’s a big investment.”

3 | Accountable stakeholder leaders

“We have to paint a vision for people: this is where we’re at, this is where we think the market is headed and this is why we’re taking these steps. If you don’t do that, it’s the burning platform conversation. People move based on two things: You either have to articulate that it’s burning and you better get off of the cinder, or there’s a better place to land going forward.“

4 | Systemwide teams with physicians in clinical practice

“When you’re as large as Advocate, you’ve got to make sure there’s representation across the entire organization, because you could win in one area and fail in another and, overall, the performance will suffer. There has to be continuity and standardization.”

5 | Conceptual framework that’s widely vetted

“Advocate, not unlike a lot of other health care systems, was hospital-based. We had a growing number of doctors who chose employment, but we tended to focus on admissions and discharges. What we found was that we needed to go upstream and identify patients when they were still in an ambulatory setting and working with their physicians to throw additional resources. On the back end, instead of discharges, we have transitions. While it’s important to get patients out of the hospital, we’re most concerned about where they’re going next.”

6 | Project management approach, using metrics and work plans

“You’re never done. You’re always trying to tweak or enhance what you’re doing. It’s not business as usual. When you’re doing population health and taking on risk, every day there’s another curve ball. So, the importance of discipline to be able to knock down projects and not run from one fire to the next can’t be underestimated.”

7 | Ongoing communication

“That speaks for itself.”

8 | Commitment to implement within an established time frame

“If you make this commitment and you start to invest in these risk types of arrangements, patients are coming. Your failure to execute is not going to be, for lack of a better word, forgiven with the payers. It really becomes mission-critical that you are realistic and you execute against your project plan.”

9 | Transition quickly to operations effectiveness and optimization

“I would phrase it differently: Fail fast. If you make a mistake, you have to recognize it and move on. That’s not the end of the world, but you can’t stay in a model or a business plan that is not effective and not be willing to tweak it or modify it, and that’s one of the things we’ve learned. You just have to be willing to be very analytical and step away from a decision you thought was right two years ago, and now you have to come back and revisit it.”