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September 29, 2016 News No Comments

Population Health Must-Haves for Primary Care
Three critical priorities as value-based care moves closer to home
By William Gillespie, MD


Value-based care is progressively becoming reality for primary care practices. Some, for example, have just considered participating in Comprehensive Primary Care Plus (CPC+), a new reimbursement model CMS calls the “largest-ever multi-payer initiative to improve primary care in America.” While the stated aim is to give doctors more control over care delivery, at its core the model is simply data- and incentive-driven population health management.

In response to such initiatives, providers are actively seeking best practices for managing their patient populations. Yet the quest for guidance poses its own fundamental challenge: Despite the endless industry buzz about population health management, fully tried-and-true best practices are still emerging. That makes it tough for primary care providers who must learn how to “quarterback” patient care at a practical level, despite ever-present manpower and resource shortages that often seem to put proactive care coordination out of reach.

However, with infrastructure and workflow designs that leverage existing data, primary care providers can realize the advantages of a sustainable population health management initiative built on these three fundamental components:

1. Stratify clinical condition within your practice population.

Managing value-based reimbursement begins with an understanding of the inherent risks within your patient populations. Practices have to identify their highest-cost, highest-risk patients — such as those with chronic conditions or complicated, comorbid conditions — to accurately predict the clinical and financial risk they face.

Armed with clinical condition stratification information, care teams can help practices minimize both clinical and financial risk by devising tailored plans to close gaps in care, manage medication adherence and heighten patient engagement. What’s important to recognize, though, is that you likely lack this crucial visibility whether or not your practice has an EHR.

While EHRs provide a nice starting point for collecting and accessing data, many don’t have the analytics capabilities needed to effectively stratify populations based on clinical condition. Acquiring this actionable intelligence, which can help capitalize on your EHR investment, requires infrastructures that overcome barriers to data exchange.

2. Stratify current and future risk.

Once a practice understands patient clinical conditions and associated risks, the next priority is preventing healthy patients from developing chronic conditions. A chronic condition equates to treating a problem that’s already arisen. The question is, how do you prevent that from happening in the first place?

The answer, again, is visibility; this time into those patients who are displaying the tell-tale signs of clinical decline. For instance: Which patients are gaining weight? Which are coming into the practice more often? Which have an increased number of complaints?

Rules-based infrastructures that track and monitor key indicators like these can enable practices to identify patients at risk of progressing toward undesirable co-morbidities and potentially chronic (and costly) clinical conditions. Through risk stratification, practices can more effectively utilize resources to prioritize treating these patients, driving down the cost of care while improving clinical outcomes.

3. Invest in your patients between and outside of office visits.

Patients spend very little time face-to-face with their doctors and care teams — even if they have, or are on the road to having, a chronic illness. What happens to patients between visits? Although it has a direct bearing on outcomes, providers historically have lacked this critical information. To thrive under value-based care, this must change.

Mobile communication can make a dramatic difference in health status and cost by allowing patients to easily engage with care teams, nutritionists, therapists, and other support systems. For instance: A care team interacting with a patient on a regular basis might determine that connecting the patient with transportation assistance increases the likelihood of care plan follow-through. This can also ensure that when patients do need care, they come to the practice rather than defaulting to an expensive emergency department. Ultimately, providers must have ways to extend care delivery outside the walls of their practices to control clinical outcomes and limit cost.

As reimbursement models and government mandates push population health forward, the real question for primary care providers is how to make the transition practical. Practices can start by embracing infrastructures and workflows that stratify clinical conditions, stratify risk, and strengthen patient communications. By focusing on these three “must-haves,” primary care providers can become elite quarterbacks for their patient care teams.

William Gillespie, MD is EVP of population health and CMO at Medecision in Philadelphia and Dallas.


JennMr. H, Lorre, Dr. Jayne, Dr. Gregg

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