Health for life

The right definition was there all along!

Writing in the March 20 issue of JAMA, Drs. Douglas Noble and Lawrence Casalino say that supporters of Accountable Care Organizations (ACOs) are all muddled over "population health."

The Disease Management Care Blog says the article is what is muddled and that the readers of JAMA deserve better.

According to the authors, after the Affordable Care Act launched the Medicare Accountable Care Organizations (ACOs), their stated purpose has morphed from Health-System Ver. 2.0 controlling the chronic care costs of their assigned patients to Health System Ver. 3.0 collaboratively addressing "population health" for an entire geography. 

Between the here of "improving chronic care" and the there of "population health," Drs Noble and Casalino believe ACOs are going to have to confront the additional burdens of preventive care, social services, public health, housing, education, poverty and nutrition. That makes the authors wonder if the term "population health" in the context of ACOs is unclear. If so, that lack of clarity could ultimately lead naive politicians, policymakers, academics and patients to be disappointed when ACOs start reporting outcomes that are limited to chronic conditions.

In short, they dont believe ACOs, as currently configured, are up to the new task.  Thats because ACOs would need to collaborate with social service organizations, be responsible for a geographically defined service area and improve long term public health outcomes.  According to the authors subtitle, the answer to the question "should they try" is "no."

The Disease Management humbly disagrees.  Thats because Drs Noble and Casalino, the editors of JAMA and the manuscripts peer reviewers seem to be ignorant of the the correct definition of population health. Its right there on the Care Continuum Alliances web site, in this longstanding page that describes the "population health model of care."  When the DMCB did a simple Google search on "population health definition," it had little difficulty finding the link.

The CCA helpfully describes population health as:

a delivery model characterized as a physician-guided health care delivery system designed to develop and engage informed and activated patients over time to address both illness and long term health.

Was that so hard?

And how is that accomplished?  According to the CCA, the ingredients to that make for population health include:

• Population identification strategies and processes;

• Comprehensive needs assessments that assess physical, psychological, economic, and environmental needs;

• Proactive health promotion programs that increase awareness of the health risks associated with certain personal behaviors and lifestyles;

• Patient-centric health management goals and education which may include primary prevention, behavior modification programs, and support for concordance between the patient and the primary care provider;

• Self-management interventions aimed at influencing the targeted population to make behavioral changes;

• Routine reporting and feedback loops which may include communications with patient, physicians, health plan and ancillary providers;

• Evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall population health

Accordingly, if an CMS-contracted ACO can identify its assigned Medicare population, perform needs assessments, promote awareness of health risks, offer education as well as support, increase self management, use data feedback and evaluate outcomes, its offering "population health."  By using that playbook, an ACO will capitalizing on the experience of a community of population health service providers that have been doing precisely this for over a decade.

This vision is far more compact than the overreaching, misinformed and muddled definition of "population health" offered in JAMA.  It is also, if ACOs invest in the right resources and partnerships, well within reach.

The DMCBs answer to the question "Should they try?" is "yes."

Care management in action?

What is "care management?"

As discussed and quoted by the Disease Management Care Blog, heres one useful definition courtesy of the New England Journal:

"A set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing the coordination of care, eliminating the duplication of services, and reducing the need for expensive medical services."

Now another one has emerged, thanks to this article by Lawrence Casalino and colleagues that appeared in the August issue of Health Affairs. The authors were interested in comparing the use of "care management processes" in small to medium sized physician-own practices that were either in or outside of an Independent Practice Association ("IPA") or Physician Hospital Organization ("PHO").

For this article, Casalino et al developed a "care management index" that reconciled five care management "processes" (1. use of a registry, 2. access to nurse care managers, 3. reliance on guideline-based reminders at the point of care, 4. sending care/health maintenance reminders to patients and 5. reporting outcomes)against the four chronic conditions asthma, heart failure, diabetes and depression. Having all 5 processes available for all four chronic conditions resulted in a top score of 4 x 5 or 20. The score therefore ranged from a high of 20 down to zero.

So, as ACO wannabes, hospital administrators, health system entrepreneurs, policymakers and regulators assess their care management landscape, they now, thanks to Health Affairs, have this handy zero to twenty scale.

To perform the study, a sample of physician-owned practices were asked to participate in a telephone survey in which the lead physician or administrator was asked about the 5 processes for each of the four conditions.

The results resembled the DMCB spouses scoring of her husbands clean-up-after-himself processes.  There were some points, but theres plenty of room for improvement against the measured baseline. 

Small to medium-sized practices with "significant" participation in an IPA or a PHO had a average care management process score of "10.4" vs. a score of "3.8" in the unaffiliated practices.  When the care management processes were provided by the IPA or PHO to the practices, the average score was 5.4. 

The value proposition for IPAs and PHOs includes care management, but they have a ways to go.