Contributor: David B. Nash, MD, WG’86
To learn more about David, click here.
The Patient Protection and Affordable Care Act (ACA) is perhaps the most important and powerful piece of population healthcare legislation ever because it lends credibility and confers legal status to a concept that those of us in the field have understood and preached for decades. True, the ACA is not the panacea that some had hoped, but it is a major step in the right direction with 20 million more citizens now having access to health insurance and primary care services. It has helped save lives, acknowledged the importance and elevated the status of primary care, compensated patient-centered outcomes, and brought about an understanding of population health that led to the expansion of insurance coverage.
Constant assaults on the ACA have chipped away at its broad-ranging mandates, but there is abundant evidence that one core concept will survive and thrive - value-based payment (VBP). Although the current administration has given mixed signals regarding mandatory programs such as the Episode Payment Models, there appears to be support for the voluntary Bundled Payments for Care Improvement Initiative.1 Payers already know the road to redemption (better health outcomes and lower costs) is paved with VBP. The shift in focus from volume to value is already firmly embedded in the policies and payment systems of some large for-profit payers as well and the Centers for Medicare & Medicaid Services (CMS).
Despite our tendency to politicize the issues, the system itself remains the overwhelming problem. In certain respects, it has stubbornly clung to the same policies and practices that have kept it from thriving, e.g., misaligned payment systems, performance standards that link financial incentives to process measures rather than clinical outcomes. We continue to spend 18% of our gross domestic product (GDP) on healthcare while tolerating substandard outcomes of that care. We lead the world in health technology innovation, but medical error is still our third leading cause of death.2 Waste is rampant - even in the medical profession that cranks out more than two specialists for every primary care physician when the opposite is what will move us toward a healthier population at a lower cost.
Looking down the road we can expect some construction delays, but I’m optimistic that VBP will eventually lead to better health for the system and the population. In the first few miles, we can expect value-based care models to gain broader acceptance in markets across the country (e.g., bundled payment, global payment, CMS initiatives). A resurgence of interest in managed care is likely in light of results from the nation’s Accountable Care Organizations (ACOs). In the first three years, most reduced Medicare spending, and 82% improved the quality of care they provided - outperforming fee-for-service providers in 81% of the quality measures.3
Some of the road’s potholes will require new approaches to construction and maintenance. The challenges are substantial but not insurmountable. It’s a matter of shifting the traffic lanes:
- Rather than engaging in relentless competition for the downstream market (e.g., the newest cardiac catheterization laboratory), begin to look outside the walls of hospitals and health systems and invest in upstream opportunities that will improve the health status of the population. Commit organizational finances and brain power to helping people modify their unhealthy behaviors. Identify the myriad and complex social determinants that affect the health of the population in the community or region and partner with other organizations to address needs.
- Rather than clinging to traditional patterns, try practicing medicine as a team sport. Create a culture that rewards specialization in primary care and that encourages health care professionals to work at the top of their licenses. We’ve already entered a new era of medical practice in which more than half of all U.S. physicians deliver patient care as employees rather than as private practitioners.4 The trend has its pros and cons, but one undeniable plus. Physician employees tend to be amenable to working within nationally endorsed professional guidelines, and this bodes well for improved quality of care and positive patient outcomes.
- Consider new ways to use technology to increase patient engagement in their healthcare, e.g., video conferencing, Bluetooth. With an app and a click on an electronic device, anyone can access performance scores for individual physicians, hospitals, and nursing homes. There is a technology that can reliably predict mental health conditions and coronary artery disease can now be predicted via a voice recognition pattern. As the volume of quality-related information expands, Americans will continue to become wiser consumers of healthcare services.
- Aspire to higher quality, safer care by adopting a collective goal - a delivery system that is free of harm. A distinguishing feature of population health is that it goes beyond the scope of public health to address the delivery of care that is cost-effective and safe. At our institution, population health is the intersection of health policy, health economics, public health and health, and quality and safety.
- Leadership won’t just happen; it must be taught. I subscribe to the premise that good leaders are those who prepare the leaders of tomorrow. On the road ahead, the ever-growing demand for patient-focused physician leadership at managed care organizations, ACOs, hospitals, and health systems will demand enterprise-wide board commitment. At our institution, one faculty member in every major department is required to take an advanced training program for leaders in quality and safety.
- Recently, our College of Population Health embarked on training leaders to turn data into actionable information. Trademarked “Population Health Intelligence,” the new curriculum couples with connections and companies to deliver training in marketplace artificial intelligence, predictive analytics, and machine learning.
For anyone in doubt about the viability of population health, consider that 10 years ago, ours was the first and only college of population health in the country. Today, there are 14 graduate programs in healthcare quality and safety and 12 new schools of population health.
The road is paved and I am confident that we’ll make progress on the repairs necessary to enhance health outcomes, rein in healthcare costs, and place patients firmly at the center of care.
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- Dinwiddle T. Reports of bundled payments’ death have been greatly exaggerated. Decision Resources Group. August 28, 2017. https://decisionresourcesgroup.com/drg-blog/health-reform/reports-bundled-payments-death-greatly-exaggerated/. Accessed July 31, 2019.
- Makary M, Daniel M. Medical error - the third leading cause of death in the US. BMJ 2016; 353:i2139. https://doi.org/10.1136/bmj.i2139. Accessed July 31, 2019.
- Livingston S. Medicare shared-savings ACOs cut $1 billion in costs over three years. Modern Healthcare. August 29, 2017. http://www.modernhealthcare.com/article/20170829/NEWS/170829881. Accessed July 31, 2019.
- Kane CK. Updated data on physician practice arrangements: physician ownership drops below 50 percent. AMA Policy Research Perspectives. 2016. https://www.ama-assn.org/sites/default/files/media-browser/public/health-policy/PRP-2016-physician-benchmark-survey.pdf.