Population Health: How Delivery Systems Can Lead Transformation

The Transformation Rx Vlog provides a variety of perspectives on efforts to improve the quality and affordability of healthcare. 

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Population Health: How Delivery Systems Can Lead Transformation

With Tom Evans, MD, FAAFP, President and CEO, Iowa Healthcare Collaborative

“How do we provide better, safer care at a lower cost?“ asks Dr. Tom Evans, a family physician and President and CEO of the Iowa Healthcare Collaborative, which sums up the goal of those working to transform healthcare. To build a culture that supports transformation and improves health for entire communities, Dr. Evans says delivery systems must be radically redesigned in the ways they provide, measure, and reimbursed for care.

We need a completely different approach that involves four key “pillars.”

Radical redesign involves four pillars: patient-centered care, transparency, commitment to eliminating waste and inefficiency, and coordinated, community-wide collaboration. “Instead of being driven by the provider community, the patient needs to be at the center,” says Dr. Evans. “That’s the first pillar. Then we establish goals built on what each person needs, and build and coordinate their care from there.”

Second, in order to build a new, systematic approach, health systems and practices need to commit to transparency – to using data to understand where they are and how they can move forward in a coordinated, efficient way to achieve common goals. “Without that data, it’s very difficult to engage that patient and move forward to where we need to be.” Third, providers need to commit to efficiency and eliminating waste or overuse of their services so they can provide better care for less. “This requires a commitment in the development of skills throughout the community. We have to master performance improvement skills and embed them into methods of delivery.” The final pillar is commitment to providing coordinated care. “It’s a team sport. And it’s not just the providers who are on the team. It’s the entire community.”

Providers and health systems need to be ready to play in a different way – think football rather than fishing.

Dr. Evan likens the change in approach to playing a completely different sport and says providers should think football rather than fishing. “Volume-based care models are like fishing. Everyone goes out every day with their own boat and at the end of the day they see who caught the most fish.” Conversely, the value-based system is about efficiency and effectiveness. It requires each individual as well as the entire practice or health system to be proactive and engaged. “It’s more like football,” says Dr. Evans. “It’s a team sport. There are 11 people on the team, each with their own specialized skill and contribution, yet they are complimentary skills and have to be carefully coordinated. We only move down the field together. We win or lose together.”

Dr. Evans says the provider community is coming around to this way of thinking and there is increasing will to make the necessary changes. “Providers, however, are showing up to the line of scrimmage with their fishing rods. We need to equip them to thrive in that value-based environment.”

Aims create systems. Systems generate results.

Edwards Deming, a well-known management expert, said, “Aims create systems,” rather than the other way around. Regional health improvement collaboratives are skilled at bringing together stakeholders from across the community to identify common aims or goals, secure buy-in, and align stakeholders’ skills to work toward those goals together.

A good example, says Dr. Evans, is taking a community-wide approach to diabetes. He suggests that stakeholders collaborate to set a community vision of what it means to be in “good control” of diabetes–agree to measures for what’s known as the D5: blood pressure, A1C levels, eye and foot exams, and cholesterol. “Imagine if we had a community commitment to have identified diabetics managed on these measures to such an extent that they do not progress in their disease? That would engage the patient, public health, employers, and all stakeholders so everyone wins.”

Radical redesign involves payment reform as well as clinical transformation.

Value-based care means operating under a very different payment system than volume-based models. Many practices have been chipping away at this change for decades but Dr. Evans considers the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to be the lynchpin for success. The resulting Quality Payment Program (QPP) engages physicians by offering incentives to provide better care for lower cost. “We go from fixing broken people to keeping people from getting broken in the first place.” The system encourages the use of data, and the development of incentive programs to help physicians align with the rest of the health community and move things forward.

The Iowa Healthcare collaborative participates in the Transforming Clinical Practice Initiative (TCPi) under the Centers for Medicare & Medicaid (CMS) and facilitates a Practice Transformation Network as part of that work. “We’re moving from enrollment in QPP to the engagement phase where providers are beginning to dissect their care practices on-site and figure out how to do things better. We’re beginning to generate data, and more importantly, identify savings based on that data.”

Dr. Evans says it’s important to note that MACRA is a bi-partisan federal law that is working and having significant impact. While national attention may be on the Affordable Care Act and the drama in Congress, the ACA only deals with whether someone has insurance. MACRA is comprehensive and is bringing about the critical changes needed to improve quality and cost of care.

Success with population health efforts means integrating social determinants of health into any system redesign.

True transformation means assuming responsibility and risk for a person’s and/or a population’s total health. Acute care services are only 20% of the equation. The other 80% is what’s called social determinants of health – things like housing, food, and behavioral health. “This is really about helping the person live a better life, not just fixing them when they are broken. This means configuring our care in a way that engages the whole person, the whole family, and the whole community in a coordinated way.”


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