For the pop health transition, small steps won’t work

By James Furbush | February 7, 2017

Data snapshot

15% of Advisory Roundtable attendees strongly agreed their organizations were well aligned around a shared vision of population health.

Key Takeaways

  1. Having visibility and insight into community organizations that can impact care has become enormously problematic.
  2. Lack of meaningful, usable data at the point of care is significant barrier to population health management.
  3. High-risk populations are the most responsive to prevention and expense management strategies.

The goals of population health are clear: To improve the quality and effectiveness of care while controlling costs for a defined group of people.

But as Megan Clark of The Advisory Board Company notes, "the transition path couldn't be murkier."

To help provide some clarity, athenahealth brought together 79 executives from 72 ACOs, health systems, provider organizations, and consulting firms for a series of five roundtable discussions. The goal: to find out what it takes to successfully transition to a population health model of care.

Participants examined obstacles and opportunities their organizations face and identified promising strategies for navigating the transition process.

“Managing population health is a challenging concept," says Anil Keswani, M.D., corporate vice president of ambulatory care and population health management at Scripps Health. “It involves a set of strategies and capabilities that many of us are still wrestling with at this point."

Throughout the discussions, athenahealth used the leadership triangle framework, articulated by Harvard Business School professor Amy Edmondson, to focus leaders on three crucial elements of their organizations — vision, culture, and operations.

Identifying obstacles

Vision refers to understanding where an organization is strategically headed and what compelling and unique value it seeks to add in its community or market. Many healthcare leaders struggle to define a vision for population health because it requires a different care model than they've been used to under fee-for-service models.

Only 15 percent of leaders polled during the roundtable discussions strongly agreed that their organizations were well aligned around a shared vision of population health. In some cases, executives reported feeling pressure from payers to enter population health management before they are ready, or said they are entering only to keep up with competitors.

Most leaders, it seems, have yet to define and communicate a clear and compelling value proposition for population health in their organizations and communities.

As a result, many leaders worry about moving too quickly. They are concerned that focusing on population health will undermine near-term revenue — that is, a healthier population will require fewer hospitalizations and procedures. Additionally, leaders report that providers are reluctant to enter into risk-based contracts, fearing they may be unfairly penalized on already low profit margins.

The greatest cultural challenge for healthcare leaders is realigning an organization's focus away from acute, episodic care and towards a team-based, collaborative model for sustaining wellness across a population. First and foremost, this shift requires buy-in from physicians. Yet many leaders point out that although many of their physicians want to be involved in population health efforts, they're reluctant to take on new roles given current workloads. In addition, specialists are still struggling to find their place in population health efforts.

Health system leaders also question how their organizations can appropriately engage patients, families, and communities in the population health model. How, for example, do they encourage high-risk patients to make positive behavior changes?

\Population health is affected by a complex array of factors which include socioeconomic status, ethnicity, and the ability to access care. Further, having visibility and insight into community organizations that can impact care, such as churches, the YMCA, or schools, has become enormously problematic.

“We underappreciate the degree to which the patient — the customer, if you will — is in the driver's seat in terms of what really happens to their health and well being," says Brian Goldstein, M.D., MBA, the executive vice president and chief operating officer at UNC Hospitals. “Population health is the aggregation of the health of each individual, and each individual is autonomous."

Healthcare leaders also face operational challenges as they continue to develop and experiment with population health. They agree that delivering meaningful, usable data at the point of care is the most significant barrier to industry-wide adoption of population health management.

The key term is "usable data," says Poonam Alaigh, M.D., an internal consultant for Atlantic Health System's ACO strategy. “Sometimes there's so much information that you can't get any directional signal. And groups can interpret that information to their advantage, versus having a unified approach and gaining an unbiased understanding of what that information means."


Provider organizations struggle with aggregating data across their systems, making the information actionable, and having the tools to scale the data to the level that's needed for population health. Physicians simply don't have access to the right information at the point of care — from costs to complete patient histories — in order to inform their treatment decisions. Leaders stressed the need to create a more seamless process for coordinating patient care and to break out of traditional silos to embrace more of a team-based approach.

Finally, leaders expressed uncertainty about the best organizational structure for population health models and how to reduce total medical expenses. Should they become fully integrated systems by offering insurance products, as Kaiser Permanente does? Should they become ACOs or clinically integrated networks? Should they take on full-risk, global capitation, or one-sided risk? Or something else altogether?

Many agreed that there would be a blurring of the lines between insurers, providers, and hospitals as organizations figure out how to effectively band together and scale up to succeed.

A roadmap for population health

It's clear that organizations face significant challenges as they transition toward managing the health of populations — and so does the entire healthcare industry. Over the course of the roundtable discussions, leaders identified five key strategies that could make the road to population health less bumpy.

1) Prioritize high-value interventions.

Wondering where to start? Many leaders recommend focusing on high-risk groups. These include medically underserved populations (MUPs), who have more limited access to care, as well as patients with multiple chronic conditions, who are associated with a high percentage of healthcare expenditures.

“True population health is about understanding the disparities in your community," says Scott Reiner, the president and CEO of Adventist Health in Roseville, California. "If you look at the management of cost, it's about managing the high risk of super-utilizers. This is the top five percent of healthcare utilizers, or the top ten percent who are about to join their ranks."

High-risk populations are the most responsive to prevention and expense management strategies. They are also common in the fee-for-service world, and leaders point out that managing their care can prove an effective “bridge" in migrating to risk-based models.

“Our approach is to try to reduce the cost of taking care of people with complex illnesses, or where there's the most opportunity to cut cost," says Goldstein, “and then concurrently, and hopefully incrementally, add populations of the healthy majority who sometimes need episodic care."

After high-risk populations, organizations should focus on the rising-risk group, meaning those patients with identifiable and preventable health risks who have yet to become high utilizers of care. Effectively managing these populations requires that leaders consider how health is impacted by economic, behavioral, and other psychosocial factors — an approach common in public health.

“We need to collect social determinants of health data and set the patient in the context of their life. It may not change the intervention, but it may change how and where that intervention is implemented," says Elizabeth Majestic, vice president of population health at Cottage Health, based in Santa Barbara, California.

2) Build a fully integrated system.

Leaders agreed that a population health model most likely to succeed under risk is a fully integrated one: a system with diversified revenue streams and strong regional partnerships and affiliations with community groups, payers, and other providers. Organizations will need to embrace this degree of alignment and share patient data among a network of medical and community groups that serve a given population.

Leaders also agreed that organizations have to shed their hospital-centric, fee-for-service culture and embrace a team-based mentality that has provider networks working together to meet the needs of a community.

“We have to move away from this model that serves self-interest," says Larry Mullins, DHA , FACHE, CEO of Samaritan Health Services, based in Corvallis, Oregon. “Whether they are hospital interests, or physicians' interests, or ambulatory surgery interests, that doesn't work when you're getting into population health. You're talking about allocating a finite amount of resources for a defined population, and you really can't have one player trying to dominate out of self-interest."

Leaders agreed that they still have work to do identifying compensation models that make the most sense and motivate providers to be part of a well-integrated care team.


3) Develop a population health workforce.

One of the most important leadership priorities is to engage and support physicians and staff on the front lines of care delivery as they take on new roles and responsibilities within the organization.

Roundtable participants uniformly agreed that physicians must be allowed to focus on providing high-quality, efficient care for their patients and not be asked to spend more time on administrative work. Organizations can have staff assume tasks such as data entry, maintaining EHRs, patient outreach campaigns, and monitoring gaps in care.

 Many leaders believe that specially-trained "population health care managers" will emerge as crucial supports to primary care physicians, much as certified medical assistants and care coordinators do within a patient centered medical home model.

 “The population health piece is not a conversation with the provider," says Tom Kloos, M.D., executive director of MSO Services, Optimus Healthcare Partners/Atlantic ACO. “We try to leverage the clinical coordinator that's identified within each PCP office. They're the ones who do the outreach. They're the ones who assess the population that the practice serves."

Organizations that want to move into the population health space will require both leaders and staff to develop new skill sets. Some are actively promoting the redesign of medical school training. Others envision new roles for staff to lead population health efforts and create relevant support systems for physicians and patients.

4) Design data systems to support population health.

In order to be effective in population health, organizations need effective ongoing data aggregation across their populations. Some health IT vendors are providing data aggregation as a service, using the cloud to bring together a patient's clinical, financial and demographic data to provide a complete picture of care. Integrating disparate EHR and claims data enables organizations to better address care gaps and manage care across the patient population.

Organizations also need clinical and financial data in real time across the enterprise. Having “situational awareness" at the point of care gives organizations the transparency needed to control costs and better coordinate care.

“Our primary care doctors hear over and over again, 'You're the gatekeeper. You're the one who controls the costs on down the line,'" says Anna Loengard, M.D., chief medical officer of The Queen's Clinically Integrated Physician Network, based in Honolulu, Hawaii.

“If they could have a single EHR where they could see a patient-centered view of that patient's care, and also know the cost of care for various referrals down the line, that would take us a long way," she adds.

5) Moving care beyond the doctor's office.

Population health leaders should maximize a multi-channel approach to managing patients, including traditional patient visits but expanding the use of online, mobile and telemedicine options. Leaders understand that to really succeed under value-based contracts, organizations will ultimately need to better engage patients and change their behaviors outside the typical 15-minute, office-based encounter.

“There are lots of people that want more from their primary care doctor," says Bill Winkenwerder, M.D., founder of The Winkenwerder Company. “They want that interaction, they want to be guided, and they want it now. Most practices are not set up for that. There needs to be a new layer where you can just either call or go onto the web, have an app on your phone, and within 30 to 60 seconds, you're talking to a doctor."

This kind of immediacy requires exploring such enhanced operational capabilities as open access scheduling, user-friendly patient portals, secure text messaging, care management mobile apps, and live and automated messaging. To achieve population health, organizations must move their outreach and patient engagement more aggressively into the ever-growing digital space.

“You want your population to be able to access the care services they need through the mechanism that works for them," says John Hitt, chief medical quality officer of Hennepin County Medical Center, based in Minneapolis, Minnesota.

Aiming for the big goal

Going forward, healthcare delivery systems will need strong leadership to navigate the “murky" transition to population health. Many organizations are so fragmented that the most important job for leaders will be advancing and communicating a strong vision, building consensus, and reshaping cultural priorities to navigate unforeseen changes — before they even get into tackling the operational nuts and bolts of delivering care.

The future is not about surviving or thriving in a risk contract or simply taking on new methods of reimbursement. That's a small goal. If healthcare leaders want a big, audacious goal, they should be rethinking how to manage entire populations and create care delivery mechanisms to support this new approach.

The changes will require the development of new capabilities, and new strategies, but the payoff for patients, providers, and organizations is significant.

Success won't happen with a series of small, isolated steps. The industry is at the cliff's edge and it is time to build the bridge — even if there is uncertainty about what rewards await on the other side.

For the pop health transition, small steps won’t work