Population Health: Evolving under ACA

When David B. Nash, MD, MBA, and his team of researchers created The Jefferson School of Population Health (JSPH), health reform efforts were just beginning to take shape.

 “Back then, some people said: ‘Population health? What’s that?’” says Dr. Nash, founding dean of JSPH. 

These days, industry stakeholders call him frequently asking for information on population health now that it’s become an emerging trend, but the nuances can’t be explained in a simple one-hour phone call. Today, the school has almost 300 students across four master’s degrees spread out in more than 25 states and in several foreign countries, and interest is growing in the practice of population-based healthcare.

Q: What are the trends in population health over the last year or so?

DR. NASH: That’s a huge question. One trend is defining the field. There is a lot of confusion about what exactly we mean by population health. The second trend can be described as a desperate search for talent-finding the appropriately trained persons, and coming up with appropriate measures to know what it is and know how to implement it. The third trend, which is actually now a national conversation, is how to create applicable measures of population health. The fourth trend is learning how to implement the systems that will improve the health of the population. 

Q: How has the Affordable Care Act (ACA) influenced population health?

DR. NASH: Population health has gained prominence under the ACA. It has given rise to several new structures and systems to promote population health. Accountable care organizations have gained traction with their creation. The patient-centered medical home, which has been around for a long time, gained prominence under the law. Accountable care organizations are fairly new and gaining traction. 

In addition, ACA is creating an urgent need for measures of population health. Or, as we like to say, the bill is making the Institute for Healthcare Improvement’s Triple Aim [a framework developed by IHI that describes an approach to optimizing health system performance] a reality. Therefore, we are going to need measures of the effectiveness of the Triple Aim to include, of course, health of the population, per capita cost and individual experience. 

The ACA has also created a huge educational opportunity; not just for our school, but frankly for every consulting company. 

You’ve heard the gag: What does ACO stand for? Awesome Consulting Opportunity.

Q: What are payers doing well in population health?

DR. NASH: There’s a spectrum. Payers are building an evolutionary structure in population health types of reimbursement that go from day-to-day incentives to do a better job all the way to a bundled payment that involves everybody from the primary care doctors to specialists to nurses and to the hospital.

The evolution goes like this: No payment for a bad outcome such as never events and sentinel events; no payment for a readmission within 30 days; no payment for a hospital-acquired infection or central-line-associated bloodstream infection; no payment for a bad outcome. Next step is a pay-for-performance program-we are going to give a little bit more money to the providers if you hit certain process measures and certain outcome measures of quality. 

Next step in the evolution is a procedural-based bundle. So here is a lump sum for that hip, for that knee, for that open-heart surgery or for that bariatric care. Then the next step after the procedural lump sum is a bundled payment for a chronic illness, and that could be for heart failure, asthma, heart disease and pneumonia. It could be an episodic bundle, so anytime your patient is admitted or a year-long bundle, here is your lump sum for heart failure for a year. That looks a lot like capitation.

 As far as improvement goes, I would like to see greater traction of chronic care bundled payment, because chronic disease bundled payment is the holy grail. The research evidence to support that is good. We used to call it gatekeeper-style capitation. If we could get chronic-disease bundled payment with good measures and connect it to reimbursement, that is our biggest hope for the future. Payers really are driving this now by driving further integration among providers. Nationwide, we are seeing unprecedented consolidation and health system integration. For example, the merger of Dallas-based Baylor Health Care System and Temple-based Scott & White Healthcare. This is all traceable back to ACA. 

Q: Population health isn’t a one-size-fits-all, but it’s costly to tailor programs. How do you find
the right balance?

DR. NASH: This is the big unknown. There is really no precedent for operationalizing the Triple Aim. There’s a handful of successful models, which are not broadly applicable, because not everyone can be a Kaiser or Geisinger. Tailoring these programs and finding the right balance for the average provider is going to be very hard to do. 

What is a good measure of a population’s health? More public health measures? A reduction in hospital readmissions? NCQA screening process measures? It comes back to how we operationalize the Triple Aim. No one is clear on how to do it.

Q: How do pharmaceuticals fit into population health?

DR. NASH: Formulary design and construction in an accountable world is going to be critically important. Health economics and outcomes research teams are front and center. Accountable care is a whole new world for big pharma because they can’t continue to market the sixth beta-blocker and the seventh ACE inhibitor; we don’t need those. We need actual head-to-head cost effectiveness trials, product versus product, and we need formularies that make sense economically speaking. 

Big pharma must also consider innovative, cutting-edge therapy. Provenge (sipuleucel-T), a new therapy for metastatic prostate cancer, costs $100,00 for one complete cycle. This means we must have better screening criteria, practice guidelines, standards of care and evidenced-based medicine. We are going to need all of that inside big pharma. That’s a huge challenge.

Q: What have been the hardest behaviors to change in population health?

DR. NASH: There are basically three things deeply ingrained in our culture and it hasn’t changed in 30 years: We eat too much, we smoke too much, and we don’t exercise. Between the eating, the smoking and lack of exercise, that’s probably 50% to 60% of all medical problems. For example, obesity among public school children in Philadelphia is a ticking time bomb. This has nothing to do with delivering healthcare. This is all the social structure.

The social determinants of medical care drive 85% of the issues surrounding how a society evaluates its quality of life. So we need to focus on the 85%, not the 15%, which is the actual delivery of medical services.  

Tracey Wallker is an Advanstar Communications Content Manager.