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In this excerpt from the interview, David Blumenthal, MD, former national coordinator for health information technology under President Obama, discusses with Richard L. Clarke, DHA, FHFMA, president and CEO of HFMA, lessons learned about population health management efforts in the 1990s.

Richard L. Clarke: More than a third of the healthcare organizations surveyed for HFMA's Value Project have already begun investing in population health management capabilities or plan to do so within the next two years. What were the lessons learned from population health management efforts in the 1990s?

David Blumenthal: We made a huge error in the 1990s by taking a fundamentally useful concept-that of health maintenance and the management of people's health in its entirety rather than episode- or visit-based care-and using it as a cost-control device. We lost the chance to move it into common use and thereby alienated the health professions and the public.

We need to move incrementally and judiciously back to some kind of shared risk. I don't think we're going to move precipitously to global capitation for individuals in the short term. It exists, obviously, in a relatively small number of organizations, such as Kaiser Permanente.

We're going to see risk transferred in increments in a variety of ways that organizations will be capable of managing-especially leading organizations, because they are working so hard at their information systems.

Within the past couple years, I served on a committee with the medical director of a large primary care and multispecialty group that had about 300 physicians. The group was capitated to a large extent and doing extremely well. The head of the group said they could manage care because their information systems enabled them to accept risk. Such systems didn't exist 20 years ago.

That means we have new opportunities to transfer risk without the calamities that befell so many groups in the 1990s. We have new opportunities because people can learn how resources are being used and where they're vulnerable and where they're not, and be intelligent managers of the risks they're accepting. But not many organizations are there yet. We're going to have to move toward risk and varieties of global payment over time. We won't move toward a single form of risk acceptance, because there is no consensus on the optimal way to do it-whether it's bundled payments for hospital stays, episode-of-care payments, the PROMETHEUS approach, or some less prescriptive, more experience-based form of care.

But we will move increasingly toward sharing risk, and that will change the sensibility of providers. One hopes that over 10 to 15 years, that changed sensibility will be as important as the narrowly construed risk-sharing arrangements themselves.

A lot of this is about psychology. Physicians don't think like auditors or economists. They think about their patients and their needs at the moment of decision. Enabling them to think as though they need to look for ways to save resources that don't jeopardize the care of their patients could be vastly more important than any mechanical payment structure.

For more information, see "David Blumenthal, MD: Using Information to Drive Value," hfm, October 2011

Publication Date: Monday, October 03, 2011

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