Population health management is at a crossroads, and one key to ensuring its viability is to bolster stakeholder trust in the potential of value-based payment (VBP) models.
That was a key takeaway from healthcare executives who took part in a September panel discussion at the 23rd annual Population Health Colloquium, hosted by the Jefferson College of Population Health.
“For a lot of clinicians who are doing this work, the biggest challenge is what I would identify as a lack of trust and a bit of cynicism about what’s going on,” said Shiva Chandrasekaran, MD, a regional chief medical officer with Lumeris, which assists providers in VBP models. “They’ve seen these models come and go. Shared savings is a black box that nobody seems to be able to make sense of.”
He added, “For us to do this work, it requires physicians, nurses and clinical teams to trust payers, to trust their large-health-system-aggregator employers, to trust the analytics platform that’s being installed every few years … to trust claims data. Just getting people to believe that the payer really cares about my patients who are here in the room, that my health system employer actually doesn’t want to fill their beds — they want my patients to not be in the hospital.”
Although policymakers and thought leaders continue to tout the potential of population health management, the disconnect with clinicians on the ground “leads to an inability to unlock a lot of the creative work that many of our clinical teams could be providing for us,” Chandrasekaran said. “It’s fun to try to get people past that cynicism into hope, but it’s getting harder each year that the payment model doesn’t move as quickly as people want it to.”
Other sticking points that came up in the discussion include:
Especially for rural providers, the mechanics of shared-savings calculations are a common concern with population health models.
“The biggest problem that we’re facing now is all of the rebasing that takes place,” said Stephen Nuckolls, CEO of Coastal Carolina Healthcare. “We are in a more rural market where we care for about 50% of the population. We’ve seen our local [cost] trend be well below the national trend … and then we’re having to compete against ourselves for that ever-lower benchmark.”
He added, “Hospital systems or medical practices like us are not going to trust the system unless we have fair benchmarks [through which] we can sustain ourselves.”
Coastal foots the bill for some items and services for which it does not get compensation, such as medications not payable by Medicare, because it knows shared savings can cover the loss.
But if the organization’s benchmark continually gets rebased, shared savings eventually won’t be adequate to cover such outlays, Nuckolls said. He hopes the Center for Medicare & Medicaid Innovation (CMMI) will follow through on pledges to change benchmarking so that organizations won’t be penalized as much by their own success.
“Maybe you just give us the Medicare Advantage rates, or something lower than that, even,” Nuckolls said. “We would be more than happy with that, but it can’t be a 20% differential, which is what we’re seeing in our market now.”
Mitchell Kaminski, MD, MBA, program director with the Jefferson College of Population Health, said the fairness of benchmarking is the leading determinant of success among accountable care organizations.
“As organizations do a better and better job of trimming the fat and enhancing services to make the population healthy, you’re left with a benchmark that you simply can’t beat anymore,” he said.
In surveys conducted by Horizon Blue Cross Blue Shield of New Jersey, said Jamie Reedy, MD, chief population health officer and senior vice president for health solutions, physicians express a strong willingness to partner on population health initiatives. They see the value in innovating to optimize care team structures and care delivery and to improve the exchange and accessibility of data.
However, Reedy said, an impediment to the success of such ventures is the widely reported level of burnout afflicting clinicians.
“It’s hard to imagine getting past that even with all of the innovative alternative payment models that we are devising and all of the support infrastructure that we’re putting in place,” she said.
Even beyond burnout, the clinician workforce faces challenges that could hamper population health strategies.
“I have colleagues who are five, 10 years senior to me who are leaving the profession,” Chandrasekaran said. “I trained residents when I started my career, and the math just doesn’t work there. There aren’t going to be enough folks to replace all of those physicians and nurse practitioners who are leaving.”
One consequence, he said, is that in Medicare, “A lot of people aren’t going to have a primary care doctor. They’re going to have an app or a chatbot or something. We’re not thinking about how to have less of a physician-centric workforce — more-intensive care for some patients, less care [overall]. I think we’re going to collapse if we just keep using these models and hope that somehow these primary care physicians and medical groups are going to figure it out.”
Ideally, he said, education and payment models will evolve to support alternatives to the traditional care model.
CMMI has acknowledged the need to better involve specialists in population health and VBP models. It’s a key step, panelists said.
“We’ve done really well with primary care, and primary care is wonderful,” Nuckolls said. “There are also many different pathways [through which] our specialists can work with us. There’s lots of waste that can be created within these systems around treating chronic diseases, with certain things that happen repetitively.”
Gainsharing arrangements (e.g., shadow bundles) can be used to ensure specialists are rewarded for their work in staying within a budget and improving population health within their specialty, he said.
“If we know that producing better health is going to require new models, we absolutely need our specialists in the room,” said Kara Odom Walker, MD, MPH, executive vice president and chief population health officer with Nemours Children’s Health.
Reedy said Horizon’s predictive analytics make clear that “the variation in utilization rates across so many of the specialty services requires really severe attention very soon. We have a lot of specialty utilization that needs to be critically examined and figure out how to right-size that. It’s going to require going upstream, as opposed to what health plans do well, which is look at the event and [determine] should we pay for it?”
Social determinants of health
Shared savings supports providers in population health models, but the price tag of offering holistic care can be prohibitive for many — especially these days.
“I would love every one of my clinics to have a social worker, a behavioral health specialist, a care coordinator, and everyone [to] be able to connect back to the schools and talk to the teachers and make sure that we’re staying coordinated,” Walker said. “But that takes resources to invest. And right now, when we see inflationary pressures in everything we purchase, whether it’s people power or supplies increasing faster than reimbursement levels, that’s creating some true pressure points.
“We’re going to see challenges, especially when we think about innovating around AI and ChatGPT and investing in new tools and toys. It certainly is something we’re going to have to figure out how to do differently — how to leverage our capacity and expertise in different ways.”
The stakes in that effort are high, nowhere more so than in pediatric care.
“It is incredibly difficult to reorient toward a prevention model in our healthcare system that is very used to just paying for the problem in front of us rather than the long-term investment,” Walker said. “We know child poverty is on the rise, and some of the consequences we’re seeing in not connecting the dots between housing and food and what happens in schools and how we invest in mental health [ultimately] result in long-term consequences.
“I’m a family physician by background, and I see this trajectory unfortunately going into adulthood and entire lives if we don’t figure out how to invest in [addressing] adverse childhood experiences.”