Population health and primary care: What to know

If primary care physicians want to succeed pursuing a population health management model of care, they’ll need to begin to radically redesign their practice and think differently about their approach to delivering patient care.

In reaction to The Centers for Medicare & Medicaid Services’ (CMS) Quality Payment Program, which has several initiatives to reward physician practices that demonstrate patient improvement, but penalizes poor outcomes, small practice physicians have a powerful incentive to boost their revenues while remodeling their practice under a population health model.

As value-based payment models take hold, primary care physicians should embrace population health management as a tool that will help them financially thrive, said J. Lloyd Michener, MD, chair of the Department of Community & Family Medicine at Duke University in Durham, North Carolina.

“Small practice physicians must participate in population health; it's the future and it's how they’re going to get paid. It's going to be really hard not to participate in this model of care,” Michener said.

By using technology, skilled staff, new forms of patient engagement and partnerships with healthcare stakeholders, small practices can better align with population health’s goal of improving the outcome of groups of individual patients.

To do this, primary care physicians, who are on the frontlines of care, will be required to think differently. Doctors must take the lead in shifting their attention away from being an individual provider to a team leader in a care coordination model that demands they follow their patients more closely, glean patient data with an investigative eye and analyze that data to look for intervention opportunities when the evidence reveals patients’ health is declining.

In a value-based model of care where reimbursements under programs like the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs) are dependent on documentation that shows patient outcomes are improving and cost reductions in care delivery have been met, the pressure is on primary care practices to improve patient care.

Next: Key population health considerations

Key population health considerations

Michener told Medical Economics there are several factors physicians need to consider as they pursue a successful population health management strategy. These include:

Change the way you practice medicine. Primary care doctors are used to thinking that they have to take care of their patients all by themselves. This is not true and won’t work in a population health model. To be successful, doctors need partners such as other physician practices, local or regional health networks, schools or other local or state government departments to help them coordinate care.

Strive for data consistency. Make sure your electronic health record, claims data system and other software is designed to capture the data required for payment. When evaluating data, especially on patients with chronic illnesses, there needs to be consistency across your systems that capture vital information such as patient identification, provider performance measures and patient prioritization.

Look for patterns in care. Make sure your data identifies the groups of people for whom a combined intervention would be useful. One example would be to look at all patients that have asthma that are not getting better. In this case, look for how often these patients have been to the emergency room in the past year and find out where they live to see if there are troubling trends that they’ll need to address.

Capture small bits of data (It can make a big difference). Small practice physicians should know that there's only a tiny bit of data they actually need for effective population health. Doctors can make an enormous difference if all they have are the names, addresses and diagnosis of the patients from their practice who visited an emergency room in the last year. That little bit of information alone is enough to start targeting interventions that will improve their ability to score high to meet population health initiatives.

Another benefit for primary care doctors is that small practices are fascinatingly advantaged in implementing population health strategies because they don’t have to deal with the bureaucracy that comes with being part of a larger hospital-owned practice, Michener said.

Furthermore, because small practice physicians often know their patients, their patients’ family members, their communities and other physicians that treat their patients, primary care doctors can better assess patients as part of groups of individuals that have similar comorbidities and similar socio-economic circumstances.

“Primary care physicians need to know that they have the power to quickly analyze groups of patient data and intervene when necessary to make better treatment and care decisions that lower the cost of care, improve outcomes, and raise their ability to earn income under a value-based payment system,” Michener said. “That’s an incredibly effective way to deliver care.”