With the recent spate of mass shootings in the U.S., I thought it would make sense to explore the connection between mental health and something I talk about a lot on this blog, population health management (PHM). Mass shootings are the result of more than just mental illness — the ease of availability of automatic weapons in the U.S. being another obvious one — but for our purposes I’ll focus on the mental health aspect of our ongoing national nightmare, and how PHM may someday soon play a role in stopping it.

The problem is formidable. Mental disorders are, as the website for Harvard’s T.H. Chan School of Public Health describes them, “the major overlooked challenge to population health both in the United States and globally” with major depression “projected to be the leading cause of burden of disease globally by 2030.” And with care for mental illness being unevenly distributed throughout the country both geographically and along ethnic lines, there is no ready-made solution.

Complicating matters is the structure of the U.S. healthcare system itself. Counter to the widely-accepted view that mental and physical wellbeing are inextricably linked, care for mental and physical conditions is often not coordinated between healthcare providers. Consequently, matching people up with appropriate mental healthcare is a complex issue.

Without going into the particular situations that led to the atrocities in Buffalo, New York and Uvalde, Texas, among others, there are some trends in the delivery of mental healthcare in the U.S. that can shed light on why these things keep happening here. Once the problem is identified in all its intricacies, I firmly believe it will become possible to mitigate the mental illness dimension of the problem. And PHM has been put forward by some as a good starting place.

A Convergence of Ideas

At this point I should note that for the purposes of this blog post, I’ll use the CDC’s definition of the term “behavioral health,” which they consider to cover “mental health and substance use conditions.” Although I haven’t seen substance abuse linked to the recent mass shootings, it’s entirely possible that I missed something. For that reason, I feel that using this more comprehensive term is appropriate in this context.

At the beginning of this post I mentioned that there’s been a steady convergence of the notions of mental and physical wellbeing for the past several decades. This idea had its origin in a 1951 article called “Outline for a study group on World Health and the survival of the human race: material drawn from articles and speeches.” In it, Dr. Brock Chisholm, the first Director-General of the World Health Organization (WHO), said, “without mental health there can be no true physical health.” Evidently this sentiment was revolutionary for its time, and in the ensuing decades, many healthcare systems across the world have taken his words to heart, supported by scientific studies that bear out the deep link between physical activity and mental wellbeing.

This connection between environmental, physical, and mental health was put to the test recently during the COVID-19 pandemic. In a 2020 CDC article titled “The Critical Need for a Population Health Approach: Addressing the Nation’s Behavioral Health During the COVID-19 Pandemic and Beyond,” the authors speculate that if a population health model of behavioral and clinical care delivery had predominated in the U.S. during the opening stages of the pandemic, the harmful mental effects of COVID would have been more muted. 

It should be noted here that I haven’t seen any research done on correlations between gun violence and COVID lockdowns, so any talk of COVID in this context is purely speculative on my part. I think it’s safe to assume that the stresses attending COVID haven’t exactly dampened people’s desire to act out in violent ways. But since the scourge of gun violence has been with us since well before COVID-19 arrived on the scene, it’s hard to know for sure.

With that said, although the CDC article doesn’t put forward many concrete solutions to moving the U.S. healthcare system toward a population health footing, its authors quite rightly note that “Adopting a population health approach helps to address the needs of the total population, including at-risk subgroups, through multiple levels of intervention and to promote the public’s behavioral health and psychological well-being.”

Barriers to Behavioral Healthcare

This “multiple levels of intervention” is the tricky part, of course, since, with some notable exceptions (two of which I’ll discuss a little further on), behavioral healthcare specialists aren’t often co-located with primary care physicians (PCPs). Under evolving guidelines, PCPs are encouraged “to perform basic screenings for depression, substance abuse, and interpersonal violence,” but this is not enough to identify everyone who needs help. Indeed, according to a recent article in the Harvard Medical School Primary Care Review, the author notes that “while many patients depend on referrals from primary care for mental health services, nearly two-thirds of primary care providers struggle to find community-based clinicians to refer to.”

Two-thirds of PCPs! And then there’s the matter of affordability, which is arguably the biggest barrier when it comes to people seeking care for mental illness. The author of the above Harvard Medical School article points to a survey run by the California Health Care Foundation, which found that “over half of respondents were concerned about out-of-pocket costs for services and postponed care accordingly.”

For those fortunate people who can find appropriate mental healthcare, study after study has document how, even after passage of legislation such as the Mental Health Parity and Addiction Equity Act of 2008, the Affordable Care Act, and developments such as Medicaid expansion, it’s still very challenging to afford these services in most places given that relatively few mental health practitioners accept insurance.

Leaving insurance aside, one study found that 18% of people who sought mental health care “reported at least 1 contact with an out-of-network mental health provider, compared to 6.8% who used a general health provider.” This means that nearly triple the number of people seeking mental healthcare pay higher costs when compared to those seeking physical healthcare.

Behavioral Care Integration

OK, that may seem like a lot of bad news. But believe it or not, I still feel optimistic about all of this! Why? Because to my mind, any instance where people are trying to implement PHM and haven’t completely given up is a win. And increasingly, that’s just what’s happening in behavioral care sites across the country. Looked at from this perspective, two examples of integrating behavioral and physical healthcare give us ample reason for hope: the behavioral health home (BHH) model of care delivery in Maryland, and Cherokee Health Systems in Tennessee.

In a 2019 Medical Care article, the authors examine healthcare leader and staff perceptions of the BHH system in Maryland. (To learn more about Maryland’s BHH program, check out this separate study). According to the article, “Behavioral health home (BHH) models have been developed to integrate physical and mental health care and address medical comorbidities for individuals with serious mental illnesses (SMIs).” And beyond that, achieving population health management is a stated goal of the program.

The BHH initiative is an example of “co-locating” mental and physical healthcare services in a single physical location to better facilitate care coordination. Although this approach isn’t specific to Maryland (Iowa, New York, and Missouri have implemented similar programs), the experience of the Maryland BHH program highlights not only the advantages of this approach, but also its challenges.  

As a starting place, since PHM is such a nebulous term, I always think it’s important to contextualize the term. In the case of the article about Maryland BHHs, the authors consider PHM to be an approach that “addresses needs along a continuum of health states for a specified population using continuous health monitoring and targeted interventions…Care coordination strategies organize patient care activities across multiple providers.”

Before we delve into the BHH program, let’s be clear: this initiative has encountered a lot of challenges. When asked to identify the biggest barriers to effectively implementing PHM, survey respondents pointed to a number of factors including lack of experience, inability to acquire health information technology, and state regulations. But it’s important to remind ourselves that embodying PHM is an uphill battle. Most providers are nowhere near working within this framework, so please don’t misread my exploration of the challenges facing Maryland’s BHHs as a criticism.

Moving on, I found it interesting that the state regulations piece — an approach meant to spur PHM — has come to be seen by some as detrimental to instituting PHM in the Maryland program. Since many providers in these frameworks lacked experience with PHM, the article states that “there were beliefs among some that direct clinical care for consumers with SMI was more important than population health management tasks.” It seems that one version of BHH in Maryland in particular, called the “Medicaid BHH,” has stuck in some people’s craw as a counterproductive approach to mental healthcare.

Medicaid BHHs are based in psychiatric rehabilitation programs and (according to a previous study run by the same group) received “a $102.86 per-member per-month payment contingent on the delivery of two health home services to each consumer per month.” Because the state requires providers in this type of setup to deliver two services per month to each participant to receive the per-member-per-month reimbursement “regardless of health needs,” this seems to have led some survey respondents to perceive this PHM approach as a distraction from focusing on delivering services to the highest-need patients.

A few possible solutions are put forward in the paper, including a suggestion to take a page from a BHH program in Vermont that runs on a hub-and-spoke model where reimbursement is split between specialty substance use treatment programs and PCPs. Such an approach actually spurs external provider participation in the BHH and encourages tighter coordination. And since financial reimbursement isn’t tied to quality metrics in the Maryland BHH program, the authors suggest that participating in alternative payment models that prioritize high-value care might help improve patient outcomes.

Another institution that integrates mental and physical healthcare is the Cherokee Health Systems in Tennessee. According to the Agency for Healthcare Research and Quality (AHRQ), “Cherokee Health Systems is a Federally Qualified Health Center (FQHC) and a Community Mental Health Center, and is a national leader in integrating primary and behavioral/mental health care.”

The current CEO of Cherokee Health, Dr. Dennis Freeman, is a psychologist who has been providing care at that institution since 1978. Early on, Freeman recognized that most people in need of behavioral health services were seeking out care at primary care clinics. In a “go where the people are” moment of insight, he recruited PCPs and “paired them” with behavioral healthcare providers. In time, Cherokee evolved into a Community Mental Health Center with primary care services, essentially becoming a hybrid of a FQHC that offers both primary care and behavioral healthcare services at 22 clinical locations.

While it’s not clear if the practitioners at Cherokee consider the care they deliver to fit into a PHM framework, as the paper makes clear, the system has “adapted to the needs of the population” with special attention paid to marginalized patients. The fact that the health system reaches out to underserved populations like migrant workers and refugees underlines this PHM approach. I encourage you to read this paper to see how, albeit with a lot of effort, behavioral healthcare can be assimilated into the physical care structure of the U.S. healthcare system.

Although behavioral and physical healthcare are deeply intertwined, this discussion goes to show how challenging it is for even the most adept healthcare consumers to pursue affordable, effective behavioral healthcare in the United States. But oftentimes, the people who most need this care are the least equipped to seek it out. If they’re lucky, they have a loved one or friend who can help them navigate this intimidating process. But for those who lack the resources or social support to get the care they need, the U.S. healthcare system can prove an insurmountable series of obstacles.

Let me finish by saying that I don’t mean to pick on the U.S. approach to behavioral healthcare, because other comparable countries like Canada and the United Kingdom have their own share of issues in this regard. But the U.S. is unique in terms of the sheer number of mass shootings and gun deaths when compared to just about every other comparable country, and mental illness undoubtedly plays a role. With this country’s substantial financial resources, coupled with a population health approach that can enhance efficiencies, we can and should do right by each other.

As the second installment in my “New to Me” series (see the first one here), I’d like to say a few words about an intriguing new idea put forward by the Health Care Payment Learning & Action Network (HCP-LAN, or “LAN” for short) called State Transformation Collaboratives, or STCs. According to the LAN website, STCs strive to formulate ways to overcome health disparities by increasing “healthcare quality, access, and outcomes” on a state-by-state basis by focusing more on person-centered, value-based care.

I attended a recent webinar hosted by the LAN during which STCs were discussed, and I get the sense that although there’s a lot of energy behind the initiative, the LAN is in the very early stages of rolling out this program. There also doesn’t seem to be much information about the effort online, but I’ve pulled together what I could find.

Four states are involved in the program, including Arkansas, California, Colorado, and North Carolina. For such a low number of states, there’s decently diverse representation here in a few key areas including geography, state size, region, politics, and willingness to expand Medicaid (according to the Kaiser Family Foundation, while California, Colorado, and Arkansas have all expanded Medicaid, North Carolina has not).

And as we’ll see in a moment, there’s a strong component of shoring up healthcare disparities baked into this initiative, so it bears mentioning that although some states on the list are more ethnically diverse than others, they’re all in the 55th percentile or better in terms of ethnic diversity. Since the effort to mitigate healthcare disparities must take into account ethnic diversity as one important factor, in my opinion it makes sense that the LAN chose to partner with these four states for the pilot study.    

Before we get to the disparities piece of this, though, it has to be said that despite the fact that this dedication “to transforming health care in a specific state or region within a state” isn’t a new concept overall (see my previous blog post on Place-Based Care in the UK), the fact that the LAN is emphasizing the importance of tailoring care in more bite-size pieces, focusing locally to meet “the needs of state populations through alternative health care payment” strikes me as different.

It’s not a knock against the LAN, but up until now, the organization’s literature and live events have tended to emphasize scalable solutions that apply nationally and across stakeholders (one look at their homepage will tell you this).

Now, on to the health disparities component of STCs. As stated on the initiative’s web page, one key component of the STC program is state initiatives that “focus on achieving health equity via payment reform and are grounded in HEAT APM Guidance for equity centered design and implementation.” But what does “HEAT APM guidance” mean, exactly?

The HEAT is the LAN’s Health Equity Advisory Team and, as its website states, it functions to guide alternative payment model (APM) design such that implementation addresses “factors that drive health inequities.” HEAT strives to influence APM development so that access to necessary care is opened up, healthcare disparities are narrowed, and patient outcomes improve. As the site says, “Patient experiences, priorities, and perceptions are crucial elements the HEAT will explore.”

The HEAT program has produced a document called “Advancing Health Equity Through APMs” which “provides stakeholders with actionable guidance on how they can leverage APMs to advance health equity in ways that are both aligned and tailored to meet their communities’ needs.” It’s a general framework for aligning stakeholders, who the group rightly lists as payers, purchasers, and providers, along with individuals, families, and their communities.

Since this post isn’t devoted exclusively to healthcare disparities I won’t go into much more detail about the HEAT’s work. In general, though, if done right, the group states that APM changes “will result in people accessing culturally appropriate and integrated care; providers delivering more equitable and accessible care; and payers, purchasers, and providers identifying opportunities for disparities reduction, setting specific and actionable health equity goals, and monitoring performance.” 

There’s a strong measurement component here which adds to accountability; indeed, in their APM design guidance, the group urges plan designers to “Meaningfully adjust prospectively paid primary care/population health APMs, earned shared savings rates, and other performance-based payments upward or downward based on equity performance credits or penalties reflected in the quality composite score.” If this guidance is followed across the board, this could have a big impact on opening up access to needed care to a larger segment of the U.S. population, which is a central goal of population health management.

As a bonus, the document doesn’t just speak in generalities, providing a few real-world examples of setting expectations in APM contract language and structuring payments around a measurement regimen. One example is Covered California’s health equity performance measure set, which consists of multiple “population health/primary care outcomes measures” which relate to hypertension and diabetes. The goal of this program is to reduce racial and ethnic health disparities of health plan members.

I will continue to monitor STCs and their associated programs, which I think on the whole have a lot of potential to move the dial on shoring up healthcare disparities and moving the healthcare system toward more equitable care.

I mentioned in a past blog post that the word “population” in the term “population health management” is open to interpretation. The PHM projects I’ve worked on have mostly considered the word “population” to denote clinical populations, whether they be current or future patient populations. This approach has the advantage of viewing populations as somewhat captive and easier to define since they’re already entered into a system, in this case a healthcare system.

But there are other, equally valid ways of looking at populations, including on the basis of geography. It’s this viewpoint that’s at the foundation of National Health Service (NHS) England’s approach to PHM, namely its so‐called “Place‐Based Systems of Care” program or, as I’ll call it, PBSC. In my opinion this is a slightly more complicated and less straightforward vision of PHM in that, as visionaries of this approach will admit, people cross geographical boundaries all the time to receive medical care, so this formulation requires a somewhat less rigid definition of “population.”

In any event, a good starting place for exploring PBSC is to ask “why would anyone want to organize care delivery geographically as opposed to, say, based on clinical condition or insurance carrier?” Well, at least in the case of the UK, the idea is based on the duality of the “fortress mentality” versus the “system mentality.” This concept was put forward by the authors of a King’s Fund study that urged a collective approach to rationing of healthcare resources as opposed to a “war of all against all” (to quote Thomas Hobbes) in which every healthcare provider is out for themselves and some patient populations thrive at the expense of others. 

To set the stage for this discussion, it’s important to note that in recent decades the NHS has devolved many responsibilities to the constituent regions of the UK (England, Scotland, Whales, and Northern Ireland); in other words, the centralized NHS in England has divested itself of certain responsibilities, empowering the different parts of the UK to become more in control of their day‐to‐day activities.

Because of this, groups like the King’s Fund are careful to note the differences (and, in some cases, similarities) between the approach to population health in the different regions. And the literature I’ve seen on PBSC, while referencing successful projects in other UK regions, tends to focus mainly on England. For the above reasons, this blog post will mostly cover what’s going on in England at the moment with respect to PHM.

And it should be noted that place‐based care is probably easier to operationalize in what’s still essentially a single‐payer system (albeit a more fragmented one than in decades past) like the NHS. Although entities outside the healthcare system are integrated into proactive care, and despite the fact that conflicts of interest exist between healthcare systems within the NHS, I have to imagine that on the whole, sharing resources based on geography is probably more achievable than in the relatively more fragmented, competing healthcare systems we have in the United States.

Also important to note up front: despite the major differences that exist between the NHS and the American healthcare systems, they share a few similarities. For one thing, both countries are (just like many nations throughout the world) are dealing with aging populations during a time of scarce resources. Indeed, PBSC recognizes that, even before the COVID‐19 pandemic, healthcare resources were scarce in England. 

PBSC and Integrated Care

To control rising costs, in the same way the U.S. healthcare system has turned to accountable care organizations (ACOs) and other alternative payment models, the NHS has in recent years begun experimenting with Integrated Care Systems (ICS). According to NHS England’s website, ICS are “new partnerships between the organisations that meet health and care needs across an area, to coordinate services and to plan in a way that improves population health and reduces inequalities between different groups.” From what I’ve read, it seems that people interchange the terms PBSC and ICS, but there may be a shade of meaning there that’s escaped me.

Officially, ICS were designed to achieve four goals:

• Improve outcomes in population health and healthcare
• Tackle inequalities in outcomes, experience and access
• Enhance productivity and value for money
• Help the NHS support broader social and economic development

In describing ICS, NHS England asserts that healthcare services should be situated as close to people who use them as possible, the foundational argument for PBSC: “For most people their day-to-day health and care needs will be met locally in the town or district where they live or work,” says the agency. “Partnership in these ‘places’ is therefore an important building block of integration, often in line with long-established local authority boundaries.” There seems to be an emphasis on not reinventing the wheel with PBSC, since much of the infrastructure needed to run ICS efficiently is already in place and all that’s needed is a reimagining of how to share resources.

King’s Fund researchers note that a place-based approach incentivizes providers in the same geographic area to collaborate because “health care provision is essentially local and the opportunities to develop systems of care are therefore best pursued among those serving the same or similar populations.” The authors contrast this approach with the “fortress mentality” in which healthcare providers work independently to secure their own resources at the expense of surrounding health systems ‐‐ and, ultimately, to the detriment of patients in neighboring communities.

“Place” Defined

While we’re in the business of defining nebulous terms, before we go any further, we should examine what the NHS and King’s Fund mean by “place” in their PBSC framework. According to an NHS Confederation document, “The NHS has defined ‘place’ as meaning geographies comprising populations of 250,000 to 500,000…Local places also build naturally on previous efforts to integrate care and local services, such as the Better Care Fund and integrated care pioneers. Strategic leadership at the place level also supports the development of primary care networks and integrated care providers.”

Also, the authors of this paper say the following:

“New systems and models need to reflect factors such as geography, rurality and other local needs, and there is no ‘one size fits all’ solution. We believe that place-based systems should be established or amended following local discussion and considering the role of all the partners who contribute to health and care in a place, including housing, employment and training, and emergency services.” 

The emphasis placed on encouraging care, even proactive care, beyond the walls of the hospital is key to PBSC, as is the understanding that organizations should have the built‐in flexibility to work across borders. While the latter would seem to fly in the face of the physical boundaries needed for PBSC to work, in fact primacy is placed on improved health outcomes of geographic populations. Therefore, if allowing patients to cross “borders” to receive care will improve their outcomes, this is permissible.

How PBSC Will Operate

I won’t delve too much into the history of how the NHS commissioned healthcare in the past, but suffice it to say that since 2012, as with the U.S healthcare system, the NHS as a whole has been shifting towards value‐based care. As part of the Health and Social Care Act of 2012, Clinical Commissioning Groups (CCGs) were established to succeed Primary Care Trusts, the latter of which used to commission (i.e. purchase) primary, community, and secondary health services from providers and, for a while, provided direct community health services. 

Again, not to go into too much detail, but CCGs are groups of general practices (GPs) that decide which services are most appropriate for their patient populations. I couldn’t find evidence of this anywhere, but although healthcare providers were involved in decisions within Primary Care Trusts, I have to imagine that they play an even stronger role in CCGs and (as I’ll mention soon) in whatever healthcare delivery schemes supersede CCGs.

In keeping with this trend to think bigger when it comes to implementing PBSC, the authors of the aforementioned King’s Fund study stress that an approach to commissioning beyond the scope possible within the current CCG framework will be necessary to make PBSC work:

“Commissioning in future needs to be both strategic and integrated, based on long-term contracts tied to the delivery of defined outcomes. Scarce commissioning expertise needs to be brought together in footprints much bigger than those typically covered by clinical commissioning groups (CCGs), while retaining the local knowledge and clinical understanding of general practitioners (GPs).”

In a pared‐down version of the King’s Fund report, ten design principles are identified that will help to operationalize this approach:

• Define the population group and the system’s boundaries
• Identify the right partners and services
• Develop a shared vision and objectives
• Develop an appropriate governance structure
• Identify the right leaders and develop a new form of leadership
• Agree how conflicts will be resolved
• Develop a sustainable financing model
• Create a dedicated team
• Develop systems within systems
• Develop a single set of measures

Another interesting aspect of PBSC is the idea of establishing “population health intelligence” and analytical capabilities to better understand where gaps in care exist. This is also known as predictive analytics. As with the U.S. approach to PHM, NHS England has recognized the need for robust data sources to enable patient segmentation into manageable groups. Indeed, says NHS England, “This typically includes segmentation and modelling to understand future demand across different population groups and care settings, working with PCNs and other partners to understand their population’s bio-psychosocial risk factors, and supporting the implementation of anticipatory care models.” 

New Payment Models

Speaking of implementing anticipatory care models, experts seem to agree that perhaps the most crucial step in the successful implementation and maintenance of PBSC over the long haul will be the development of sustainable financing models. If done right, these incentive structures will reward healthcare providers for efficiently sharing resources to provide quality care to patient populations while holding down costs.

I should note here that in my research I didn’t come across any concrete examples of payment models that are currently in use, so I may revisit this topic in a future blog post. At any rate, although this post isn’t meant to contrast new payment models with how the NHS has allocated healthcare funds in the past, a brief summary will help set the stage for the changes that have been accelerating over the past ten years or so.

Let’s start with what hasn’t changed: NHS funding sources. Insofar as I can tell, NHS England hasn’t changed much about how it pays for healthcare in the past decade or so. The King’s Fund says it better than I could:

“The level of NHS funding in a given year is set by central government through the Spending Review process. This process estimates how much income the NHS will receive from sources such as user charges, National Insurance and general taxation. If National Insurance or patient charges raise less funding for the NHS than originally estimated, funds from general taxation are used to ensure the NHS receives the level of funding it was originally allocated.”

But I suspect that in recent years, NHS England has admitted to itself that, going forward, allocating funds simply based on analysis of past spending habits won’t be enough on its own to keep their health system afloat. If I understand correctly, that’s why, in 2015, NHS England established organizations called “vanguards” to help reimagine care delivery that reduces waste and improves care outcomes by trialing new payment models. As a point of comparison, this program shares features with the Pioneer ACO program in the U.S.

In another publication, one of the co authors of the King’s Fund report linked to earlier states that, in order to avoid conflicts in how resources are distributed, paying for healthcare will need to change in three important ways:

• Identifying and pooling collective resources needed to achieve agreed‐upon objectives. “In practice,” the author writes, “this is likely to mean commissioners of health services and local authorities working together to pool their budgets and commission services jointly.” 
• Developing new ways of contracting with providers to align incentives behind the aforementioned objectives. The author favors capitation, longevity of provider contracts, and a portion of provider payments being linked to outcomes as keys to holding down costs.
• Lastly, providers should agree on how resources are allocated, and the basis on which costs, risks, and rewards will be shared. The author states, “More important than the technical detail, this will require strong relationships between local leaders willing to work together rather than compete for resources.”

Again, these are general guidelines and not very concrete, so if I see any practical applications of these ideas in the UK, I’ll let you know.

PBSC and Healthcare Inequalities

Apart from effectively using scarce resources, a real effort has been made to try and tackle healthcare inequalities within the system. The subject of PBSC and healthcare inequalities could be a blog post of its own, but suffice it to say that NHS England has foregrounded this issue.

This coincides with efforts being made within the U.S. system to address inequities that were starkly revealed by the COVID‐19 pandemic. Actions already taken to combat this issue in the United States include everything from State Transformation Collaboratives to requiring specific language within some Medicaid Managed Care (MMC) contracts that incentivizes and promotes equality in care delivery. Some of these state‐level contracts even incorporate community-based strategies targeting Social Determinants of Health (SDOH), expanding responsibility beyond hospital walls and encouraging proactive healthcare.

Since improving access to care is a central goal of both PHM and PBSC, we can point to the Wessex Kidney Centre in the UK as a successful example of PBSC in practice. At this site, they have recognized that not all renal outpatient appointments add a tremendous amount of value since each appointment presents a burden to patients, especially considering that originally, clinical visits were set up during times that suited the clinical team. Since routine appointments, which system administrators have designated as a “low value add,” dominate outpatient care at this center, the center realized a change was needed.

This set of circumstances resulted in the team establishing a virtual clinic as a pilot project in which 100 patients participated. The virtual clinic puts patients in the driver’s seat, empowering them to undertake routine monitoring like taking their own blood pressure, keeping track of their weight, and reporting any abnormal symptoms, which they submit virtually to an app as opposed to having to physically visit the site. In addition, patients can schedule any necessary tests at a convenient place and time.

Once all of this is done, the physician reviews the data in the app, a process that takes about five minutes on average. The physician then proceeds to upload their feedback into the app and lets the patient know when the review is complete. At this point the clinician sets up the next “routine” virtual clinic check-in.

Baked into this process is the understanding that if something significant has changed with the patient’s health since their last visit, they are allowed to set up another in-person office visit. When surveyed at the conclusion of the pilot, 82% of patients said they preferred virtual visits, and 57% felt more involved in their care. This is a great example of PHM in the sense that this clinic used technology to streamline their workflow in a way that opened up access to more patients and made patients feel more invested in their own care.

In the spirit of more deeply involving patients in their own care, NHS England has taken inspiration from the Nuka System of Alaska. Administered by the Southcentral Foundation, the Nuka System of Care, which is based in Anchorage, Alaska, has been described as the “result of a customer-driven overhaul of what was previously a bureaucratic system centrally controlled by the Indian Health Service.”

Before 1999, Alaska Native people residing in Southcentral Alaska received their health care from the Indian Health Service’s Native hospital, a large, bureaucratic system controlled from Washington, DC. There was a tremendous amount of waste and dissatisfaction with this system, as patients often waited weeks to get an appointment, seeing different providers each time. In response to residents advocating for changes to the system, Congress passed a federal law that allowed for a complete redesign based on “Alaska Native values and needs.” 

Ultimately, residents become “customer-owners” more in control of decision-making and administration. The approach ticks many of the same boxes that PBSC aims to cover: the Nuka System administrators have a shared mission and vision (“A Native Community that enjoys physical, mental, emotional and spiritual wellness”), the system is based on geography (covering a 108,000-square-mile service area), and healthcare providers strive to establish “trusting, accountable and long-term relationships” that allow them to “be in a better position to understand symptoms, answer questions, have meaningful conversations about risks and benefits, and work with each customer to make better health decisions.” As a result, the Nuka System has successfully improved patient outcomes and satisfaction while holding down costs, the aims of the IHI Triple Aim.

I’ll conclude by saying that PBSC is an enormous area of endeavor, and I could write a number of blog posts about it. At the end of the day, NHS had made the decision to undertake this massive reshaping of their healthcare system because they really don’t have any other choice. As with the American healthcare system, there is a substantial amount of wasted time and money that could be used to improve the care citizens of each country receive. I hope we take inspiration from the UK’s example and continue on the track toward value-based care. I will update this post if I learn of any significant changes in the UK’s approach.

Something I’ve become interested in lately is quality measure development. Measuring quality is a high priority these days not just for CMS, but for many private payers as well. But how should one go about developing measures that not only providers value, but patients as well? This seems to be the key question, and it’s fascinating to see how different groups approach the question.

In their report brief on a study called “Toward Quality Measures for Population Health and the Leading Health Indicators” published nearly 10 years ago, the Institute of Medicine (IOM) of the National Academies made an explicit connection between quality metrics and population health. At the request of the U.S. Department of Health and Human Services (HHS), the IOM convened a committee to look at “the intersection of HHS’s public health quality effort and the Leading Health Indicators (LHIs)” which had been marked out as “a subset selected from a much larger range of objectives.”

Why do I bring this up? Because sometimes I feel like the connection between quality measures and PHM is foggy at best. I think we basically all agree that quality measures that reward providers for implementing and iterating on PHM initiatives ‐‐ and perhaps enforce financial penalties when they don’t ‐‐ will be needed for providers to take responsibility for the health outcomes of populations. But when it comes to adopting payment models that reward this sort of thing, adoption is lacking.

At any rate, as part of this effort, the IOM developed a logic model highlighting factors and behaviors that lead to healthy outcomes. And it should be said before going on any further that, in their view, the term “population” meant all persons living in a specified geopolitical area. This isn’t necessarily how I think of populations when working on PHM initiatives (I’m biased toward thinking more in terms of clinical patient populations, or potential patient populations). 

No matter what your chosen definition of “population” is, though, I think the IOM is right to focus on leading health indicators in an effort to keep large portions of the U.S. population healthy. At any rate, the IOM committee developed a logic model “to help categorize the LHIs and select measures of quality related to them.” Factors and behaviors within this logic model that lead to healthy outcomes include resources and capacity, interventions, healthy conditions, and healthy outcomes.

I think this is an interesting way of deciding which quality measures will have the greatest impact on population health, and you can see a graphic representing their logic model on page 2 of the report brief. The model allows a user to categorize LHIs and select measures of quality closely related to them. As an example, the report looks at one LHI, Air Quality Index and other measures related to it, and associates it with a healthy outcome, i.e. “the reduction in illness and deaths caused by cardiovascular and respiratory problems, which air pollution aggravates.”

Additional criteria for choosing quality measures include the following:

• Measures should be reflective of a high preventable burden—referring to preventable health problems responsible for the largest proportion of disease and death in the population
• Measures should be actionable at the appropriate level for intervention
• Measures should also be: timely, usable for assessing various populations, understandable, methodologically rigorous, and accepted and harmonized 

The committee concluded that this logic model should serve as “a basis for building a consistent approach to measuring quality across sectors,” and I have to say they make a convincing case. 

As an example of rigorously developing quality measures that take the full gamut of factors into account, I came across an interesting blog post titled “Centering measurement on patients and family caregivers while developing two novel quality measures” on “The Medical Care Blog,” which is produced by the American Public Health Association. The post recounts how the American Academy of Hospice and Palliative Medicine, the National Coalition for Hospice and Palliative Care, RAND Corporation, and the National Patient Advocate Foundation (NPAF) collaborated to develop two new measures.

From the outset, the partners set out to create “patient-reported measures of care provided by outpatient palliative care teams.” In recent years, including the patient voice in this value‐based reimbursement conversation has taken on increasing importance within CMS’ Quality Payment Program (QPP), particularly with respect to MIPS Value Pathways, or MVPs. In fact, one of the “MVP Guiding Principles” is to “Include measures and activities resulting in comparative performance data that is valuable to patients and caregivers in evaluating clinician performance and making choices about their care.”

To this end, the palliative care measure development team sought a range of perspectives when gathering input throughout the development process, which I get the feeling isn’t the norm when developing quality measures. Specifically, the team convened a Technical Expert Clinical User Patient Panel (TECUPP), which included:

• Individuals bringing lived experience with serious illness as a patient, family caregiver, or advocate
• Professionals with expertise in measure development and research
• Physicians, nurses, and physician assistants
• Chaplains, pharmacists, and social workers
• Representatives of specialty societies and the healthcare industry

Following best practices laid out in the CMS Measures Management System Blueprint while also gathering together different voices is a terrific way to start a project like this, ensuring investment from some of the very stakeholders who will ultimately be involved in the measurement process right from the beginning. The blog post shares lessons learned about how timely communication can make or break a project like this.

Here are some interesting things I learned from the team’s experience:

• The team provided regular updates to TECUPP members, field testing sites, project advisors, and members of the National Coalition for Hospice and Palliative Care. 
• They prioritized stakeholders who would be impacted if the final measures are integrated into the QPP, including patient advocacy groups, palliative care professionals, medical specialty societies, and health system leaders. 
• They kept an open mind when it came to inviting stakeholders to ask questions, raise concerns, or suggest improvements to the measures to ensure the metrics remained relevant to all stakeholders. These “communication cycles” helped the team “iteratively refine the measures.”

Next came a public comment period, during which the group received over 200 suggestions on ways to improve the measures. Comments were received from a wide array of stakeholders, from patients, family caregivers, and advocates, to clinicians and other health care professionals. Overall, the comments reflected strong support for these measures, with the majority of patients, family caregivers, and advocates noting that the measures would capture information they found important.

“Ultimately,” conclude the authors, “this collaborative process resulted in measures that both clinicians and patients rated as meaningful and ready for use. We found that by creating space within our process for making measurement patient-centered, we were inviting all stakeholders to collectively reach consensus on what to measure and where to focus quality improvement efforts.”

When it comes to optimizing medical reimbursement, particularly in an environment where the payer mix skews toward Medicare and Medicaid, making the transition from a fee-for-service (FFS) environment to one that aims to deliver value-based care on a population level is no easy matter. When looked at through a population health management lens, adopting alternative payment models (APMs) is important because they incentivize healthcare providers to level-up the patient experience and improve the health of populations while also lowering per capita costs (satisfying the IHI Triple Aim).

Much of this comes down to providing better access to care for everyone, regardless of background or socioeconomic status; to me, this is the beating heart of PHM. But how can physicians care for traditionally underserved communities if they’re stuck in a FFS payment model that prioritizes one off procedures that often result in fragmented care delivery?

The answer: health systems need to embrace value-based payment models that are completely untethered to FFS. Anyone who’s spent any time looking at the medical reimbursement landscape, however, knows this isn’t nearly as straightforward as it sounds. Since the Affordable Care Act of 2010, the U.S. healthcare system has been locked in a transition period where CMS – along with a number of commercial payers – is encouraging a shift to risk-based payment models that hold providers responsible for providing care that patients deem valuable at a lower cost.

For a snapshot of how slow things are progressing, check out “The Future of Value-Based Payment: A Road Map to 2030,” a white paper published by the Leonard Davis Institute of Health Economics at the University of Pennsylvania. Although back in 2015 Health and Human Services (HHS) committed CMS to tying 90% of traditional Medicare FFS payments to quality by 2018, the chart in the UPenn white paper makes clear that we’ve fallen well short of that goal nearly four years after the original target date.

Consequently, there are still a large number of providers who, although on the path toward practicing value-based care, are still involved in hybrid payment models that combine both value-based and FFS elements. Still more concerning, as the white paper makes clear, on the topic of access to care for underserved groups including racial and ethnic minorities, rural populations, and individuals with disabilities, with some exceptions “value-based payment has yet to improve (or even explicitly address) access to care or health outcomes.” 

So how do providers with an eye toward improving the health of patient populations ensure that they chart a steady course through this proverbial no man’s land? The need for equilibrium is key, says Rick Foerster, Senior Vice President of Value-Based Operations at Privia Health, in a recent blog post. As Foerster sees it, advancing toward true value based care where all members of society can obtain quality care requires a cool head and a steady hand.

In his blog post, Foerster lays out four steps that can help maintain a practice’s or health system’s equilibrium during this time of transformation. I won’t go into detail because you can read his post for yourself, but these four steps include solidifying the base of your practice management, upgrading your patient experience, implementing the fundamentals of value-based care, and taking greater responsibility for the totality of your patients’ care and costs. “Fortifying your fundamentals,” writes Foerster, “can give you a solid foundation to build upon.” Everything should be moving like clockwork, from payroll to workflow to virtual patient access points; if not, you may have trouble making the shift to value‐based care.

Part of enhancing access to care means making your practice as convenient as possible to the needs of your patient population. Providing direct online scheduling and telehealth options are good examples of lowering barriers to entry. If patients feel your practice is unable to accommodate their often busy schedules, they may seek care at other, more expensive establishments where they risk being unable to afford necessary care.

On the “taking greater responsibility for the totality of your patients’ care and costs” front, Foerster brings up an interesting point that not enough heath systems are considering, mostly because there aren’t many incentives in place to do so currently: ascertaining patients’ behavioral health and taking non-clinical social determinants of health into account. He puts it this way: “To manage these elements, you must upgrade your accountability. Shift from reactive to proactive care; from understanding the average patient to understanding each individual patient; from facing the problems in front of you to problems you’re not yet aware of.” No easy feat to be sure, but necessary as a group or health system transitions to value-based care.

While taking on risk is just that – a risk – he concludes by noting that, in addition to getting your house in order in the ways outlined above, it may also help to find a partner because a “lack of resources or expertise is a frequent obstacle to implementing value-based care.” 

This notion of entering into partnerships to help chart a steady course through this period of transition is echoed in a 2017 report by the HFMA about the future of value-based care. As part of a workshop laboratory the group put together “to help facilitate problem-solving dialogue among a diverse cross-section of thought leaders in finance, clinical medicine, and health plans,” one of the major points of agreement was the need for establishing partnerships to accomplish the following:

• Leverage infrastructure with providers in new markets
• Develop products
• Partner with health plan(s) to gain a larger provider network, access to membership, and direct-to-employer contracts

“To address cost and improve outcomes, many organizations are focused on high-risk populations,” the report reads, making reference to population health management. “But the real opportunity is to focus on the rising-risk population so that people and providers better understand how to manage chronic conditions to save costs for the long term.” The idea of focusing on such populations and entering risk-based arrangements through a phased approach is intriguing and something to keep an eye on. 

I was reading a recent article in Fierce Healthcare about how an accountable care organization (ACO) has partnered with a population health management company to expand value-based care in rural Colorado, and it got me thinking: what is a population health management organization? And I don’t mean societies or trade organizations ‐‐ I mean companies that provide services to entities interested in shifting to a PHM footing. I’ve heard tell of such things, but never looked into it.

Until now.

As it turns out, there are a range of such companies that provide a plentitude of different population health services. Since they are too numerous to go into detail about here, I decided to focus on the PHM company spotlighted in the Fierce Healthcare piece, Collaborative Health Systems (CHS). And let me say right off the bat: I have no ties whatsoever to CHS and no experience working with them. Because of this, I can’t honestly say if they’re worth collaborating with or not. So this post shouldn’t be seen as an endorsement of any sort.

With that out of the way, let’s jump in. According to the article linked to above, CHS recently partnered with an ACO in Colorado called Community Care Alliance (CCA) to expand value-based care in rural parts of the state. The venture, called Collaborative Choice Healthcare, will aim to “reach rural health practices, critical access hospitals, and health systems throughout Colorado and eastern Utah…to improve quality outcomes and lower healthcare costs for Medicare beneficiaries.” 

The article notes that “CHS will provide CCA with data, strategic growth planning, care coordination and market leadership,” but it doesn’t go into much further detail except to note that the two entities will “enter value-based contracts with Medicare Advantage organizations,” and that CHS “helps payers align their goals more closely with health outcomes.”

This last part about value-based contracts and helping insurance entities align goals with health outcomes is interesting and may, in fact, be fodder for a future blog post. But for now I want to focus on what so‐called PHM companies like CHS do, and how they expand value‐based care to populations in need.

Before we go any further, it’s also important to note that CCA isn’t the only Colorado healthcare entity throwing its hat into the PHM ring. This article states that Montrose Regional Health, a healthcare facility servicing the San Juan Valley of Colorado, is joining the Collaborative Choice Healthcare venture. A source quoted in the article states that the technology needed to arrive at actionable insights “can often be cost-prohibitive for providers. Through this joint venture, Collaborative Choice Healthcare enables its provider partners to stand up their own technology, share data, and pull deeper clinical insights. More data allow providers to identify an emerging need before it becomes an emergency, which is a critical element of providing higher quality care at a lower cost.”     

On CHS’ LinkedIn page the Tampa, Florida‐based organization describes itself as “a management services organization that partners with primary care physicians as they move to value-based payment systems.” Founded in 2012 by a group of primary care providers, their website notes that as of 2021, “CHS managed two Next Generation Model ACOs, eight Medicare Shared Savings Program (MSSP) ACOs, and one Direct Contracting Entity with over 2,500 providers, mostly primary care physicians, covering nearly 130,000 Medicare beneficiaries.”

Aside from managing ACOs and other medical entities, CHS “partners with physician groups that have come together to form Independent Physician Associations (IPAs) and state-based primary care programs.” To help bridge their clients over to a value‐based care environment, they provide “administrative and management services such as care coordination and quality reporting, risk management and contracting, population health capabilities, and actionable data insights.” CHS works in conjunction with Centene Corporation Company, a large, multi-national managed care organization to provide these services.

As I stated earlier, although there are a number of companies starting to populate this space, CHS is pretty representative of others I’ve seen. I’ll keep watching this trend and highlight any innovations I come across in this area.