Maternal Mortality and PHM — Part 2

Since the U.S. Government Accountability Office (GAO) recently released a report titled “Maternal Health: Outcomes Worsened and Disparities Persisted During the Pandemic,” I thought this would be a good opportunity to write the promised follow-up to my first blog post about maternal mortality and population health. After doing further research since I first published that post, in retrospect a more accurate title for the series would’ve been “Maternal, Infant, and Population Health” since maternal health and newborn health are often closely linked, and maternal mortality only tells part of a larger story.

But what’s done is done, so let’s proceed.

In my first post I largely focused on strategies for improving maternal health before, during, and after giving birth, mostly zeroing in on the utilization of midwives. Contrary to the post’s title, however, I didn’t introduce much of a population health perspective. So let’s take this a step further and look at how population-level care strategies might optimize maternal and newborn health.

A Broken System

Since I delved pretty far into how the U.S. stacks up against other peer countries in terms of our healthcare system (spoiler alert: we rate significantly worse in almost every category, including maternal health), I won’t cover the same ground here. To help orient us, though, I do want to offer a snapshot of where we are now that the COVID-19 pandemic is (hopefully) receding, and the GAO report helps us do that.

The authors of the report analyzed CDC data through much of the pandemic and compared it to the same data sets collected in pre-pandemic years. They found some interesting things, all of which point to the fact that, as the report’s title suggests, maternal health declined during the pandemic. Here are their top-line findings:

  • Maternal deaths increased during the pandemic compared to 2018 and 2019
  • COVID-19 contributed to 25% of maternal deaths in 2020 and 2021
  • The maternal death rate for Black or African-American women was disproportionally higher compared to White and Hispanic or Latina women

Access to care was flagged as a major contributing factor to these outcomes. And key to any discussion of population health, negative social determinants of health (SDOH) played a central role:

“Stakeholders and Department of Health and Human Services (HHS) officials told GAO that the pandemic exacerbated the effects of social determinants of health—factors such as access to care, transportation, or technology; living environment; and employment—on maternal health disparities.”

Given that the U.S. healthcare system was not well-positioned to intervene in social drivers of maternal health problems before the pandemic, lockdowns and other measures meant to protect people’s health ironically led to a worsening of the situation. So that we don’t drop the ball again and allow pregnant women to go untreated until it’s too late, how can we learn from our failures over the past few years? I believe that a population health approach holds many of the answers.

Incentivizing Maternal and Infant Care

One doesn’t have to look farther than the annual measurement efforts done by the Health Care Payment Learning & Action Network (HCPLAN) to see that among other insurers, Medicare and Medicaid are pushing medicine toward two-sided risk alternative payment models (APMs), where both insurers and providers bear a portion of the financial risk for treating patients, with special emphasis on so-called Population-Based Payment Models, or PBPMs (which I discussed in a previous blog post).

Between 2019 and 2020, U.S. healthcare payments flowed through two-sided risk APMs at rates that increased from 16.5% to 17.9% of payments. Yes, PBPMs only made up a small fraction of these payments, but it’s clear CMS is pushing in this direction. As promising as two-sided risk APMs are to improving care of all kinds, including maternal care, in their current form they only go so far, often focusing on process measures instead of more holistic care that targets access-to-care issues.

One possible solution to this issue would entail combining something called “bundled payments” with a PBPM such as an accountable care organization (ACO). This idea, which is being championed by the folks at the Duke Margolis Center for Health Policy, involves some outside-the-box thinking as it entails aligning disparate stakeholders to ensure a continuity of care of both mother and child over a much longer time horizon that often currently exists.

The Importance of Bundling Care defines bundled payments like this: “A payment structure in which different health care providers who are treating you for the same or related conditions are paid an overall sum for taking care of your condition rather than being paid for each individual treatment, test, or procedure. In doing so, providers are rewarded for coordinating care, preventing complications and errors, and reducing unnecessary or duplicative tests and treatments.”

This coordination of care is key to improving maternal and infant health – in the form of physical care and, for the mother, behavioral health services – before, during, and after pregnancy. including coverage for whole-person care where midwives and doulas play a critical role (I discussed the central importance of midwives to maternal and infant health in my previous post on the topic).

On the payer side, continuity of care is very important to shoring up healthcare disparities, considering that so-called “Medicaid enrollment churn” can lead to disruptions in care; for example, one study found that 55 percent of women enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) between 2005 and 2013 experienced a coverage gap in the six months prior to giving birth. And since Medicaid covers 42 percent of all births, CMS can exert significant influence in improving longitudinal health outcomes and reducing healthcare disparities, since many of those covered by Medicaid for pregnancy-related services are in minority or rural populations.

As things stand, relatively few perinatal bundles of care focus on intervening in social drivers of health. Indeed, as the Duke report makes clear, “most existing evaluations of perinatal bundles focus on performance measures such as spending, care processes, and limited pregnancy outcome measures (such as rates of early elective delivery, vaginal delivery and cesarean delivery), but not on patient experience or broader maternal health outcomes like morbidity and mortality.”

Returning to the idea of combining bundled payments with PBPMs, the authors of a 2021 JAMA study found that “compared with inclusion in bundled payments alone, simultaneous inclusion in both ACOs and bundled payment programs was associated with lower institutional postacute care spending and readmissions for medical episodes and lower readmissions but not spending for surgical episodes.” In other words, maternal and infant patients who receive care simultaneously under ACOs like a PBPM and bundled payments can experience optimal outcomes. This approach seems to hold great potential to shore up gulfs in coverage and longitudinal care, and it’ll be interesting to watch how it progresses.

Vox Populi

Can a population health approach to healthcare exist beyond the bounds of organized medicine and public health? Technically, at least right now, the answer appears to be no. Although there is no single agreed-upon definition of population health, the one many point to was posited by Kindig and Stoddart in their seminal 2003 paper titled “What Is Population Health?”:

“We propose that the definition be ‘the health outcomes of a group of individuals, including the distribution of such outcomes within the group,’ and we argue that the field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two.”

Without a way to quantify and track health outcomes not just of groups, but of the distribution of health outcomes within those groups, a healthcare solution cannot properly be called population health. Still, this strikes me as rather limiting; is preventative, segmented care only the domain of public health professionals, physicians, and academics…or can anyone with the right mix of ambition and good intentions take it upon themselves to intervene and improve upstream negative social determinants of health (SDOH) irrespective of metrics?

And if such interventions prove successful, can they not in turn be thought of as adjuncts to a population health model of care delivery? To me, any endeavor that helps people live their best life is worth trying, whether or not it proceeds within a deploy-measure-iterate model such as that outlined in the Institute for Healthcare Improvement’s “10-Step Path to Progress” in population health (details on page 7 of the document).

That being said, let me be clear that I’m not a physician or a mental health professional, and the thoughts in this post are strictly the result of my own research. None of this should be taken at face value, and in some cases – for instance, if one has profound mental health issues – seeking help from a trained professional is the right way to go. It’s clear that depending on one’s circumstances, agency in one’s own healthcare will vary.

But for those who feel a persistent, non-clinical level of melancholy, I’m encouraged that the possibility exists to take the upper hand and improve levels of contentment. This mindset aligns with the “self-care” movement, which has been defined as “the ability to care for oneself through awareness, self-control, and self-reliance in order to achieve, maintain, or promote optimal health and well-being.” This outlook reflects a growing awareness that people don’t have to necessarily fill a prescription to optimize their experience of life.

Part and parcel of this DIY approach (again, within reason) is, I believe, a loosening of the definition of population health – or at least an expansion of the definition that includes grassroots initiatives that may not tick every box of an improvement regimen. One aspect of this more inclusive description involves not always assigning metrics to every aspect of one’s life. While some people are motivated by numbers (as we’ll see in a moment), for those who don’t look at health maintenance as a competition, moving the needle on improving population health will likely be more qualitative. 

Health By the People, For the People

To set the stage for our discussion, let’s talk for a minute about how metrics in self-care can induce health improvements. For those who like to quantify improvement in a way that keeps them in the driver’s seat, the healthcare landscape of today truly differs from that of even a few years ago. With respondents to a recent survey from the Deloitte Center for Health Solutions saying they’d “be ‘likely to’ or ‘maybe would’ use retail clinics for preventive care (55%) or mental health care (47%),” it’s becoming clearer every day that people are more willing to try new approaches to healthcare that are more tailored to their own lifestyles. 

Put another way, a clear majority of people are willing to at least entertain the idea of seeking healthcare at places like CVS and Walmart, and nearly half of respondents said the same thing about mental healthcare. This makes a sort of sense, given that Walmart stores are often closer to many people’s homes than their doctor’s office.

This is a big change, and it doesn’t stop with retail medicine. According to Insider Intelligence, “use of wearable technology has more than tripled in the last four years and “more than 80% of consumers are willing to wear fitness technology,” signaling broad interest in people monitoring their own health. This includes tech we’re all familiar with like FitBits and smart watches, but extends to wearable electrocardiogram and blood pressure monitors, and even self-adhesive patches that collect data on a person’s biological signals.   

Opinions may vary on the effectiveness of self-monitoring tech, and I need to do more research before coming to a conclusion on it. But the more I read about it, the more optimistic I’m becoming that many of us can (or will soon be able to) exercise a degree of control over our health status with the help of personalized health technology. 

Another way in which people are practicing so-called DIY population health is by banding together to overcome certain shared barriers. And these barriers, while related to medical conditions, often reside outside of clinical settings. In addition, given their improvised nature, the practitioners of this approach often don’t have the means to collect and analyze data to track health improvement. Although stories of success don’t always guarantee a one-size-fits-all approach, a couple of real-life examples illustrate how this organic, crowd-sourced approach to addressing negative SDOH can be done well. 

Men’s Sheds

One interesting illustration of this can be found in England. In that country, as in the United States, an epidemic of loneliness has swept through in recent years. Made worse by the COVID-19 pandemic, many vulnerable groups have been hit particularly hard. One of these groups, the elderly, are in a class by themselves: the NHS states that “more than 2 million people in England over the age of 75 live alone, and more than a million older people say they go over a month without speaking to a friend, neighbour or family member.”

One of these people was Philip Jackson, a man born in England who moved to Australia in adulthood before returning to his homeland in old age. Although Jackson expected a level of familiarity in returning to his native town, he was met by the unwelcome fact that everyone he’d grown up with had either left town due to a decline in industry or passed away. This left Jackson unexpectedly rootless and lonely. 

But then something interesting happened: realizing he wasn’t the only lonely person of a certain age, Jackson recalled hearing about The Australian Men’s Shed Association. The organization, which grew out of a desire to help men form social bonds with other men through “communal woodworking” and thus improve their mental and physical health, defines their modus operandi this way: “A good Men’s Shed has a Management Committee that has developed a safe and happy environment where men are welcome to work on community projects, specific Men’s Shed projects or a project of their choice in their own time and where the only ‘must’ is to observe safe working practices….all in a spirit of mateship.”

It is this “spirit of mateship” that Jackson was sorely missing. Through the help of a grant and generous donations, he was able to set up a site and stock it with woodworking equipment in hopes that it would attract like-minded men in his town (he also set up a “She-Shed,” a communal space for local women who also shared his interest in woodworking). In time, community involvement in the shed grew to the point where it now boasts a membership ranging in ages from 22 to 87 and from all walks of life.

They “make everything from ornaments, dog kennels, bird and plant boxes through to wheelbarrows,” but more than that, says Jackson, it’s an excuse for people to break out of their usual routine and establish friendships in a comfortable environment. During COVID, Jackson took the lead on checking in on everyone to ensure they were OK, going so far as to set up live chats online to keep up people’s morale.

Looked at one way, the idea of establishing a Men’s Shed (and a She-Shed) in a community is nothing more than an expression of civic pride, a way to cultivate a sense of fellow spirit in a world that sometimes feels out of balance. But I contend that it goes deeper than that: if you look past the fact that no one in the Men’s Shed movement seems especially concerned with measuring the happiness and health levels of its members, to me this is an organic example of population health in action.

Caregiver Support

In some cases, the more specific and non-traditional a person’s circumstances are, the more the need may exist for them to improvise when seeking both mental and physical healthcare (within reason, of course). People facing unique challenges may not fit into traditional population health care delivery models, particularly if they themselves are caregivers.   

Just such an example was featured on NPR recently: the story involves a woman named Jacquelyn Revere who has attracted a large following on TikTok by authentically talking about her life providing care for her mother, who had Alzheimer’s.  In her late 20s Revere was forced to move back home when her mother, who herself was caring for Revere’s ailing grandmother, was diagnosed with Alzheimer’s. Like the 16 million Americans who annually provide more than 17 billion hours of unpaid care for loved ones suffering with Alzheimer’s disease and other dementias, Revere was asked to put her life on hold.

Understandably, dealing with multi-generational health issues became hard for Revere to navigate. And it wasn’t just her loved ones’ health that worried her. As with so many people facing mounting doctor’s bills, she worried about bills going unpaid and ultimately losing their home – in other words, upstream social determinants outside the clinical sphere. 

When she tried explaining her predicament to friends her age, they just couldn’t relate. And support groups were no help either, as they were often composed of much older, more financially secure people. Because of her relative young age and financial burden, it is perfectly possible that in these early days of understanding upstream SDOH – not to mention the lack of a social safety net for younger people in our society in general and for caregivers in particular – there may not be a segmented population into which Revere neatly fits.

Finding these traditional means of support lacking, Revere turned to social media. TikTok became her platform of choice, allowing her to search for and ultimately find a community more in line with her own experiences. Taking the initiative to connect, she began posting under the handle @MomOfMyMom about her daily struggles, helping to build the community she could never find offline. In time she attracted over 650,000 followers who discuss everything from early signs of their loved ones’ cognitive decline to how to provide basic daily care.

Unfortunately, Revere’s mother passed away recently, and she has used TikTok as a means to express her grief. The platform has acted as a way for people to pay their respects, and because of this, Revere doesn’t have to hurt in isolation. In addition, the platform allows her to continue her work providing emotional support to other dementia caregivers online who may not have cultivated as big a following as hers. Social media has allowed Revere to connect and grow with a similar “population” of caregivers that just wouldn’t have been otherwise possible.

Revere’s example reminds us that when the system fails us, we can still rise above our circumstances to help others. From veterans’ groups organizing volunteer transportation for fellow veterans to attend doctor’s appointments, to a green building consultant on a mission to help land developers create sustainable buildings with people’s mental and physical wellbeing in mind, population-level health initiatives are showing up everywhere, and many times outside of their traditional confines. It will be interesting to see if and how such efforts are integrated into our understanding of population health going forward.

Social Prescribing

I recently learned about an approach to addressing negative social determinants of health (SDOH) called “social prescribing,” and it has the potential to be a complete game-changer. The movement, if I can call it that, seems to have caught fire in places like the United Kingdom, Canada, Australia, Singapore, and, to a lesser extent, the U.S. The concept, which combines the best parts of co-located care (which I discussed in a former blog post) and community-based healthcare, will very likely prove to be an important tool in the transition to value-based healthcare.

Social Prescribing and Community Health

Social prescribing, sometimes referred to as “community referral,” is a relatively new concept that, while in limited use in the United States, has taken on a key role in some countries’ approaches to population health. In the UK, where the concept has perhaps seen its greatest uptake, the National Health System (NHS) is aiming “to have nearly one million patients referred for social-prescription interventions by 2024.”

Social prescribing is seen as one part of a larger concept called “community health.” Community health is a fairly malleable term, but as defined by NHS England, “Community health services cover a wide range of services and provide care for people from birth to the end of their life. Community health teams play a vital role in supporting people with complex health and care needs to live independently in their own home for as long as possible.”

OK, so what does the “community” in “community health” mean exactly? The UK’s National Institute for Health and Care Excellence provides a useful definition of the term that I think works well for our purposes: “A community is a group of people who have common characteristics or interests. Communities can be defined by: geographical location, race, ethnicity, age, occupation, a shared interest or affinity (such as religion and faith) or other common bonds, such as health need or disadvantage. People who are socially isolated are also considered to be a community group.”

That last part about socially isolated or underserved people representing a community is key to social prescribing, which facilitates the improvement of people’s circumstances by employing non-medical interventions. For example, some of these interventions include things like “art classes for wellbeing, knitting, singing, or walking groups.” In other words, social prescribing allows general practitioners (GPs) in the UK to refer patients to designated community health professionals who can, in turn, involve these patients in non-clinical activities that can help improve their overall wellbeing.

Social Prescribing in the UK

Now that we’ve got a few definitions out of the way, let’s examine how social prescribing has come to occupy such an important place in the UK’s National Health System. Central to the success of this approach is something called a “link worker.” NHS England describes link workers like this:

“Link workers give people time, focusing on ‘what matters to me’ and taking a holistic approach to people’s health and wellbeing. They connect people to community groups and statutory services for practical and emotional support.”

In the service of improving the day-to-day lives of patients, link workers leverage an in-depth familiarity with local, community-based non-medical support resources. Social prescribing is ideally suited to people fitting one or more of the following descriptions:

  • Those with one or more long-term conditions
  • Those in need of support with their mental health
  • Those who are lonely or isolated
  • Those who have complex social needs which affect their wellbeing.

So how is any of this different from a typical social worker, one might ask? Well, for one thing, the sheer number of stakeholder agencies who can refer a patient to a link worker is quite broad: “general practice, pharmacies, multi-disciplinary teams, hospital discharge teams, allied health professionals, fire service, police, job centres, social care services, housing associations and voluntary, community and social enterprise (VCSE) organisations” represent this potential pool of referrers.

Secondly, the requirements for becoming a social worker (sometimes called a “social care worker”) in the UK differ significantly from those involved in becoming a link worker. Life experience, good communication skills, and a willingness to be trained — and, in some instances, other skills as described here — are all that are required to join the ranks of link workers. This sounds great, because given the pressing need for this kind of work, I can only assume that removing high barriers to entry would help to more quickly address the issue.

By contrast, there are relatively more rigorous requirements involved with becoming a social care worker. A list of these requirements, including having either a BA or a master’s degree, can be found on the British Association of Social Workers website. While there are fast-track options for going into this line of work, the profession seems more highly regulated. 

Why Social Prescribing?

When looked at through the lens of population health or population health management, it becomes clear why social prescribing can be so effective. If you skip to the 3:47 mark of this video produced by the Healthy London Partnership, you’ll see a physician attest to the fact that, although initially skeptical that social prescribing interventions could help his patients, he was bowled over by how much the link workers were able to lighten his workload by mitigating negative SDOH. And at the 4:12 mark, another physician explains how in his practice, they’ve seen a reduction in the number of GP appointments for patients where link workers have been involved.

Although its advocates focus on its many merits, real-world evidence for the effectiveness of social prescribing is mixed at best. For instance, a social prescribing pilot project was conducted with much success between April 2012 to March 2014 (and was subsequently re-contracted for another three years starting in 2015) in Rotherham, a metropolitan borough of South Yorkshire in the UK which has a population of over 100,000 people. Here is a summary of the project that appears on the Social Care Institute for Excellence website:

“The service is especially aimed at users with complex long-term conditions (LTCs) who are the most intensive users of primary care resources. The service receives referrals from GPs of eligible patients and carers, and assesses their support needs before referring on to appropriate voluntary and community sector services. The service also administers a grant funding pot, through which a ‘menu’ of voluntary and community sector activities is commissioned to meet the needs of people who use services.”

Top-line results include the following:

  • An estimated social return on investment (which the WHO defines as “value produced for multiple stakeholders in all three dimensions of development: economic, social and environmental”) of £570,000–£620,000 
  • A 7% reduction in non-elective inpatient episodes
  • A 17% reduction in accident and emergency department (A&E) attendances
  • An initial return on investment of 43 pence for each pound invested in terms of avoided costs to the NHS

All of these points speak to the potential positive impact of social prescribing, but I find this last point most compelling: the upfront investment in preventative care paid dividends. Devoting time and resources to improving people’s lives outside of the clinical space could save health systems money while at the same time leading to better patient outcomes — and this study proves it.

Data provided in the Open Data Institute’s (ODI) November 2021 report on social prescribing seem to back this up the practice’s effectiveness. “If GP appointments fall by 2-5% as a result of social prescribing operating at scale,” say the report’s authors, “it could lead to a diversion of between 3.2-8 million GP appointments per year.” This extra capacity could be used to see more patients, which is key in a system like the NHS which has seen major backups due to the pandemic.

As much success as the Rotherham social prescribing project enjoyed, however, the advent of the COVID pandemic has proved a major headwind for link workers. Given that so much of this kind of work is done face-to-face, strict social distancing orders and lockdowns over the past couple of years have taken their toll. 

Although a recent article in The Lancet highlights how primary care doctors have adapted social prescribing during the pandemic to leverage phone and internet engagement when connecting nurses and health-care assistants with patients, resources haven’t been fully aligned to maximize the practice. The ODI’s report exposed several barriers that have conspired to limit social prescribing’s potential in recent years. A few of these issues highlighted in the report include the following:

  • Local Authorities, health, and voluntary sector organizations maintain separate directories of locally available services which can lead to duplication of effort and issues with interoperability
  • Data sharing is limited when multiple community service directories exist in a local area due to a lack of trust between organizations
  • A lack of information on attendance/user satisfaction and challenges means that link workers may have to invest time exploring the suitability of a new service with which they may be unfamiliar

Despite these shortcomings, I think social prescribing holds a lot of promise. It hasn’t made many inroads in the U.S. yet, but it seems to be catching on across the globe. I may highlight examples of social prescribing in other countries in future blog posts.

Payment Models and Metrics

Healthcare quality measures are a study in contrasts. Their overall purpose is straightforward enough: quality measures incentivize physicians and other healthcare workers to provide cost-effective care that ideally leads to better patient outcomes. But the sheer number of them can seem overwhelming. What’s more, figuring out the interplay between these measures and healthcare payment models adds a layer of complexity that can leave the most dogged researcher scratching their head.

This being the case, I thought it would be interesting to explore what healthcare quality measures are, who should be using them, and how they’re connected to healthcare payment models.

An Ongoing Healthcare Crisis

Let’s start with a quick history lesson to put things into context. For many years, a range of experts have been warning that America’s healthcare system was on the brink of collapse. Since at least 1969, and to some extent before that, American leaders have been sounding the alarm about a looming “healthcare crisis.” The Health Affairs article linked to above notes that “national health expenditures have grown from 6.9 percent of GDP in 1970 to 17.9 percent in 2016, according to the Centers for Medicare and Medicaid Services (CMS),” with that number having grown to 19.7% by 2020.

Over time, several attempts have been made to reign in spending and improve patient outcomes. The latest of these major efforts was the 2015 Medicare Access CHIP (Children’s Health Insurance Program) Reauthorization Act, otherwise known as MACRA. Among other things, MACRA aims to tie healthcare provider performance to reimbursement, incentivizing providers to participate in alternative payment models (APMs). This effort is ongoing and, as we’ll soon see, has begun bearing fruit. 

While there is a lot of inertia holding the current fee-for-service (FFS) physician reimbursement system in place, according to the website for the American Society of Health-System Pharmacists, or ASHP, there’s ample reason to try another approach: “In a FFS payment model, the provider or facility get reimbursed for each service provided. This can create an incentive for providers to increase the volume and cost of services provided versus focusing on value of care provided. This model can also lead to uncoordinated and fragmented care through inefficiencies within the healthcare system, which can also drive up overall healthcare costs.” 

The Rise of Alternative Payment Models

APMs have been proposed as an antidote to the U.S.’ fixation on FFS. These payment models come in different forms depending on a range of factors including how many direct patient encounters a physician/group has/have, and how much financial risk physicians are willing to take on. Financial risk-sharing refers to the concept that the cost burden for medical treatment should be shared by payers, physicians, and patients (as opposed to just insurers and patients). 

Within this concept is the idea of upside and downside risk-sharing: in upside risk models, physicians are permitted to share in any savings their efficiencies help create; in downside risk models, not only can physicians share in the savings, but they can also see their reimbursement levels adjusted downward if they miss quality goals. As the authors of one article put it when talking about a form of shared-risk payment model called “bundled payments,” “if healthcare costs exceed the set amount, providers lose out on the revenue they would have received from a traditional payment structure.”

Like most things, the big idea behind risk-sharing is that the bigger risk physicians are willing to take on, the bigger the potential reward.

Some flavors of shared-risk payment models include “accountable care organizations (ACOs), the Medicare Shared Savings Program (MSSP), pay for coordination, pay-for-performance (P4P), bundled payments, upside- and downside-shared savings programs, partial- or full-capitation, and global payments.” A thorough examination of APMs would require multiple blog posts, but, since capitation shares similarities with things like bundled payments and global payment models, looking at how capitation works might shed some light on the overall concept of risk-sharing. 

A useful definition of capitated payments can be found on the website of the American College of Physicians: “Capitation is a fixed amount of money per patient per unit of time paid in advance to the physician for the delivery of health care services. The actual amount of money paid is determined by the ranges of services that are provided, the number of patients involved, and the period of time during which the services are provided.”

In other words, payers and physicians look at historical trends to arrive at a lump-some payment for blocks of patients who require a range of services. If the doctors are able to provide efficient, high-value care that saves money, they can share in the savings; if, however, they go over budget for a given patient population, they’ll owe money to the insurer.

Capitation seems to work pretty well: a scoping review of 76 studies showed that, when done right, capitation can both improve health care utilization and reduce spending — all while not affecting the quality of care provided. Central to the concept of population health, the study also showed that capitation prompted an increase in preventative health visits. 

Importantly, physicians working in a capitated environment can’t restrict necessary care in the service of hitting agreed-upon benchmarks, so, as the ACP website notes, “managed care organizations measure rates of resource utilization in physician practices. These reports are made available to the public as a measure of health care quality, and can be linked to financial rewards, such as bonuses.”

While we’re on the topic of payment models, I should also say that there’s a parallel track for ensuring value-based care called the Merit-based Incentive Payment System, or MIPS. This value-based care system is reserved for qualifying physicians who meet certain criteria, including something called a “low-volume threshold” in which they fall short of dealing directly with a set number of patients and are thus exempt from full APM participation (although, somewhat confusingly, there’s a whole subsection of MIPS called “MIPS APMs”).

For the purposes of this blog post, I’ll focus on full APMs and leave MIPS and its associated value measures for a possible future blog post.

Alternative Payment Models in Practice

Pivoting away from the FFS payment model in which physicians are reimbursed for the individual services they provide instead of being held accountable for patient outcomes — and in the process attempting to mitigate suboptimal circumstances for each individual patient (a concept called whole-person care) – is, in a word, ambitious. This transition, which has been in full swing since 2015, is particularly challenging because not every physician provides the same level or intensity of care, so metrics for those participating in full APMs must be tailored such that the greatest number of doctors possible can participate. 

As a consequence, uptake of value-based care hasn’t been as swift as many had hoped. In 2015, Health and Human Services (HHS) chief Sylvia Burwell set the following targets: “85% of Medicare FFS payments should be tied to quality or value by 2016, and 30% of Medicare payments should be tied to quality or value through alternative payment models by 2016 (50% by 2018).” (The bold is mine.) These challenging targets would be met, HHS theorized, by enticing physicians and healthcare systems into upside and downside risk-sharing arrangements (as discussed above).

According to the latest data compiled by the Health Care Payment Learning & Action Network (HCPLAN), while a little behind schedule, FFS is on the road to becoming an antiquated concept. In its “2020 APM Measurement Effort,” the HCPLAN surveyed representatives from not just Medicare, but also commercial health plans, Managed Care Organizations (MCOs), state Medicaid agencies, and Medicare Advantage (MA) plans to find out the mix of FFS versus value-based reimbursement flowing through each of these “lines of business.”

For starters, 39.3% of U.S. healthcare payments were FFS payments not linked to quality and value (which includes more than just Medicare, as described above). In other words, over a third of payments made for healthcare services are doled out on the basis of discreet services performed by healthcare providers without any tie to coordinated care.

That being said, there is some good news: 19.8% of all reimbursements made in the year 2020 (again, across all “lines of business” surveyed) were FFS payments linked in some way to quality. The HCPLAN defines this FFS designation as “Payments that are set or adjusted based on evidence that providers meet quality standards or improve care or clinical services, including for providers who report quality data, or providers who meet a threshold on cost and quality metrics.” Further, 34.2% of payments made in 2020 belonged to a category called “APMs Built on FFS Architecture.”

Taken together with “Population-Based Payment Models” (which I covered in a previous blog post here), the HCPLAN website reports that “In 2020, 40.9% of U.S. health care payments, representing approximately 238.8 million Americans and 80.2% of the covered population, flowed through Categories 3&4 models” (category 3 and 4 models include  “APMs Built on FFS Architecture” and Population-Based Payments).

Comparing Payer Lines of Business

That’s great, but how does it match up with HHS projections way back in 2015?

Well, let’s take a look at what they said one more time: “85% of Medicare FFS payments should be tied to quality or value by 2016, and 30% of Medicare payments should be tied to quality or value through alternative payment models by 2016 (50% by 2018).” (Again, the bold is mine.)

I couldn’t find a snapshot of where things stood in 2016 with respect to uptake of value-based payment models, but if you look only at the Medicare-related “lines of business” on the most recent HCPLAN survey — that is, Medicare Advantage and traditional Medicare — payments linked to quality and value (and, consequently, not strictly FFS) accounted for 62% and 85%, respectively.

While Medicare has undoubtedly made progress toward ensuring that payments flowing to physicians are adjusted based on quality metrics, it’s significantly ahead of both commercial payers and Medicaid. If you zoom in on Categories 3 and 4 payments (again, the categories that most resemble pure APMs with no FFS elements) these markets accounted for only 35.5% and 35.4% of payments linked to value, respectively. It’s also important to realize that as of 2021, in all its forms, total Medicare enrollment was only 63,964,675. In a country of 331,893,745 people (as of 2021), that equates to about 19% of the population.  

While I grant that it’s easy to become jaded, and you might be forgiven if you think of value-based care as just the latest fad, destined to be tossed into the waste bin of history when it inevitably fails, I think this whole approach holds a lot of promise. What keeps me optimistic about it is that, in a sense, we can’t afford the quality care movement to fail. Too many people are losing everything to pay for their healthcare these days, and that’s just plain wrong (I’ve covered how insurance works in previous blog posts here and here). For this reason, we have to figure out a way to make care more affordable while also ensuring optimal patient outcomes.

The Importance of Metrics

One quote you often hear repeated when researching quality measures is some variation on “What gets measured gets done.” This thought is often attributed to a Scottish mathematician and physicist named William Thomson, a.k.a. Lord Kelvin. Even though Lord Kelvin didn’t have healthcare quality metrics in mind when he uttered these words, they can just as easily be applied to physics as they can to improving healthcare provider performance.

Given a growing emphasis on patients becoming active participants in their own care, it has been understood for some time that while quality metrics linked mainly to process or adherence to clinical practice guidelines (for instance, the percentage of diabetes patients who had their blood sugar tested and controlled) can play a role in physician compensation, patient-reported outcome measures would likely take center stage at some point.

And that point is quickly approaching. Patient-reported outcomes measures, also called PROMs, have indeed begun factoring into the mix. CMS defines PROMs as “tools used to capture patients’ reports of their outcomes, which measure developers can use as the basis for patient-reported outcome-based performance measures (PRO-PMs).”

PROMs have been around for a while, but only recently have they bubbled up to the surface enough for me to notice them. In a publication called RTI Press, the authors of a 2015 paper noted a range of PRO measures, from functional status measures, to those quantifying patient outcomes in dealing with chronic illnesses, to measuring the intensity of fatigue, to getting a handle on health behaviors.

One common element among these measures seems to be that they’re best reported by patients, as opposed to solely being assessed by physicians. Most PROMs I’ve read about involve healthcare interventions in one way or another, but I imagine some could be dedicated to measuring social determinants of health outside of the clinical setting. This bears more research and I’ll aim to follow up with more blog posts in the future on this topic.

Quality Measure Development

I’ve been looking into how to develop Patient-Reported Outcomes-based Performance Measures (PRO-PMs) lately, and I figured I’d list some helpful resources here. Quality metrics are important in medicine, in that they incentivize physicians to accomplish the IHI Triple Aim:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and
  • Reducing the per capita cost of health care.

Payers like the Centers for Medicare & Medicaid Services (CMS) are increasingly trying to integrate patient preferences into these measures to enhance patient experiences of care and, thereby, improve their buy-in to maintaining their own health – which theoretically should lead to better patient health outcomes and lower overall costs to the system.

MIPS Value Pathways, or MVPs (which I’ve discussed previously here and here) are one manifestation of this effort. CMS’ Quality Payment Program website describes the MVP framework as one that works “to align and connect measures and activities across the quality, cost, and improvement activities performance categories of MIPS for different specialties or conditions.” And there’s a population health angle as well: “the MVP framework incorporates a foundation that leverages Promoting Interoperability measures and a set of administrative claims-based quality measures that focus on population health in order to reduce reporting burden.” 

Ultimately, the MVP framework strives to keep the patient at the center of care by aggregating performance data to help guide patients toward make better informed decisions about their own care. 

According to CMS’ “Finalized MVPs and Policies” (available for download here), MVPs have to include at least one outcome measure, and one such outcome measure is the PRO-PM. At the present time, CMS is encouraging “interested stakeholders” to submit MVP candidate measures for consideration “that measure the patient journey and care experience over time.” Additionally, CMS is exploring how MVPs can be used within a multi-disciplinary, team-based care model. 

There’s a lot more to say about MVPs and PRO-PMs, and as this framework evolves I’ll check back in to elaborate on how things are progressing. For now, here is a helpful description of the difference between patient-reported outcomes measures (PROMs) and PRO-PMs, and how they’re related: 

  • PROMs are tools used to collect patient-reported outcomes
  • Measure developers can use PROMs as the basis for patient-reported outcome-based performance measures (PRO-PMs). More specifically, a PRO-PM is a way to aggregate the information from patients into a reliable, valid measure of performance at the measured entity level, e.g., clinician. The CMS consensus-based entity (CBE) only endorses use of PRO-PMs in performance improvement and accountability. The same measure evaluation criteria and justification principles that apply to other outcome measures also apply to PRO-PMs.

And without further ado, here some helpful resources for the PRO-PM development process:

Maternal Mortality and PHM — Part 1

By now you’ve likely heard that the U.S. leads all wealthy nations in terms of maternal mortality rates. This statistic is hard to swallow, especially since two in three such complications are preventable. Given that the U.S. is the wealthiest country in the world, these outcomes are clearly not acceptable. We spend more per person on health than comparable OECD countries, and we also spend a higher proportion of GDP on healthcare than other high-income countries. 

Indeed, in a recent analysis of 71 performance measures, the U.S. came in last out of 11 comparable countries in healthcare system performance. For the purposes of this discussion, it’s worth noting that the U.S. performs particularly poorly with respect to maternal mortality, and that it has the highest infant mortality rate among its peer countries.

In a country so rich in terms of both money and medical innovation, we can certainly do better. But how? Since this is a complex problem, I’m going to split this subject into two blog posts: one post about the problem of maternal mortality in the U.S., and a second about how a population health management (PHM) approach — plus improvements in federal legislation — might help turn the problem around.


Opinions vary on what makes a good healthcare system, but one constant theme that emerges is the importance of patients establishing a relationship with their primary care physician. Although it’s important for a range of physician types to establish a rapport with their patients, our current system essentially places PCPs as gatekeepers of patient health. For that reason, the PCP-patient relationship is an important place to start.

As I discussed in a past blog post, the usual way PCPs conduct business in the States, i.e. acting as point people for assessing both mental and physical health, leaves a lot to be desired. In the current setup, people with some of the worst healthcare problems end up slipping through the cracks because PCPs aren’t highly trained at catching symptoms of poor mental health. Because of this, co-location of mental and physical care services is crucial. Sadly, this isn’t usually the case in the United States. 

Although PCPs in this country are strapped for time and resources when it comes to treating physical ailments (let alone mental issues), at least there’s a chance they’ll catch a problem before it worsens. This is a key point, because research has found that establishing a relationship with a primary care provider can lead to positive health outcomes.

In keeping with these findings, a nationally representative survey study carried out in 2019 sought to find out if there was a connection between receipt of primary care and both high-value services and positive patient experience. The survey designers also analyzed temporal trends from 2002 to 2014. In the end, they discovered that “receipt of primary care was associated with significantly more high-value care, slightly more low-value care, and better health care experience.”  

In an ideal world, everyone would establish an enduring relationship with a PCP based on deep trust, and they would seek primary care through their trusted doctor. This would be a particularly useful relationship in the case of women who plan to become pregnant, as their PCP could help point out potential causes of morbidity early on and help their patient avoid bad outcomes.

In the real world, however, these relationships don’t fulfill their potential. Case in point: instead of seeking medical care through primary care practitioners, on average some groups – either due to access to care issues, affordability, historical issues related to racism, or any number of other reasons – avoid forging a bond with a PCP.

One group in particular that suffers from this trend is African-Americans. In one study, African-Americans were found to be more likely than whites to use either the emergency department or hospital outpatient department as their “usual source of care.” A subset of this group, African-American women, are almost three times more likely to die from pregnancy-related complications than are white women. This mindset of avoiding institutional care for fear of experiencing poor outcomes (or because it’s flat-out inaccessible) seems to be one factor in America’s dismal performance when it comes to maternal mortality, particularly when it comes to African-American women.  

But avoidance of primary care is just one factor among many. According to the Commonwealth Fund, here are three other significant causes:

  1. Obstetrician-gynecologists (ob-gyns) are overrepresented in the workforce compared to midwives. A recent study in the Lancet showed that increasing midwife-delivered interventions “could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, equating to 2.2 million deaths averted per year by 2035.”

  1. There is a shortage of maternity care providers (both ob-gyns and midwives) relative to births. “In most other countries,” say the authors, “midwives outnumber ob-gyns by severalfold, and primary care plays a central role in the health system.” In the U.S., the supply of midwives is negatively affected by “state licensure laws, restrictive scope-of-practice laws, and rules requiring physician supervision of midwives.”

  1. The U.S. doesn’t guarantee access to provider home visits, nor does it guarantee postpartum paid parental leave. In making the argument that postpartum paid leave is necessary to allow mothers time to recover after childbirth, an opinion piece on the Bloomberg website noted that “40% percent of maternal deaths occur in the six weeks following labor. Almost 20% occur between six weeks postpartum and one year” and that “Just 8% of workers in the bottom wage quartile had access to paid family leave in 2020, with Black and Hispanic people being less likely to work in jobs with access to paid leave.”

Models of Success

At this point, it might help to examine what a high-functioning health system looks like with respect to maternal health. Although maternal health is only one criteria by which healthcare systems were judged in a 2021 Commonwealth Fund report, this study throws a spotlight on four central factors to keeping a country’s patients as healthy as possible:

  1. In high-performing countries, universal coverage is provided, and cost barriers are removed.
  1. Countries invest in primary care systems to ensure that high-value services are equitably available in all communities to all people.
  1. They reduce administrative burdens that divert time, efforts, and spending from health improvement efforts.
  1. They invest in social services, especially for children and working-age adults.

The study authors used indicators across five domains in their assessment: access to care, care process, administrative efficiency, equity, and healthcare outcomes. In terms of these metrics, two of the top-performing countries were Norway and the Netherlands. To illuminate what these countries do to stand out so much, let’s dive a little deeper into how they handle maternal health.

Norway: As noted in an article in the Infant Mental Health Journal, citizens of Norway have universal access to healthcare. This universal care is financed by a mix of taxation, income‐related employee and employer contributions, and out‐of‐pocket copayments. The authors highlight the fact that “All residents, including migrants, labor immigrants from EEA, legal immigrants, refugees, or asylum seekers under assessment, are covered by the National Insurance Scheme (Folketrygden, NIS), managed by the Norwegian Health Economics Administration (Helseøkonomiforvaltningen).”

Importantly, all pregnant women in Norway, regardless of legal status, have access to “free abortion, prenatal care, and care related to delivery, and the immediate follow up at the Maternal and Child Health Care Service (MCHS).” Newborns in Norway receive one home visit by a public health nurse, along with one home visit by a midwife. Further, each infant receives “monthly clinic‐based checkups of growth and development during the first year of life.” And this medical monitoring continues at regular intervals where children receive development assessments, clinical examinations, and vaccines.

Emblematic of the country’s approach to nurturing the health of mothers and their children, and to address rapidly-changing demographics, Norway recently launched an initiative that supports immigrant mothers and children called the New Families Program. This program supports first‐time mothers and their infants in one Oslo district that’s composed of 53% minorities from 142 countries. “Anchored in salutogenic theory,” write the authors, “the program aims to support the parent–child relationship, children’s development and social adaptation, and to prevent stress‐related outcomes.”  

The Netherlands: Over the past few decades, cultural norms in the Netherlands have shifted toward placing a higher premium on maternal health. As a 2021 JAMA article points out, in the Netherlands, “access to health care is universal and free of charge and access to perinatal care is fully covered by basic mandatory health insurance.” When a Dutch woman begins her course of treatment, an approach called “risk selection” is used to place them into one of two tracks: one for low-risk pregnancies, or one designed for high-risk pregnancies. Care is then calibrated to the appropriate risk level. These tracks are further subdivided into three possible paths which allow for greater flexibility. 

Midwives, who – as is the case in Norway – play an important role in the country’s healthcare system, are allowed to specialize, forming two groups: community midwives and clinical midwives. Similar to “birthing centres” throughout the world, as defined in one study, Dutch birthing centres “are midwifery-managed locations that offer care to low risk women during labour and birth. They have a homelike environment and provide facilities to support physiological birth. Community midwives take primary professional responsibility for care. In case of referral the obstetric caregiver takes over the professional responsibility of care.”

In the community setting, midwives are assisted by maternity care assistants. Birth centres in which community midwives work are family-oriented and encourage client participation in the decision-making process when it comes to their own care.

Clinical midwives, on the other hand, work exclusively in hospital settings. If risk factors emerge during pregnancy, a woman is referred to secondary care and put under the responsibility of an obstetrician. In this scenario, clinical midwives can also be involved. Evidently, clinical midwives and obstetricians agree that continuity of intrapartum care (i.e. the period from the commencement of labor through the first, second, third, and fourth stages of labor) could be improved by extending the role of primary care midwives, but they disagree on how to redistribute responsibilities. Still, the fact that midwives are even in this conversation speaks volumes about the value the Dutch system puts on the field.

And the results from embedding midwives in the pregnancy and birthing process are stunning. Although women with a non-western ethnic background had an increased maternal mortality ratio (MMR) when compared to Dutch women, overall maternal mortality was halved between 2006-2018 when compared with the years 1993–2005. This should be taken in its proper context, however: one study noted that people living in neighborhoods with a low socioeconomic status (SES) were associated with “higher odds of adverse birth outcomes.”  

Potential Solutions

As frustrating and tragic as these outcomes are in the United States, there is some reason for optimism that things can improve. This is particularly true when it comes to government-sponsored health coverage.

More to the point, the Centers for Medicare and Medicaid Services (CMS), has proven to be a significant source of coverage for low-income women, covering about four in ten births nationwide. Up until recently, postpartum care only extended a couple of months, but this changed with the passage of the American Rescue Plan Act, or ARPA, in 2021 (a piece of legislation I discussed previously in this blog post). Now, most states have exercised an option (or plan to exercise the option) to extend Medicaid postpartum coverage to a full year.

In another promising development, during the COVID-19 pandemic, states including Maine, New Jersey, and New York issued emergency orders that expanded midwifery services. In addition, the Affordable Care Act (ACA) requires Medicaid to cover midwifery care that’s provided in freestanding birth centers.

While these are steps in the right direction that will hopefully remain after the public health emergency ends, there’s still a lot of work to do when it comes to stemming the tide of maternal mortality in the U.S. The current landscape is at best a patchwork of solutions that cause stress in those affected. As other nations have shown us, this approach can and must change. In my second blog post on this topic, I’ll explore how population health management, in tandem with effective federal legislation, can help the U.S. begin to make maternal health a higher priority.

What Is a Health Insurance Exchange?

For the newest installment in my “What is…?” series, I’d like to explore what a health insurance exchange is. Health insurance exchanges, a.k.a. health insurance marketplaces, have been in the news as of late because a couple of programs enacted to help Americans get through the COVID pandemic, the American Rescue Plan Act (ARPA) of 2021 and the Families First Coronavirus Response Act (FFCRA), stand a good chance of expiring toward the end of this year. Since these programs made Patient Protection and Affordable Care Act (ACA) plans more affordable to a wider range of people, their expiration means that fewer people may be able to maintain their insurance payments in 2023.

But I’m getting ahead of myself. What are health insurance exchanges, what do they have to do with the ACA/ARPA/FFCRA, and what can someone at risk of losing their insurance do to make sure they maintain continuity of coverage?

To get a better sense of how these programs work (and will hopefully continue to work into the foreseeable future), and their connection to the ACA and health insurance exchanges, it might help to fill in some of the backstory on the ACA itself. In turn, this should help shed light on the important functions health insurance exchanges serve.

The Affordable Care Act: A (Very) Brief History

Don’t worry, this isn’t a deep dive into how health insurance works in the U.S. That would be like taking a guided tour of a rabbit hole built during the Byzantine Era, and I’m frankly more interested in discussing what folks can do to help maintain a smooth transition between types of coverage. 

So in short I’ll say that the ACA – otherwise known as Obamacare – was signed into law on March 23rd, 2010 with an aim to cover more Americans with health insurance. It also had the goals of expanding Medicaid coverage, improving healthcare quality, encouraging innovation to reduce costs, and putting guardrails on what the insurance industry could and couldn’t do. Although the ACA does a variety of things, it’s perhaps best known for outlawing the practice of insurers denying coverage to people with preexisting conditions.

An article in Health Affairs recounts how preexisting conditions used to be handled in stark detail: before the ACA was passed, says the author, “millions with preexisting conditions faced significant barriers in accessing individual market coverage. Health insurers in the individual market in nearly all states could refuse to issue a policy, charge higher premiums, and exclude coverage for specific illnesses and the body parts and systems they affect.”

Because of this, millions of people were left uninsured or underinsured.

By 2014, however, insurers could no longer raise premiums for “infants or children due to a preexisting health condition or disability.” In addition, adults previously denied coverage because of this type of condition, along with those who’d had a break in insurance for six months or longer, could now get insurance. Another important result of the law was that prenatal care and births became identified as preexisting conditions, and therefore had to be covered. Although the preexisting condition component of the ACA was challenged in 2018 and the case ultimately made its way to the Supreme Court, the ACA was upheld by the Court and remains the law of the land to this day.

Health Insurance Exchanges

Now that we’ve got a firmer understanding of what the ACA is, let’s delve into health insurance exchanges. According to, exchanges (a.k.a. health insurance marketplaces) is “a service available in every state that helps individuals, families, and small businesses shop for and enroll in affordable medical insurance.” The ACA established the marketplace as a platform for extending coverage to uninsured Americans, and the first open enrollment period lasted from October 1st, 2013 until March 31st, 2014.

Before exchanges existed, it had become obvious to many that U.S. healthcare spending was out of control. According to the AMA Journal of Ethics, “Health care expenditures in the United States reached $2.6 trillion in 2010, comprising 17.6 percent of gross domestic product.” 

I should say here that although I’m a firm believer in insurance exchanges because they expand much-needed coverage to Americans, it’s important to acknowledge that spending on healthcare remains at high levels, to the tune of 19.7% of GDP in 2020. So, although Obamacare is relatively new, it’s not like insurance exchanges have massively mitigated spending. And for those who would chalk this up to COVID, you’re not completely wrong…but spending was still 17.6 percent of GDP in 2019, exactly where it was in 2010.

Anyway, since healthcare spending is the major cause of rising health insurance premiums, in the years preceding 2010, government officials knew something had to be done to curb this upward trajectory in costs.

Enter the marketplace approach. A key part of Obamacare, the marketplace “facilitates competition among private insurers in a central location where people who do not have access to employer-sponsored insurance can find a suitable plan. Individuals can compare and apply for plans via the Marketplace during the open enrollment period.” So rather than forcing uninsured people to continue to pay the full price for prescription drugs, physician visits, or hospital stays, a new model for care delivery began to emerge where tens of millions of people could obtain care with a copayment or coinsurance rate.

Without going into too much detail, there are a few varieties of exchanges. According to, “As of the 2020 plan year, there were 13 state-based marketplaces, six SBE-FPs (state-based exchange on the federal platform), six state-federal partnership marketplaces, and 26 fully federally-run marketplaces.” (Parentheses mine) There have been some other minor adjustments since then, and I won’t go into the jargon of “SBE-FPs” vs. “federally-run marketplaces,” but suffice it to say that each type of marketplace runs slightly differently.

In addition to changing how Americans pay for healthcare, the ACA also included provisions for reforming the healthcare payment structure when it comes to physician reimbursement. According to the Commonwealth Fund, “The law instituted several mandatory national payment reforms through the Medicare program and created the Center for Medicare and Medicaid Innovation (CMMI), which was funded with $10 billion every 10 years to develop, test, and promote innovative payment and delivery models.”

This complex reimbursement scheme, which involves risk-sharing between physicians and insurers, is something I’ve touched on in previous blog posts. If you want to learn more about these payment models, called alternative payment models or APMs, I’d start with perusing the Health Care Payment Learning & Action Network website. Value-based payment models are at the heart of trying to incentivize physicians to provide higher-quality care at a lower cost and, as a result, decelerate overall healthcare spending. As I said earlier, though, the program has had mixed results.

The American Rescue Plan Act 

And now we come to why health insurance exchanges are making news these days: the ARPA and FFCRA. Let’s talk about what these programs are for a minute, then we’ll discuss how, if you find yourself caught up in the confusion of whether or not they’ll expire, you can try to ensure continuous insurance coverage through next year.

First, let’s focus on ARPA. If you’re covered by this program, you already know that, as an article on the Kaiser Family Foundation website puts it, “The American Rescue Plan Act, the COVID-19 relief package that became law on March 11, 2021, contains a number of provisions designed to increase coverage, expand benefits, and adjust federal financing for state Medicaid programs.”

Specifically, ARPA increased financial help to those already eligible for ACA coverage, and also temporarily expanded subsidies to bring in people whose income levels previously made coverage unaffordable. For example, without ARPA, a 60-year-old couple making $70,000 would’ve had to have paid about 32% of their income to insurance versus 8.5% for the same level of coverage in 2022. 

In other words, the program provided the 14 states that hadn’t yet expanded Medicaid under the ACA with a temporary financial incentive to do just that, and made it easier for people to qualify for the ACA insurance marketplace.

As a consequence of this temporary expansion, insurance enrollment jumped from 12 million people in 2021 to 14.5 million people in 2022, a nearly 21% increase. Enrollees also saved approximately $67 per month per person in premiums, equating to overall savings of around $800 per year per person. Put another way, ARPA, FFCRA, and ACA safety-net coverage had a substantial effect on the uninsured population: “the U.S. uninsured rate among people under age 65 fell from a pandemic peak of 12.3 percent in late 2020 to 10.7 percent in the fall of 2021.” If the subsidies should expire, there will not only be a rise in the underlying premium, but inflation will also play a role, increasing out-of-pocket premium payments even more, regardless of the type of exchange.

Although there’s talk that Congress could extend the temporary subsidies into next year, it’s impossible to know for how long the program will endure.

The Families First Coronavirus Response Act

Similar to ARPA, though more narrowly focused on supporting people during potential bouts with COVID, the FFCRA of 2020 functioned to expand the insurance rolls during uncertain times. According to The Commonwealth Fund, the FFCRA “required states to keep people continuously enrolled in Medicaid in exchange for enhanced federal matching funds through the end of the COVID-19 public health emergency (PHE).”

Among other provisions, the FFCRA ensures that employees who work for qualifying employers are given two weeks of paid sick leave if the employee either is quarantined due to COVID, or has COVID symptoms and is in the midst of getting a medical diagnosis. The act additionally covers employees with two weeks of paid sick leave at two-thirds pay if they’re the main caregiver of someone who has been quarantined due to COVID, and up to to 10 weeks of paid family leave for similar caregiving duties. 

In other words, it allows employees to take time off for reasons related to COVID such that they don’t lose their jobs and, in doing so, maintain their insurance coverage. With COVID hopefully entering an endemic stage soon, and with the CDC loosening their language on quarantine standards, barring the emergence of new, more dangerous variants, I suppose it makes sense that this program should wind down by next year. But we’ll see what happens.

What to Do

Although a lot of very smart people are working arduously to ensure people maintain coverage if ARPA and FFCRA expire, if you think you might be vulnerable to a lapse in insurance in the near future, it would be wise to plan ahead. The Princeton University State Health & Value Strategies group has a great breakdown of the infrastructure needed to make this happen. As awesome as it is, though, in my opinion it’s a little inside baseball to be very useful to the layperson. 

What, then, can the average person do in this situation? Your first move will likely be to find a list of health insurance exchanges and find the one, should your current insurance coverage become unaffordable, that works best for you. A good first step would be to visit CMS’ state-based exchange website.

“Since January 1, 2014,” says the website, “consumers and small businesses in every state (including the District of Columbia) have had access to obtain health and/or dental insurance coverage through Individual or Small Business Health Options Program (SHOP) Health Insurance Exchanges, operated by States through State-based Exchanges (SBEs), or operated by the Federal government through the Federally-facilitated Exchange (FFE).”

If you scroll down a bit further on that web page, you’ll find a list of SBEs, along with a few state-based exchanges on the federal platform, which I noted earlier are known as SBE-FPs. If you reside in a state represented on that list, it might make sense to reach out to them and get a better understanding of next steps involved in making a smooth transition from your current coverage onto the ACA exchange.

If you live in an area that doesn’t have an SBE and instead has a federally-run exchange, take a look at this map. Click on your state, and it’ll give you a breakdown of when the open enrollment period is, how to enroll if you’re outside of that time period, which insurance carriers offer coverage in that marketplace, and whether or not that state has expanded Medicaid under the ACA, among other things. If you scroll down, under the map there’s also an “Obamacare Subsidy Calculator” that can help tell you if you’re eligible for ACA premium subsidies, and how much you could save if you qualify. 

And lastly, to check and see if you qualify to enroll outside of the usual enrollment period check here.

Insurance and PHM

A key component in the medical industry’s drive to adopt value-based care is health insurance. Although I’m not an expert on health insurance, I’ve delved into the topic a fair amount on this blog, mainly focusing on government-provided insurance like Medicare and Medicaid with only a passing reference to private insurance. This is because the big players in value-based care for years have been CMS, along with, to some extent, state-level health insurance marketplaces established under the federal Patient Protection and Affordable Care Act. 

But that unfairly sidelines private payers from the discussion, a stakeholder group who, in recent years, has been increasingly jumping on board the value-based train. So I thought now would be a good time to take in the broad sweep of how both public and private insurers are trying to lower healthcare costs by A) encouraging their beneficiaries to live healthier lives, and B) by incentivizing physicians to provide care that satisfies pre-determined health measures, the latter of which includes providing proactive care and opening up access to underserved populations. All of these aims are central tenets of something I talk about a lot on this blog: population health management (PHM).

Before we get into how PHM can help right the healthcare ship, though, it might help to provide some context to help you better understand why value-based care is fast becoming a focus of the healthcare industry. And let me say up front: although I am a critic of the U.S. health insurance industry, there are certainly bright points, as I’ll illustrate below. In addition, I try not to assign malicious intent to most health insurance entities; yes, they are often at fault for loading inhuman financial burdens onto people (as I’ll demonstrate below), but the incentives baked into the U.S. healthcare system often run in the wrong direction.

Put another way, I can understand what’s going on without condoning it. 

OK, let’s get started. According to the Alliance for Health Policy, “At the national level, the net cost of major health care programs has grown from 2.3% of Gross Domestic Product (GDP) in 1990, to 6.1% in 2020, and this proportion is projected to climb to 9.2% in 2050 absent any policy change.” Both a rise in healthcare costs and a large, aging population account for most of these costs. 

On the state level alone, the share of healthcare spending is even more daunting: according to the Medicaid and CHIP Payment and Access Commission website, in state fiscal year 2016, “Medicaid accounted for 28.7 percent of spending from all sources,” with federal funding accounting for most Medicaid expenditures.

To put these numbers in their fullest context possible, although it’s true that the rate of spending on healthcare in the U.S. has trended upward at a dizzying pace over the past few decades, some argue that these figures are rising at an ever slower rate. Some, like the health actuaries at Deloitte, have even speculated that “emerging technologies, an ability to cure and prevent disease (or detect disease in the earliest stages), and highly engaged consumers will lead to a deceleration of health spending between now and 2040.”   

That’s potentially great news for the future, but what about the here-and-now? To make the cost curve point in the right direction, we’ll need to first face the reality that despite astronomical levels of healthcare spending – and in spite of the fact that most Americans are covered by some sort of insurance (only 8.6% of Americans weren’t covered in 2020) – a remarkable number of people are still experiencing unacceptable outcomes, both physically and financially.

By now I’m sure you’ve heard that although the U.S. spends more on healthcare than any other high-income country, we come in last in many important measures. Indeed, life expectancy is far worse in the U.S. than among its peer countries, particularly for poor Americans without access to care. And not only are health outcomes and life expectancy lagging: even among those who manage to overcome these obstacles, many find themselves skipping doctor’s appointments in an attempt to avoid high costs, or becoming outright bankrupted by the exorbitant costs involved.

If you’re lucky enough to be in good health and have ready access to healthcare, it’s easy to become desensitized to facts like those mentioned above. But all you have to do is read real-life stories of healthcare-induced hardships like one that recently appeared on NPR for your blood to boil. The article features a mental health counselor and single mom of several foster children who managed to beat breast cancer, only to be left with a $30,000 bill! Mind you, this is someone with health insurance and even she has had to take on extra shifts just so she doesn’t lose her home and her family, all while trying to stay healthy. 

The article is worth a read not just as an indictment of the U.S. healthcare system, but also as a story of hope and resolve. It is a case study in “financial toxicity,” a concept the National Cancer Institute uses to describe “problems a patient has related to the cost of medical care.” Health insurance is supposed to act as a barrier against financial toxicity due to unforeseen illnesses, but in its most vital function, many plans aren’t working as advertised.

Multiply this experience across the patient spectrum, and you can see why we’re in the midst of a serious crisis. If we focus solely on cancer patients – who are by no means the only group affected by financial toxicity – we’ll see that, according to one study, “Patients with cancer are 71% more likely to experience a severe adverse financial event and 28% more likely to have past-due credit card payments than controls, adjusting for age, sex, year, neighborhood deprivation, and average baseline available credit.” And this is to say nothing of the further mental and physical problems that financial strain due to medical debt can bring on. 

To underline the problem, a recent Commonwealth Fund survey found that 79 million Americans are struggling with medical debt. A Kaiser Family Foundation survey illuminated similar issues related to healthcare costs, including that “Half of U.S. adults say they put off or skipped some sort of health care or dental care in the past year because of the cost. Three in ten (29%) also report not taking their medicines as prescribed at some point in the past year because of the cost.”

This all adds up to a shameful picture. So how can we modify a system that saves people’s lives only to plunge them into a different sort of hardship?

Enter population health management. PHM is an approach to healthcare that incentivizes proactive care, uses predictive analytics to stratify risk, encourages healthier lifestyles, opens up access to care across the patient spectrum, and endeavors to tailor care in line with health equity best practices. Pinpointing and mitigating negative social determinants of health (SDOH) is a central tenet of this approach. 

On the insurance side, PHM strategies are often built around either government-supported or private alternative payment models (APMs) that incentivize healthcare providers to deliver care congruent with pre-determined quality metrics. These metrics work to optimize health system performance, an approach the Institute for Healthcare Improvement calls the “Triple Aim”: improving the patient experience, improving the health of populations, and reducing the per capita cost of healthcare. 

To ensure that providers are deeply invested in the success of such models, an increasing number of reimbursement schemes encourage shared risk between insurer and provider. In other words, if healthcare providers can achieve favorable quality metrics while saving their health systems money, they are permitted to share in those savings by receiving a bonus payment; if, on the other hand, the providers deliver substandard care and don’t hit their cost and quality goals, they are dinged financially.

There are many flavors of APMs, from ones that incorporate fee-for-service (FFS) arrangements to ones that are completely severed from FFS. The latter type of APM, which represents the farthest departure from the FFS payment model, is called a Category 4 or Population-Based Payment Model. This model is subdivided into a few different models that “involve prospective, population-based payments, structured in a manner that encourages providers to deliver well-coordinated, high-quality, person-centered care within either a defined scope of practice (4A), a comprehensive collection of care (4B), or a highly integrated finance and delivery system (4C).”

CMS, along with state-level health insurance marketplaces, have been the clear leaders in APM adoption for the past decade. Some of them, like Covered California, have begun signing APM contracts that, for example, include a health equity performance measure set consisting of multiple “population health/primary care outcomes measures” which relate to, for instance, hypertension and diabetes. The goal of such a program is to reduce racial and ethnic health disparities in outcomes, and also to keep a lid on spiraling costs.

As much as CMS and state marketplaces have been the bellwethers for value-based care, private insurers have begun to catch on. Aetna, for example, has more than 2,000 value-based contracts in place which represent more than 50% of their medical expenditures, and their Accountable Care Organization product has the potential to save as much as $675 per member per year. 

In another example UnitedHealth Group is aiming to directly influence upstream SDOH by investing nearly $800 million in affordable housing across the country. This effort is “resulting in the creation of nearly 19,000 homes for individuals and families struggling with housing insecurity.” These new housing units will include health-related support services, and the company is making additional investments “in programs and partnerships focused on food, health literacy, behavioral health and social isolation” to help shore up SDOH.

As a managed healthcare and insurance company, UnitedHealth Group acknowledges that most of an individual’s health is determined by factors outside of a doctor’s control. The project is the outgrowth of a belief on the part of the group that “access to safe and affordable housing remains one of the greatest barriers to better health for many people.”

The topic of PHM and insurance is an incredibly complicated one, and it would take many blog posts to even scratch the surface. I will continue to monitor insurance industry innovations when it comes to encouraging physicians to practice higher quality care while cutting costs, and will report back on what I hear. Until then, here’s to hoping that things keep going in the right direction.

What is a PCMH?

It seems like the term “Patient-Centered Medical Home,” or PCMH, has been getting a lot of attention lately, particularly in discussions related to value-based care. For that reason, as the first installment in my new “What Is?” series, I’d like to focus on this concept.

So what is a PCMH?

According to the National Committee for Quality Assurance, a PCMH is a model of care where participants emphasize “better relationships between patients and their clinical care teams” with care coordination being an important facet of the program. 

To put the concept in historical context, the “Joint Principles” formally establishing the concept of PCMHs back in 2007 was put forward as part of a collaboration between the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA), which envisioned PCMHs as “an approach to providing comprehensive primary care for children, youth and adults.”

The Agency for Healthcare Research and Quality (AHRQ) holds that there are five components of the PCMH: that it provides comprehensive care, it’s patient-centered, emphasis is placed on coordinated care, services are widely accessible, and it “demonstrates a commitment to quality and quality improvement.”

Taken together, these components create a tightly-coordinated care environment. To get a better feel for what the AHRQ sees as the ideal PCMH, let’s examine each facet separately.

Comprehensive Care: The care delivery model of a PCMH is comprehensive in that it must meet the majority of both a patient’s physical and mental health care needs. I’ve covered the importance of co-locating services like this in previous blog posts about mental health and PHM and place-based care in the UK. Services covered by a PCMH include “prevention and wellness, acute care, and chronic care,” and can include both in-person and virtual teams of physicians.

Patient-Centered: Medical teams comprising the PCMH model focus on the “whole person.” And what is whole-person health? According to the NIH, this idea involves examining “the connections between lifestyle, diet, genetics, health, and disease” to improve people’s health. It stands in stark contrast to the way medicine has traditionally been practiced, i.e. ignoring social and environmental context and looking only at separate bodily systems and organs to isolate problems and find remedies. 

Approaching care in this way facilitates earlier, more effective interventions that can, in many cases, mitigate poor outcomes. To this end, says the NIH, “Understanding the condition in which a person has lived, addressing behaviors at an early stage, and managing stress can not only prevent multiple diseases but also help restore health and stop the progression to disease across a person’s lifespan. 

Coordinated Care: AHRQ states that “the primary care medical home coordinates care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports.” But why is coordinating care important? 

One study out of the University of Texas at Austin makes the case:

“A decade of research into organizations that have achieved better outcomes while often lowering costs suggests a strategic framework for value-based health care implementation that starts with identifying and understanding a segment of patients whose health and related circumstances create a consistent set of needs. An interdisciplinary team of caregivers then comes together to design and deliver comprehensive solutions to address those needs.”

And funding is increasingly tied to this kind of team-based care. Said another way, to achieve better outcomes, coordinated care is often one major goal of value-based care models. PCMHs excel in this area. Indeed, one study found that “PCMH performed significantly better in care coordination compared to non-PCMHs” in their use of case managers, the clinical quality of care reports, and their diligence in sending reminders for preventive or follow-up care. Adopting features of the PCMH model, say the authors, can improve care coordination, especially when it comes to preventive care services.

Wide Accessibility: One simple phrase that appeared in an American Journal of Medical Care article nicely sums up this concept: “Outcomes start with access.”

The authors go on to say that “Patients with limited access to care, whether the barriers are geographic, financial, or cultural and linguistic in nature, are more likely to delay necessary care and, down the road, be hospitalized for their condition.” 

Access to care is a central tenet of population health management, and this includes providing diverse channels of communication (emails, phone calls, patient portals), ensuring shorter waiting times, and even extending working hours to accommodate patients with non-traditional job schedules.

I find this latter example – extending working hours – particularly compelling with respect to expanding accessibility. In keeping with this idea, this 2016 article now seems prescient given the enormous hurdles COVID has constructed over the past couple of years. Beyond providing multiple successful examples of physicians extending hours to accommodate their patients, the author also cites a UK study that found that “Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for ‘minor’ problems.” 

Demonstrated Commitment to Quality and Safety: “In healthcare,” say the authors of a recent blog post about quality measure development, “what gets measured gets done.” This sentiment has never been more true than in the current era of alternative payment model adoption.

The Health Care Payment Learning & Action Network (HCP-LAN, or “LAN” for short) is my go-to place for keeping up with trends in quality measure adoption, and according to their latest data, “In 2020, 40.9% of U.S. health care payments, representing approximately 238.8 million Americans and 80.2% of the covered population, flowed through Categories 3 & 4 models.” According to the LAN, “Category 3” alternative payment models (APMs) are those built on fee-for-service architecture, whereas “Category 4” APMs are “Population-Based Payment Models” (read more about Population-Based Payment Models here).

More comprehensive information can be found here, but suffice it to say that these numbers, which track how much care is being delivered through APMs, are generally on an upward trajectory. That means that fee-for-service is slowly going away, with these value-based forms of physician reimbursement taking its place.

Given the evolving payment landscape, PCMHs are well-situated since the AHRQ points to “engaging in performance measurement and improvement” and “measuring and responding to patient experiences and patient satisfaction” as two hallmarks of the PCMH model. It remains to be seen if PCMHs will emerge from this transitional period intact, but from everything I’ve seen, I think they stand a good chance of going the distance.

Mental Health and PHM

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.