New to Me: State Transformation Collaboratives

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

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

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

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

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

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

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

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

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

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

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

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

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

Place-Based Care in the UK

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

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

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

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

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

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

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

PBSC and Integrated Care

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

Officially, ICS were designed to achieve four goals:

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

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

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

“Place” Defined

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

Also, the authors of this paper say the following:

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

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

How PBSC Will Operate

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

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

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

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

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

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

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

New Payment Models

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

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

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

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

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

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

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

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

PBSC and Healthcare Inequalities

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

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

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

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

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

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

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

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

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

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

Designing Effective Quality Measures

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

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

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

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

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

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

Additional criteria for choosing quality measures include the following:

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

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

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

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

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

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

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

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

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

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

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

Balancing Reimbursement Strategies

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

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

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

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

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

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

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

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

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

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

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

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

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

What Do PHM Companies Do?

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

Until now.

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

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

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

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

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

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

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

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

Helping Children with Asthma

I just became aware of an interesting program that works to repair homes in Southeast Washington, DC and Maryland. The initiative, called the Healthy Housing Virtual Home Visiting (VHV) Program, seeks to improve the living conditions of residents in some of the lowest income parts of the District and surrounding areas. Since this program is happening in my city, and because it aims to improve health outcomes for children in particular, I thought it was worthy of note.

The backstory is this: Children’s National Hospital (CNHS) in Washington, DC won an Innovation Challenge contract award through Fannie Mae to help improve the health of children with asthma in low socioeconomic areas by cutting down on the level of allergens in their homes. The award helped the project team accomplish the following:

  • Hire a project coordinator, a program lead, and a physician to lead all virtual health visits.
  • Pay for remediation equipment and work, including HVAC filters and vacuums, mattress bedding, and roofing and plumbing repairs.
  • Evaluate outcomes of the virtual visit program.
  • Write a paper evaluating the program using key performance indicators.

According to the American Lung Association, “Asthma is the most common chronic condition among children, currently affecting an estimated 6.1 million children under 18 years.” Further, according to the Fannie Mae website, “In Washington, D.C., pediatric asthma rates are highest in Wards 7 and 8, an area southeast of the Anacostia River where the District’s greatest share of older, poorly maintained housing is also concentrated.”

This is no coincidence, says the website, since, “according to doctors at Children’s National Hospital…substandard housing conditions can act as environmental triggers for asthma.” That’s a serious problem that might prompt someone to ask, “So why don’t folks just move out of these old, run-down buildings?” Aside from the fact that members of lower socioeconomic groups often don’t possess the capital to simply pick up and move, there is also a deep sense of dislocation that comes with leaving a home where, in some cases, the same family has lived for generations.

And if that’s not enough reason, on the political front, these DC wards are undergoing redistricting. That means that shifting political boundaries will likely be accompanied by vibrant economic expansion. So while these changes may usher in challenging times, they may also herald opportunities. For example, as the article notes:

“When advisory neighborhood commissions negotiate community benefit agreements with developers constructing new buildings in the District, they sometimes include clauses requiring the developer to preferentially hire residents of the ward where the building will be built. If developers on the Wharf or in Navy Yard have to hire residents of Ward 8, lower-income communities could benefit.”

For the uninitiated, the Wharf is a “mile-long stretch along the Potomac River…with restaurants, retailers, residences, and businesses,” and the Navy Yard is “an area that has been reborn as a haven for sports fans, nature lovers and foodies.” The bottom line is this: by staying put, residents might be able to land a good job, becoming upwardly mobile without having to uproot their family.

All this talk of politics and economics is taking us a little afield from the scope of this blog, so let’s regain focus on what’s most important from a population health standpoint: this program seeks to improve the health of a specific patient population ‐‐ children dealing with asthma ‐‐ so that they can live happier, more productive lives.

But how to ensure this group is equipped to change with the shifting landscape, and stay healthy while doing it? That’s where the VHV project comes in. Program stakeholders represent a wide gamut of specialties both within and outside of medicine, and to me illustrate how coordinated care can overcome social determinants of health and improve the wellbeing of specific populations: in short, they agreed on a goal, worked in close collaboration to achieve it, and then assessed population-level outcomes at the conclusion of a set time period (comparing numbers of sick patients six months before and six months after the intervention) to ensure that they were on track with their objectives.

How It Works

The project team consists of both medical and housing experts who understand the unique needs of populations throughout the Washington, DC area: IMPACT D.C. Asthma Clinic and Child Health Advocacy Institute, an award-winning pediatric asthma program run through Children’s National Hospital; a nonprofit housing remediation organization called Yachad; Local Initiatives Support Corporation (LISC) DC; and the Institute for Public Health Innovation (IPHI).

To start the program rolling, stakeholders agreed on a working hypothesis: can asthma-related illnesses in children be improved by identifying possible triggers inside the home and connecting families to remediation resources? The project’s initial objective was to reduce the number of asthma-related hospital visits by identifying indoor asthma triggers and establishing remediation plans, though it’s not clear to me if at the outset they had any firm numbers in mind for target goals.

That said, one thing I really like about this program, and a prime reason why I think it could scale to other settings, is that it leverages a telehealth approach in assessing the overall state of a given home. Each Virtual Home Visit includes a visit from a medical provider, a VHV coordinator, and two housing specialists from Yachad, with each VHV lasting about 30 minutes. According to the Fannie Mae website:

“Using a telehealth platform on their smartphones, families connect with providers who conduct virtual medical and home assessments. Once housing conditions that trigger asthma, such as mold or pest infestations, are identified, families receive education and a remediation plan.”

Once a remediation plan is agreed upon by residents and the project team, that’s when the Yachad organization seems to get more involved:

“Yachad provides remediations ranging from new furnace filters and dehumidifiers to extensive roof repairs. The remediations improve the quality of housing and reduce the risk of future displacement of long‐term residents.”

Program Success

During its first year in existence, the VHV program seems to have been a success. A number of children in affected homes have seen their health improve. According to an overview of the program, “The frequency of emergency visits, hospitalizations, and oral steroid courses dramatically decreased in the six months following the VHV, compared to the six months prior.”

As the resulting paper chronicled, the team provided remediation support to 46 homes, with most participants receiving two or more remediations. Further, “The most commonly provided home remediation services were dust mite covers (100%), pest control (52.1%), and HEPA vacuums (52.1%)…In total, the pilot program completed over 112 home remediation services.”

In one example of program success, Yachad was able to provide a family with “two treatments for roaches and mice, advised them to remove all the carpeting in the house, and repaired the roof and a leaking sky light.” On the medical front, children in the household “are being treated with daily doses of prescribed asthma medication.”

Progress made in improving children’s health was reflected in satisfaction surveys administered 72 hours, one month, and six months following the VHV. According to the paper, these results “clearly highlight the acceptability of this format by patients and their families. Nearly all families would recommend the VHV to another person (98%) and expressed overall satisfaction (100%). Most families felt the VHV had a positive impact on their child’s health (76%).”

Future Plans

Although Fannie Mae has agreed to extend the award contract by a year, it sounds like CNHS is already exploring ways to finance home remediations beyond the length of the contract via reimbursement models through Managed Care Organizations. In the meantime, here are their short term goals for the next year:

  • Sustain the Virtual Home Visit (VHV) model by completing 75 virtual home visits and 100 home remediation measures
  • Develop an interactive property-level map for Washington, DC that identifies high morbidity properties and their remediation needs
  • Estimate the projected healthcare savings that could result from remediation at problematic properties
  • Collaborate with Fannie Mae’s Multifamily Asset Management to review property inspection guidelines and identify opportunities to enhance them using findings from the mapping project

This is encouraging news, and I’ll be sure to keep checking in to see how it goes. If they can build on what they’ve accomplished here and make this a sustainable program over the long haul, I don’t see any reason why it can’t scale to other cities.

Involving Specialists in PHM

In a recent Harvard Business Review article titled “Enlist Medical Specialists in the Drive to Improve Population Health,”  authors Ryan Howard and Michael Englesbe make a compelling argument with respect to population health management: recruit specialties to become entry points into the population health management ecosystem.

The issue they highlight is straightforward, if not challenging to surmount: “Today,” the authors write, “a patient in the United States and other developed countries may see an array of specialists, undergo a variety of procedures, but never speak to a doctor about fundamental health behaviors such as smoking, diet, or exercise or chronic conditions such as diabetes, obesity, and stress.”

In other words, a treating physician will zero in on the narrow health issue with which the patient presents, ignoring the possibility of screening for potential comorbidities or unhealthy lifestyle choices and, in so doing, squander a chance to enroll that patient into an early disease management program. Howard and Englesbe, who are both physicians at the University of Michigan, characterize this as a missed opportunity. And I have to agree.

This focus on the here-and-now, as opposed to providing longitudinal, coordinated care that heeds warning signs about future health complications to course correct, does us all a disservice. For those of us in the U.S., there are many reasons we’ve ended up here, not the least of which being a reimbursement system where providers are paid separately for each individual service they perform, which is known as fee-for-service (FFS).

As a side note, there’s currently a push within CMS and among many private insurance carriers to get beyond FFS by incentivizing health systems and healthcare groups to enter into accountable care organizations (ACOs) and alternative payment models (APMs). These payment models spread risk between payers and healthcare providers, providing incentives for providers to provide top-quality care at affordable costs (I’ve written about APMs before). Although there’s room for optimism that risk sharing is the wave of the future, so far uptake of APMs has remained relatively low.

But don’t despair! The authors propose a solution that could work within today’s care delivery infrastructure: “integrate existing resources that address foundational health issues like health behaviors and chronic conditions — which account for the majority of premature deaths — into specialty care pathways.” Although it would represent a big shift in how medicine is currently practiced in countries like the U.S., if the capacity could be built into every specialist/patient encounter to screen for potential health issues, more people could get the care they need, and in the long run our healthcare system would become more economically sustainable.

This isn’t just speculation; a few sites of care are already engaged in this kind of work both in the U.S. and abroad. The two domestic programs spotlighted in the article are the Michigan Surgical Home and Optimization Program (MSHOP) at Michigan Medicine and the Preoperative Anesthesia and Surgical Screening (PASS) program at Duke Health. The authors call them “interdisciplinary programs that address longitudinal health around the time of surgery” and in each, whenever a patient comes in for surgery, they’re screened for a range of chronic conditions including “diabetes, obesity, smoking, malnutrition, physical inactivity, frailty, and stress.” Anyone found to be struggling with these indications are then referred to providers who can establish appropriate longitudinal care pathways for them.

As an illustration of how this works in action, a 2020 article on the website for the University of Michigan’s Institute for Healthcare Policy & Innovation details how MSHOP guided high-risk surgical patients to live healthier lifestyles ahead of their surgeries. This so-called “prehabilitation” program is unique in that it “uses the weeks before surgery to encourage patients to move more, eat healthier, cut back on tobacco, breathe deeper, reduce their stress and focus on their goals for after their operation.”

The parameters of the program are well-defined:

“Once enrolled, (patients) received a call or electronic message from a member of the MSHOP team, and materials about the importance of better nutrition, tobacco cessation, engaging in positive thinking and goal-setting, and reducing stress to their pre-surgery preparation. They also received a pedometer to track their steps, and an incentive spirometer to encourage them to practice taking deep breaths, to improve their lung function before and after surgery.”

Although the compliance rate seems reasonable, with 62% of participants tracking their walking “three or more times a week, entering them into their medical record or calling them in to a secure voicemail box,” what I find even more impressive is that the program staff followed up to encourage reluctant participants to complete their prehab regimen. 

Not surprisingly, the results have been promising. According to the article, the program had the effect of reducing medical costs for patients, along with their length of stay in the hospital. A recent study found that “prehab patients across the state left the hospital one day earlier, and were more likely to go straight home rather than to a skilled nursing facility, compared with similar patients treated at the same hospital. Total costs for all care up to three months after surgery were nearly $3,200 less on average for those who went through prehab.”

What I like most about the MSHOP approach, aside from the fact that it’s clearly helping people live healthier lives, is the fact that its advocates frame the program in business-style language that members of the C-suite can clearly understand. Witness the following quote from Michael Englesbe, MD, co-author of the HBR article and leader of the U-M Department of Surgery team that has published multiple studies related to the prehab approach: “Every time the prehab study has been studied, it’s found to increase the value of surgical care by improving care while reducing cost. This study cements the business case for hospitals to support it.”

It’s an approach I’ve long supported: while making the case for PHM, it’s as important to emphasize the bottom-line, downstream revenue features of preventative care as it is to highlight how it betters people’s lives.

Similarly, the PASS program at Duke Health seeks to position surgery patients for success. According the the program’s website, prior to undergoing anesthesia, PASS program workers ask participants to complete a preoperative assessment. This assessment “includes a physical exam that helps identify and evaluate medical conditions — such as anemia, diabetes, nutritional deficiencies, or other conditions — that could affect how you do during surgery.”

In an article on the website for the American Society of Anasthesiologists, Jeanna Blitz, MD, FASA, director of the PASS Clinic at Duke, makes a key connection between preparation and good patient outcomes: thinking of preoperative medicine as proactive medicine.

“We must expand our involvement in our patient’s preoperative care,” notes Blitz, “and challenge ourselves to consider the impact of health behaviors (smoking, dietary choices) and socioeconomic factors such as living environment, social support, education, and employment status.”

Many of these factors fit in the category of social determinants of health, and it’s great to see that the PASS Clinic is taking a targeted approach to improving health outcomes like this.

Like the MSHOP program, the Duke PASS Clinic offers a specific intervention to make each patient’s surgery and recovery a success. In Duke’s case, this comes in the form of providing access to tobacco cessation and nutrition specialists. As the clinic’s website states, “A licensed social worker can provide cognitive behavioral therapy for people who want to quit smoking and/or who want to improve stress management before surgery. Our registered dietitian can provide nutritional counseling.”

Both programs also consider the patient a true partner in ensuring optimal health outcomes. Getting patients invested in their own care seems to me a crucial element if proactive health interventions are to work. One advantage to an approach like this, state Howard and Englesbe, is that it’s a way to “improve population health within current care-delivery pathways” as opposed to having to create a whole new care delivery infrastructure. To prove their point, in the article they refer to a substantial body of evidence supporting these kinds of practical interventions.

Of course, this new solution will necessitate a shift in mindset; after all, if people are focused on the ailment that brought them to specialty care to the exclusion of their overall health, being met with screening questions at a “one-off” health encounter may seem strange. And unless quality measures that reward this kind of proactive course are adopted, there will be real challenges in convincing the medical establishment to take this path.

Indeed, as Howard and Englesbe state, “Expanding measures of quality to include things like referral for longitudinal health management at the time of surgery — an equally important component of high-quality care — is an essential step in changing clinical practice.” Some insurance carriers, like Blue Cross Blue Shield of Michigan, have begun incentivizing physicians to report screenings and referrals for certain conditions, along with bonuses for referrals to smoking cessation counseling. But there is still a long way to go.

I wholeheartedly agree with Howard and Englesbe’s conclusion that specialists are currently an undervalued piece of the PHM puzzle. Specialists should begin to view themselves as entry points to improving patient health in a more holistic way, and there’s a business case to be made for doing it.

There are also international efforts underway to bring specialties more into the PHM fold. For example, as the HBR authors point out, a UK National Health Service program called Making Every Contact Count, or MECC, has made real inroads to improving population health. In this program, “(p)atients undergoing anything from a routine eye examination to a minor operation are screened for chronic health conditions and offered brief interventions and referral to treatment.”

Even though we have a long road ahead of us in the U.S. before longitudinal care becomes the norm, I’m encouraged that surveillance for comorbidities is starting to spread out beyond primary care. And I hope this trend continues to take root in specialties across the medical industry.           

PHM: Passing Fad or Here to Stay?

Something I’ve often wondered while reading up on population health and PHM is if they’re really new concepts, or if they’re just different names for older ideas. Updated branding, if you will. After all, the concept of patient-centered care has been around since at least the 1980s, if not since the dawn of medicine. So too have related concepts such as improving access to care and affordable healthcare.

So, I find myself wondering, is PHM just an old idea wrapped in shiny new paper?

One comparison often made by skeptics is to health maintenance organizations (HMOs). Although HMOs may be making a bit of a comeback in the COVID era, their promise of fixing counterproductive incentives in the U.S. healthcare system back in the 70s and 80s has never fully panned out. Instead, as one writer notes, “HMOs solved a problem of counterproductive incentives but then this led to a new problem of counterproductive incentives.”

So I come back to my question: is PHM just HMOs by a different name?

In her article titled “Population Health Management is So in Vogue,” author Dr. Helen Davies attempts to answer this question. Davies, a general practitioner (GP) and PHM clinical lead in the UK’s National Health Service (NHS), argues that, despite her article’s cheeky title, PHM isn’t just a fad; quite to the contrary, says Davies, PHM is here for the long haul, and we’d all better get used to it.

Although the NHS is different in many ways from the U.S. healthcare system, it shares some common features and many of the same challenges. Primary among these challenges is how to provide top-quality care to a large aging population. As an outsider looking in, it seems to me that the NHS has been on a decades-long march toward decentralization, so there may be even fewer differences between the fundamentals of our two systems than I’m aware of. Because of this, it’s no surprise that looking forward, their care delivery models give every evidence of stressing the importance of localized care.

In the spirit of this more focused, targeted care, Davies favors a definition of PHM that I would endorse: “Service redesign for the whole population by targeting groups with similar needs.”

She builds her article around three pitfalls to avoid as we continue into a new era of accountable, patient-centered care. These landmines include re-labeling activity, entrenching the public health gap, and conflating enablers with the endgame for what PHM is trying to achieve.

Avoid Re-Labeling

Although I really like that Davies believes deeply in PHM, I’m of two minds about her first point. On the one hand, I keep telling people that if everything is PHM, nothing is PHM. We cannot simply lump every patient-centered activity or process improvement initiative into the PHM bucket or else, as Davies accurately says, we will risk reinforcing the status quo.

On the other hand, ensuring adoption of this new, complex ecosystem of care will require a fine balance of system overhaul with not asking all physicians to completely change their workflow. As a case in point, witness the U.S. government’s attempt at modernizing healthcare by passing the 2009 HITECH Act and attendant Meaningful Use Rules. These innovations functioned brilliantly to get a huge number of physicians hooked up to electronic health record (EHR) systems in a relatively short period of time; however, in the end, they never fulfilled their promise of ushering in appreciably higher quality care.

Although Meaningful Use has morphed and still exists in some form, many physicians initially balked at the burden of extra work the legislation entailed. My worry is that if healthcare practitioners perceive PHM as just another government mandate grafted on top of their already challenging profession, uptake will lag. Another quote by Davies captures this idea perfectly: “It is only when we use the best available insights to understand groups with common needs and design services around them that we are doing PHM.”

In this spirit, if we can demonstrate to physicians and other caregivers that PHM, while indeed a new way to conceptualize medical care delivery, may also build on some activities they already do regularly (such as cancer screening or coordinating care in rural settings to streamline care visits for patients who must travel great distances), then maybe PHM will make real inroads.

Entrenching the public health gap

Losing the forest for the trees is one thing, but it’s also possible to lose sight of individual trees when gazing at a timberline. For this reason, Davies urges advocates for PHM chart a middle course (to mix my metaphors) and not get so close to the fringes that we lose perspective. Speaking from experience, she puts it like this:

“Many of us will recognise the position of frontline pragmatists, who tend to describe PHM as being all about individual care and view the big picture with its trappings of analytics and incentive alignment, as remote and out of touch with the harsh realities of delivery. Meanwhile at the other end of the spectrum are those focused on whole-system strategy who risk becoming distracted by the act of planning and perhaps removed from ‘true’ care delivery.”

While systems-level thinking is important in this discussion, PHM won’t be adopted successfully unless it’s perceived as being adaptable to different circumstances. To my mind, this kind of allowance is even more important in decentralized settings like the U.S. healthcare system. Sure, one in three Americans are covered by Medicare and Medicaid, and those agencies will exercise significant influence over how PHM plays out in this country. But there is no central agency that can guide implementation a unified program of proactive interventions; for this reason, PHM must be conceptualized with maximum flexibility built into it, and the rewards infrastructure must be similarly adaptable.

Conflating enablers with the endgame

“Just as a car cannot be summed up by just the engine, the wheels or the chassis,” says Davies, “critical though all these things are, they are not the car!” I couldn’t agree more. Sometimes it seems like instead of jumping in and changing how things are done, the medical industry likes to plan every detail ahead of time, assigning roles and maximizing accountability. While there’s something to be said for planning ahead, Davies’ point is that this over-planning can be, and often is, taken too far.

Her “just get on with it school of PHM” is an idea that should be emulated within reason here in the U.S. Here is how she defines it:

“As my colleague Dr. Steve Laitner puts it – focus, function, finance, then form – in that order. Identify the group you are going to focus on, use the best available insights, codesign with users the best care function or delivery model then establish what contractual model will drive the behaviours needed for success, then and only then formalise the governance structures needed for accountability and monitoring.”

At the end of the day, she says, it’s all about inspiring and engaging the workforce tasked with delivering care. If PHM frameworks can deliver demonstrably better care, momentum will build and healthcare will be transformed for the better.

PHM in Action: Addressing SDOH in an Ohio County

I’m finishing up an online course on PHM, so I figured I’d publish my final paper here. It’s called “Addressing Healthcare Disparities in Tuscrawas County, Ohio” and the idea was to propose an intervention targeting a real population health indicator/social determinant of health that, if improved, would bring about an attendant improvement in a related population health outcome. Although I don’t have a track record of creating interventions like this, I hope it provides insight into how targeted, population-level interventions can work in the real world.


In this assessment and improvement activity, I will be focusing on outcomes and indicators of social determinants of health (SDOH) for residents of Tuscarawas County, Ohio. Members of my extended family live in the area, so I have a keen interest in how the county stacks up against national and state health benchmarks, along with strategies the population can employ to improve their collective health.

According to the website County Health Rankings & Roadmaps put together by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation — the high-quality data resource I chose to use for this project — Tuscarawas County ranks in the higher middle range in terms of “health outcomes” (higher 50%-75%) and in the lower middle range for “health factors” (lower 25%-50%) among counties in Ohio.1


For the assessment portion of this project, under the category of “population health outcomes” I chose to focus on the areas of adult obesity, teen births, and mammography screening. As far as “health indicators of social determinants of health” are concerned, I will zero in on the low scores earned by the county on the following measures: access to exercise opportunities, those residents who have attended some college, and those who are uninsured.

The outcomes in my list correspond to the SDOH that I chose such that, if each of the latter were improved, that action should bring about a corresponding improvement in each item’s related health outcome. To illustrate what I mean, take the outcome “adult obesity,” which I will further elaborate on later in this paper, for example: improving “access to exercise opportunities” to all adults in Tuscarawas County should in theory lead to a lower overall adult obesity rate. Adult obesity is an appropriate focal point for this discussion, since Tuscarawas’ percentage of obese adults ranks a bit higher than the state average (35% versus 34%, respectively), and well above the “Top U.S. Performers” (35% versus 26%, respectively).1

To provide context to the problem of adult obesity, in the article “A review of evidence-based strategies to treat obesity in adults” which appears in the journal Nutrition in Clinical Practice,the authors state the following: “In simplest terms, weight loss and maintenance depend on energy balance, and a combination of increased energy expenditure by exercise and decreased energy intake through caloric restriction is the mainstay of behavioral interventions.”2 The authors focus on lifestyle changes as the key ingredient to lowering adult obesity rates, which include “regular physical activity, healthy food choices, and portion control,” all of which require “ongoing support.”

When it comes to exercise, the authors of a separate literature review say that although all types of physical activity (PA) are associated with better health outcomes, “moderate to vigorous PA (MVPA) is considered especially crucial to the prevention of chronic disease and premature mortality.”3 But when one examines the level of participation in MVPA, one sees there is a disparity between those living in underserved communities versus residents of more privileged areas. One important reason for this difference is a lack of access to, and a perceived lack of safety in being able to use, exercise facilities in underserved areas.3 Since Tuscarawas County, Ohio underperforms both nationally and within the state on certain key SDOH measures like “access to exercise opportunities,” it is an appropriate setting for deployment of MVPA interventions.

For the racial and ethnic minority residents of Tuscarawas County, which make up less than 4% of the population, culturally-appropriate MVPA interventions should be tailored to different groups. As a case in point, the authors of the above-mentioned literature review cited The Body and Soul Health Initiative, a “24-week PA and dietary intervention targeting members of predominantly black churches.”3 Aimed primarily at African-American women, this program employed meetings to educate participants about diet and exercise, and were led by African-American staff members. The initiative resulted in a substantial improvement in participants’ minutes exercised over the course of 24 weeks.

When predicated on socioeconomic status (SES), the design of intervention strategies might look somewhat different. SES can be defined as “a combined measure of an individual’s income, education level and occupation.”4 The SES measure is most often inclusive of all members of a society, regardless of background. When looking at the health of low-SES communities, it is important to remember that although the terms “overweight” and “obese” are not interchangeable, they are not as divergent as one might think. Indeed, the WHO defines adults who are overweight as having a body mass index (BMI) greater than or equal to 25, and those who are obese have a BMI greater than or equal to 30.5

When evaluating ways to lower the adult obesity rate in low-SES communities, highly-structured programs involving goal-setting and accountability are likely essential. One study identified “goal setting, self-monitoring and goal review” as key ingredients of any community-based weight-loss program.4 In addition, in an article titled “Exploring Community-Based Weight Loss Initiatives, Retention, and Motivation,” the author notes that “due to the complex interplay of factors contributing to obesity, the International Obesity Task Force and the World Health Organization (WHO) recommend population-based community approaches that connect people, families, schools, and municipalities.”6

While some interventions target adults who are already obese, an alternate approach could involve focusing on adults who are at risk for becoming obese. According to the Mayo Clinic website, “Being overweight is a primary risk factor for prediabetes.”7 Since many overweight people are pre-diabetic, one qualifying factor for such a program could be community members who are prediabetic. 

Proposed Solution

To ameliorate the effects of adult obesity in Tuscarawas County, Ohio, I would propose addressing the SDOH of limited access to exercise by establishing a cost-effective weight-loss program that targets overweight, pre-diabetic community members at risk for becoming obese through a combined exercise and healthy eating regimen. This program would incorporate goal-setting, self-monitoring, and accountability as crucial features. In addition, the initiative would have to be aligned with a local organization to facilitate buy-in by the maximum number of participants.

Such a program might look similar to the YMCA’s Diabetes Prevention Program (DPP). This national program promotes modest weight loss through healthy eating and regular physical activity.8 The program found that an intensive lifestyle intervention in line with its approach can reduce the development of diabetes by more than half in adults with prediabetes.9

The DPP is a one-year program consisting of weekly and monthly sessions in a group setting.10 These sessions are facilitated by coaches who lead small groups of adults. The overall goal of the program is that each participant sets out to lose 7% of their body weight while increasing physical activity each week. The program has achieved real-world success: nearly 30,000 people have attended at least one session, an average of 5.6% of participant’s body weight has been lost over the course of one year, and more than 2,775 lifestyle coaches have been trained to run the program.10

Eligibility requirements for my proposed intervention would track closely with those of the DPP. In line with WHO standards, DPP participants must have a BMI of greater than 25, with fasting plasma glucose levels between 100-125 mg/dL, 2-hour plasma glucose between 140-99 mg/dL, and a 1c between 5.7% and 6.4%. A previous diagnosis of gestational diabetes will suffice, but if no blood test is available, “a qualifying risk score based on a combination of risk factors” including family history and age can count toward eligibility.10 It is important to note that anyone already diagnosed with either type 1 or type 2 diabetes is unable to participate in the DPP, and people in those groups would be similarly ineligible to participate in my proposed intervention.


The goal of this intervention, much like the DPP, would be for each participant to lose at least 7% of their body weight. Participants would also be required to aim to increase their overall physical activity by 10 minutes each week.

The Intervention

Similar to some versions of the DPP, the program would be free contingent upon a physician referral.11 Participants in this intervention would meet in a mixture of group and one-on-one sessions with trained lifestyle coaches for 16 weekly core sessions.12 Coaches would instruct participants on how to make healthy food choices. In addition, the curriculum would cover effective exercise regimens, how to make more time for physical activities, and also how to manage their weight more effectively.

Program participants would be tasked with tracking their eating and exercise habits during this time, setting modest, attainable goals for each week. At the conclusion of the 16 weeks, as in the DPP, participants would be expected meet each month thereafter in a series of support sessions to ensure their continued progress. Participants and coaches would make a joint decision as to when the program would end for each individual, with the understanding that each participant would continue to be accountable to themselves for maintaining a healthy balance of good nutrition and exercise.

Organizations/Agencies/Systems/People Required to Perform the Intervention

Since no YMCAs in Tuscarawas County, Ohio currently offer the Diabetes Prevention Program, this intervention could be sponsored by the local government in a central location. The city of New Philadelphia, Ohio is the county seat, so I would propose setting up the counseling location there since it is geographically central to the area.

Due to COVID-19, at least for the time being, I would set up large-group counseling sessions over zoom but allow in-person, one-on-one meetings with lifestyle coaches — done in a safe manner in line with CDC guidelines — in a meeting room at the main branch library in New Philadelphia, Ohio. Participants would be given the option to go fully remote even for one-on-one meetings to bolster participation. Similarly, after the 16-week program concluded, I would ask lifestyle coaches to honor participants’ wishes to either do hybrid or fully remote one-on-one sessions in a way that conforms to CDC guidance.


The main challenge to uptake of this program, apart from inherent motivation issues with individual participants, would likely stem from the ongoing pandemic. There is no substitute for in-person counseling when it comes to overcoming deeply entrenched habits, so the physical distance imposed by remote coaching sessions may be insurmountable for some people. Consequently, placing extra emphasis on the value of personal accountability may be warranted.

To foster this accountability, it may be necessary to involve friends and family members when personal accountability becomes tenuous. Engendering the value of self-improvement is of paramount importance, and tactics to bring that about may vary from person to person, necessitating a tailored approach.

Other challenges may include wifi and internet connectivity issues in lower-SES communities that would make involvement in the remote aspect of this initiative challenging. Also, even though the USDA has found that by almost every metric it is more affordable to eat healthy foods versus unhealthy foods, it may be difficult to overcome the perception that eating healthy foods is more expensive.13 Relatedly, it may prove challenging to overcome preconceived notions about the time commitment involved with preparing one’s own meal as opposed to eating prepackaged or fast food. Finally, for any in-person components, it may be challenging for lower-SES participants to show up if public transportation is an issue in their local community.

Why the Intervention Should Work

This intervention should work in Tuscarawas County, Ohio because one of the prime social determinants of health at work there, namely a paucity of exercise opportunities and its attendant high adult obesity rate, can be mitigated by a program of guided exercise and healthy eating interventions. As long as thought is given to facilitating a hybrid (or fully remote) course of coaching sessions, and also a targeted approach to attaining buy-in from both attendees and their support networks, this plan should yield positive results.

One way to overcome the bandwidth issue might entail subsidizing wifi in participants’ residences for the duration of the pandemic. Additionally, ensuring transportation to and from one-on-one meetings (if a given participant opts for the hybrid option) would also bolster participation. This might involve distributing vouchers for Uber or arranging carpools for those participants who do not have reliable transportation. 


  • Laddu D, Dow C, Hingle M, Thomson C, Going S. A review of evidence-based strategies to treat obesity in adults. Nutr Clin Pract. 2011 Oct;26(5):512-25. doi: 10.1177/0884533611418335. PMID: 21947634. [Link]

  • Curr Sports Med Rep. 2016 Jul-Aug; 15(4): 290–297. doi: 10.1249/JSR.0000000000000276 [Link]

  • BMC Public Health. 2018; 18: 967. Published online 2018 Aug 3. doi: 10.1186/s12889-018-5877-8 [Link]

  • Martinez, M. (2020). Exploring Community-Based Weight Loss Initiatives, Retention, and Motivation. UTHealth School of Public Health. [Link]

  • Am J Prev Med. 2008 Oct;35(4):357-63. doi: 10.1016/j.amepre.2008.06.035. [Link]

  • USDA. Carlson A, Frazao, E. “Are Healthy Foods Really More Expensive? It Depends on How You Measure the Price.” 2012. [Link]

New to Me: The CHR&R Program

Those of you who have worked in the public health field for a while are probably already familiar with the County Health Rankings & Roadmaps (CHR&R) program. A joint effort of the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation, the CHR&R program “works to improve health outcomes for all and to close the health disparities between those with the most and least opportunities for good health.” I found out about this awesome resource via an online course I’m currently taking called “Assessing and Improving Community Health” through the University of Michigan.

The big idea behind the CHR&R program is that health equity is of paramount importance, and the project’s stated goals are as follows:

  • Build awareness of the multiple factors that influence health.  
  • Provide a reliable, sustainable source of local data and evidence to communities to help them identify opportunities to improve their health.
  • Engage and activate local leaders from many sectors in creating sustainable community change.
  • Connect & empower community leaders working to improve health.

Further, The CHR&R program focuses on people’s health in nearly every U.S. county by providing “data, evidence, guidance, and examples to build awareness of the multiple factors that influence health and support community leaders working to improve health and increase health equity.” 

I’m working on the final project for my course now, and the CHR&R has proven to be an invaluable resource. My plan is to create three interventions for health disparities in a U.S. county that will remain nameless, where much of the population falls into the category of “lower socioeconomic status” or lower SES. The project asks that we identify three suboptimal population health outcomes that have beset the population I’ve chosen to focus on, and to correlate these outcomes with social determinants of health (SDOH) that, if improved, would result in a corresponding improvement in the population health outcomes.

As I said above, I’ve chosen to focus on a specific U.S. county, and three population health outcomes that score low on the CHR&R for this county are adult obesity, teen births, and mammography screening. SDOH that the county scores low on include access to exercise opportunities, percentage of residents who have attended some college, and the percentage of those residents who are uninsured. In my essay I will attempt, for example, to make an argument that, by designing exercise programs, building walking trails, etc. for adults, this will open up exercising opportunities and thus lead to a corresponding decline in adult obesity.

That’s the theory, anyway.

I’m currently in the research stage of this project and have only sketched out a few ideas. But I thought it might be helpful to share the CHR&R resource with you all in case it would come in handy in your work. I’ll follow up once I get further into my research and share any interesting facts that I come across along the way.