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.           

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