The challenge of attribution: responsibility for population health in the context of accountable care

Social Needs Screening in Academic Health Systems: A Landscape Assessment

Screening for social needs has gained traction as an approach to addressing social determinants of health, but it faces challenges regarding standardization, resource allocation, and follow-up care. The year-long study, conducted by the Association of American Medical Colleges, integrated data from conferences, surveys, and key informant interviews to examine the integration of social needs screening into health care services within Academic Health Systems (AHS). The authors' analysis unveiled eight key themes, showcasing AHS's active involvement in targeted social needs screening alongside persistent resource allocation obstacles. AHS are dedicated to efficiently identifying high-risk populations, fostering partnerships with community-based organizations, and embracing technology for closed-loop referrals. However, concerns endure about the utilization of reimbursement codes for social needs and regulatory compliance. AHS confront staffing issues, resource allocation intricacies, and the imperative for seamless integration across clinical and nonclinical departments. Notably, opportunities arise in standardized training, alignment of AHS priorities, exploration of social investment models, and engagement with state-level health information exchanges. Aligning clinical care, research pursuits, and community engagement endeavors holds promise for AHS in effectively addressing social needs.

Leveraging Population Health Expertise to Enhance Community Benefit

As the Internal Revenue Service strengthens the public health focus of community benefit regulations, and many states do the same with their tax codes, hospitals are being asked to look beyond patients in their delivery system to understand and address the needs of geographic areas. With the opportunities this affords come challenges to be addressed. The regulations' focus on population health is not limited to a defined clinical population—and the resulting emphasis on upstream determinants of health and community engagement is unfamiliar territory for many healthcare systems. At the same time, for many community residents and community-based organizations, large medical institutions can feel complicated to engage with or unwelcoming. And for neighborhoods that have experienced chronic underinvestment in upstream determinants of health—such as social services, housing and education—funds made available by hospitals through their community health improvement activities may seem insufficient and unreliable. Despite these regulatory requirements, many hospitals, focused as they are on managing patients in their delivery system, have not yet invested significantly in community health improvement. Moreover, although there are important exceptions, community health improvement projects have often lacked a strong evidence base, and true health system-community collaborations are relatively uncommon. This article describes how a large academic medical center tapped into the expertise of its population health research faculty to partner with local community-based organizations to oversee the community health needs assessment and to design, implement and evaluate a set of geographically based community-engaged health improvement projects. The resulting program offers a paradigm for health system investment in area-wide population health improvement.

Tools for Population Health Management

As systems shift to value from fee-for-service, new tools are needed to manage networks and operations, and more importantly, make meaningful impacts on patient lives. The integration of data from electronic health records and claims as well as from patients and caregivers has become a key element in any population health management strategy. Visualization of the most appropriate data at the right time and place, while often overlooked, can make the difference between effective use and poor use of data. We provide a summary and guidance on the appropriate tools needed to be successful in population health management efforts.

Advancing Population Health at Academic Medical Centers: A Case Study and Framework for an Emerging Field

The Triple Aim framework for advancing health care transformation elevated population health improvement as a central goal, together with improving patient experiences and reducing costs. Though population health improvement is often viewed in the context of clinical care delivery, broader-reaching approaches that bridge health care delivery, public health, and other sectors to foster area-wide health gains are gathering momentum. Academic medical centers (AMCs) across the United States are poised to play key roles in advancing population health and have begun to structure themselves accordingly. Yet, few frameworks exist to guide these efforts. Here, the authors offer a generalizable approach for AMCs to promote population health across the domains of research, education, and practice. In 2012, NYU School of Medicine, a major AMC dedicated to high-quality care of individual patients, launched an academic Department of Population Health with a strongly applied approach. A rigorous research agenda prioritizes scalable initiatives to improve health and reduce inequities in populations defined by race, ethnicity, geography, and/or other factors. Education targets population-level thinking among future physicians and research leadership among graduate trainees. Four key mission-bridging approaches offer a framework for population health departments in AMCs: engaging community, turning information into insight, transforming health care, and shaping policy. Challenges include tensions between research, practice, and evaluation; navigating funding sources; and sustaining an integrated, interdisciplinary approach. This framework of discipline-bridging, partnership-engaging inquiry, as it diffuses throughout academic medicine, holds great promise for realigning medicine and public health.

Integrating Social And Medical Data To Improve Population Health: Opportunities And Barriers

Recent efforts in medical settings to identify social determinants of health have focused primarily on screening for the purpose of improving care for individual patients and getting standardized data into electronic health records (EHRs). Relatively little attention has been given to processes needed to extract data on social determinants of health out of medical records with adequate validity and efficiency to facilitate analysis across individual encounters to inform population health efforts relevant to the health care sector. In this article we describe the rationale for extracting data on social determinants of health from EHRs, including the potential influence of aggregated data on quality improvement activities and health care payment reform. We then discuss opportunities and challenges to pulling these data from EHRs to enable population-level applications, focusing on the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, as one potential data aggregation resource. Standardizing methods for extracting data on social determinants of health from EHRs will require understanding current challenges and refining existing translation tools.

The Case for Enrolling High-Cost Patients in an ACO

Though accountable care organizations (ACOs) are increasingly important to American healthcare, ethical inquiry into ACOs remains in its nascent stages. Several articles have raised the concern that ACOs have an incentive to avoid enrolling high-cost patients and, thereby, have an incentive to deny care to those who need it the most. This concern is borne out by the reports of consultants working with newly formed ACOs. This paper argues that, contra initial appearances, there is no financial incentive for ACOs to avoid enrolling high-cost patients.

Meaningful Engagement of ACOs With Communities: The New Population Health Management

OBJECTIVES

Population health management (PHM) activities within health care organizations have traditionally focused on coordinating services for populations who present for care in physicians' offices. With the recent proliferation of Accountable Care Organizations (ACOs), however, the reach of PHM has expanded. We aimed to study ACOs' evolving definitions of their patient populations, and how these definitions might be linked to different types of PHM activities pursued by ACOs.

METHODS

Over a 2-year period, we conducted in-depth case studies of 4 ACOs operating in the private sector, including 149 interviews with 89 informants. Although the main study focused on the ACO implementation process, our use of both inductive and deductive qualitative methods enabled us to study emergent topics such as we report here about PHM.

RESULTS

Interviewees across sites described their ACO populations using terms indicating both panel management and community/neighborhood involvement in the context of PHM. Further, all 4 sites reported conducting PHM activities that extended beyond traditional provider-based PHM; these ranged from wellness registries to school-based clinics. Executives at all 4 ACOs also discussed providing, or planning to provide, health care services to all community members in local settings.

CONCLUSIONS

Administrators and physicians in private sector ACOs were proponents of ACO-led programs delivered in community settings that provided health care to all members of the community, and reported their ACOs engaged in multisector collaborations designed to improve neighborhood health. These community engagement activities point to a distinction from 90s era managed and integrated care organizations and may contribute to the sustainability of the ACO model.

Patient Population Loss At A Large Pioneer Accountable Care Organization And Implications For Refining The Program

There is an ongoing move toward payment models that hold providers increasingly accountable for the care of their patients. The success of these new models depends in part on the stability of patient populations. We investigated the amount of population turnover in a large Medicare Pioneer accountable care organization (ACO) in the period 2012-14. We found that substantial numbers of beneficiaries became part of or left the ACO population during that period. For example, nearly one-third of beneficiaries who entered in 2012 left before 2014. Some of this turnover reflected that of ACO physicians-that is, beneficiaries whose physicians left the ACO were more likely to leave than those whose physicians remained. Some of the turnover also reflected changes in care delivery. For example, beneficiaries who were active in a care management program were less likely to leave the ACO than similar beneficiaries who had not yet started such a program. We recommend policy changes to increase the stability of ACO beneficiary populations, such as permitting lower cost sharing for care received within an ACO and requiring all beneficiaries to identify their primary care physician before being linked to an ACO.

Telepsychiatry integration of mental health services into rural primary care settings

From a population health perspective, the mental health care system in the USA faces two fundamental challenges: (1) a lack of capacity and (2) an inequitable geographic distribution of services. Telepsychiatry can help address the equity problem, and if applied thoughtfully, can also help address the capacity problem. In this paper we describe how telepsychiatry can be used to address the capacity and equity challenges related to the delivery of mental health services in rural areas. Five models of telepsychiatry are described, including (1) the traditional telepsychiatry referral model, (2) The telepsychiatry collaborative care model, (3) the telepsychiatry behavioural health consultant model, (4) the telepsychiatry consultation-liaison model, and (5) the telepsychiatry curbside consultation model. The strong empirical evidence for the telepsychiatry collaborative care model is presented along with two case studies of telepsychiatry consultation in the context of the telepsychiatry collaborative care model. By placing telepsychiatrists and tele-therapists in consultation roles, telepsychiatry collaborative care has the potential to leverage scarce specialist mental health resources to reach more patients, thereby allowing these providers to have a greater population level impact compared to traditional referral models of care. Comparative effectiveness trials are needed to identify which models of telepsychiatry are the most appropriate for patients with complex psychiatric disorders.

Ethical Practice Under Accountable Care

Accountable Care Organizations (ACOs) are a key mechanism of the Patient Protection and Affordable Care Act (PPACA). ACOs will influence incentives for providers, who must understand these changes to make well-considered treatment decisions. Our paper defines an ethical framework for physician decisions and action within ACOs. Emerging ethical pressures providers will face as members of an ACO were classified under major headings representing three of the four principles of bioethics: autonomy, beneficence, and justice (no novel conflicts with non-maleficence were identified). Conflicts include a bias against transient populations, a motive to undertreat conditions lacking performance measures, and the mandate to improve population health incentivizing life intrusions. After introducing and explaining each conflict, recommendations are offered for how providers ought to precede in the face of novel ethical choices. Our description of novel ethical choices will help providers know what to expect and our recommendations can guide providers in choosing well.

Population health measurement: applying performance measurement concepts in population health settings

Introduction:

Whether the focus of population-health improvement efforts, the measurement of health outcomes, risk factors, and interventions to improve them are central to achieving collective impact in the population health perspective. And because of the importance of a shared measurement system, appropriate measures can help to ensure the accountability of and ultimately integrate the efforts of public health, the health care delivery sector, and other public and private entities in the community to improve population health. Yet despite its importance, population health measurement efforts in the United States are poorly developed and uncoordinated.

Collaborative Measurement Development:

To achieve the potential of the population health perspective, public health officials, health system leaders, and others must work together to develop sets of population health measures that are suitable for different purposes yet are harmonized so that together they can help to improve a community’s health. This begins with clearly defining the purpose of a set of measures, distinguishing between outcomes for which all share responsibility and actions to improve health for which the health care sector, public health agencies, and others should be held accountable.

Framework for Population Health Measurement:

Depending on the purpose of the analysis, then, measurement systems should clearly specify what to measure—in particular the population served (the denominator), what the critical health dimensions are in a measurement framework, and how the measures can be used to ensure accountability. Building on a clear understanding of the purpose and dimensions of population health that must be measured, developers can then choose specific measures using existing data or developing new data sources if necessary, with established validity, reliability, and other scientific characteristics. Rather than indiscriminately choosing among the proliferating data streams, this systematic approach to measure development can yield measurement systems that are more appropriate and useful for improving population health.

Public health departments and accountable care organizations: finding common ground in population health

We examined areas of potential collaboration between accountable care organizations and public health agencies, as well as perceived barriers and facilitators. We interviewed 9 key informants on 4 topics: advantages of public health agency involvement in accountable care organizations; services public health agencies could provide; practical, cultural, and legal barriers to accountable care organization-public health agency involvement; and business models that facilitate accountable care organization-public health agency collaboration. Public health agencies could help accountable care organizations partner with community organizations and reach vulnerable patients, provide population-based services and surveillance data, and promote policies that improve member health. Barriers include accountable care organizations' need for short-term financial yield, limited public health agency technical and financial capacity, and the absence of a financial model.

Answering the call for integrating population health: insights from health system executives

PURPOSE

The Affordable Care Act is transforming health care practice nationwide through emphasis on population health and prevention. Health care organizations are increasingly required to address population health needs. However, they may be ill equipped to answer that call.

DESIGN/METHODOLOGY/APPROACH

This study identified ways that health care organizations might better integrate public and population health efforts to better respond to this new emphasis on population health. Employing semi-structured key informant interviews, barriers to and facilitators of integration were explored and implications for health care and public health leaders were developed.

FINDINGS

- Participants (n = 17)--including senior hospital executives, group practice administrators, and health department officials--dentified strategies for health care and public health leaders to more effectively integrate in order to achieve better performance and popula-ion health gains. These strategies and their implications are discussed. OORIGINALITY/VALUE:The results of this study provide important value to health care administrators leading efforts to integrate population and public health.

Sleep health: can we define it? Does it matter?

Good sleep is essential to good health. Yet for most of its history, sleep medicine has focused on the definition, identification, and treatment of sleep problems. Sleep health is a term that is infrequently used and even less frequently defined. It is time for us to change this. Indeed, pressures in the research, clinical, and regulatory environments require that we do so. The health of populations is increasingly defined by positive attributes such as wellness, performance, and adaptation, and not merely by the absence of disease. Sleep health can be defined in such terms. Empirical data demonstrate several dimensions of sleep that are related to health outcomes, and that can be measured with self-report and objective methods. One suggested definition of sleep health and a description of self-report items for measuring it are provided as examples. The concept of sleep health synergizes with other health care agendas, such as empowering individuals and communities, improving population health, and reducing health care costs. Promoting sleep health also offers the field of sleep medicine new research and clinical opportunities. In this sense, defining sleep health is vital not only to the health of populations and individuals, but also to the health of sleep medicine itself.

Doing good and doing well: corporate social responsibility in post Obamacare America

This paper looks how health systems can go beyond clinical care to address the social determinants of health and considers why this approach might be particularly relevant for Accountable Care Organizations (ACOs) touted by the Affordable Care Act. ACOs make profits by reducing the medical expenses of patient populations. The leading causes of death in the United States are tobacco use, insufficient physical activity, and an unhealthy diet. These risk factors are linked to increased incidence of a wide range of chronic diseases, the treatment of which places a tremendous financial burden on our health care system. Health care delivery and access are just a small part of the solution to our chronic disease crisis. Increasingly, strategies that address the social determinants of health--"the conditions into which people are born, grow, live, work, and age"-- are the ones that hold the most promise. In Massachusetts, Steward Health Care System supports a number of initiatives to address the social determinants of health in its patient population. Steward provides an example of how a hospital system can address the health of its patient population by moving beyond clinical care. The varied initiatives have also resulted in cost savings for the system.