The Primary-Care Population Health Primer

The concept of population health is straightforward. Achieving it, not so much, because it requires numerous fundamental changes in our delivery system.

A lot of physicians are holding off on steps that will prepare them for a transformation of how they are paid from fee-for-service to reimbursement for results. Some are skeptical that such a transformation will actually take hold. Some are just running out the table until change comes. Many don't know where to start, or, more prominently, with whom.

The initial steps to population health are in the form of incentives to reach quality measures, and they differ from payer to payer. Some pay more, some pay less, but all are focused on closing gaps in care at the primary-care level to better manage chronic disease, which represents 80 percent of the cost of care at the commercial insurer level. Medicare, which has 33 quality measures, aims to stem its 96 percent of expenditures associated with chronic disease.

For primary-care physicians in particular, if you plan to be in practice beyond 2016, the time is now to start repurposing your practice operations to address population health.

Here are the five steps that primary-care physicians can take on their own:

• Qualify for and enroll in a Patient Centered Medical Home (PCMH) program. Many payers help financially and operationally. A growing number of third parties will help with the process, some at no cost or at a subsidized price. All will vary by location and the place to start is with your primary commercial insurer representative. All programs provide financial incentives for successful implementation and operation and they can be meaningful. PCMH transformation and meaningful use qualification sets your practice on the right path for the future. A fundamental is adding a care coordinator, who should not only be coordinating referrals, admissions, and discharges, but, within the practice, particularly with the next two steps.

• Stratify disease within your practice. It's the added effort that counts, and pays. EHR report capabilities are crude instruments to convert data into actionable information, but they are a start. Enrolling capable staff in advanced courses provided by your EHR provider or third parties is a good investment. Implementation and follow through give the investment value. If you can identify the segments of your patient panel with chronic disease, you will have guidance on where to apply added focus on closing gaps in care, medication and lifestyle management, and enhanced attention.

• Stratify risk. This is harder without the right tools, particularly for patients who are at risk of converting to chronic disease status. Still, you can't manage what you can't measure. Your EHR is unlikely to be able to identify higher risk patients, but, many can identify patients by risk markers such as weight gain, increased utilization, physical complaints, and progression to co-morbidities. This can get the ball rolling with some elbow grease and creativity, and is a care coordinator function.

• Begin to transform from a service provider to a clinical manager. Rely more extensively on midlevel clinicians for day-to-day and follow-up visits to free more time for hands-on attention to the higher risk patients that you have identified. Experience shows that patients accept the trade-off of more attention from PAs and ARNPs for their day to day needs; for those who do not, a brief visit before or after can ease the transition.

• Invest in behavioral and lifestyle support in-between office visits. Chronically ill patients spend an hour or less per year in office visits. Patients on the pathway to chronic illnesses often spend even less time. Both are left to their own devices for the rest of the time. A relatively small investment in the right nutritionist, therapist or support program can make a dramatic difference in health status - and cost.

Taking these steps can add up to tens of thousands of dollars and more in added net income per physician per year, but, the head start and qualification for high-performing, gain-sharing networks can make an enormous difference in future income, security, and independence. One important piece of advice on gain-sharing networks: Be sure that they are physician-owned and managed.