Population Health Really Does Work

At self-insured Houston Methodist, a population health pilot designed for staff members saw 50% of high-risk participants move into the low-risk pool within the first six months.

Houston had a problem.

Julia Andrieni, MD, went to Houston Methodist from UMass Memorial Medical Center two and a half years ago to see if the work she had helped pioneer under former Massachusetts Governor's namesake 'Mitt Romney' insurance plan, would also work in a market where population health wasn't necessarily dictated by payment policy.

Romneycare, you'll recall, was the model after which Obamacare, (the Patient Protection and Affordable Care Act) was patterned.

"In Massachusetts, I was there at a time when everyone had to have primary care overnight under the Mitt Romney plan," she says. "We realized immediately the need for new models of team-based care, the patient-centered medical home, [advanced-practice registered nurses, and] nurse practitioners as we were developing our primary care network."

So why come to a market where none of that was in place?

"I love a challenge," she says.

Signing on with Houston Methodist, the hospital where Michael DeBakey, MD, pioneered open-heart surgery, was especially exciting and challenging for Andrieni, given the hospital's history as a surgical specialty-oriented medical center.

As the new vice president of population health and primary care, she was tasked not only with building population health-based teams and treatment protocols, but also with building up a primary care network that didn't really exist when she arrived.

In the northeast, Andrieni says hospitals and physicians were already accountable for outcomes. "It started with process measures, then moved to outcomes measures," she says. "The expectations were that you had to reach them."

In contrast, fee-for-service is booming in Houston, just like the local economy, despite the recent oil market crash. That means a lot of independent physicians aren't feeling the pressure from payers to be in any type of risk arrangements.

Yet Houston Methodist brought Andrieni in because senior leadership realized that their days of risk-free provision of services are numbered, and without a primary care network, the health system is vulnerable.

Here and now, Andrieni's experience in risk contracting is on the back burner as she works to build an employed primary care network and an alignment model for those who want to stay independent.

Those physicians, in addition to the employed cohort, make up the Physicians Alliance for Quality, an internal physician organization at Methodist. Employed and independent doctors work together to improve handoffs and the care continuum generally, and independents pay a small membership fee to be part of it.

The Alliance then helps them with meaningful use targets, other pay for performance programs, and helps them achieve financial incentives for quality care. Since Andrieni arrived two and a half years ago, the Alliance has grown to 218 aligned and about 70 employed physicians.

Data-driven
"We're doing it from the perspective of improving outcomes and lowering risk. We're very data-driven," Andrieni says.

Though building the Alliance has been her top priority, Andrieni's experience with population health has proved valuable as well. New employees at Houston Methodist get a discount simply for undergoing a routine biometric screening. Andrieni was no exception.

But the discount was for getting the screening. Nothing was really done with the data the screening collected. Andrieni decided to work with the human resources department (Methodist is self-insured) to construct a population health pilot that would make use of all the data collected during biometric screenings of staff members.

"So I took one of our community hospitals, San Jacinto, and used those employees as the population."

She used the nursing care navigator program, developed to aid transitions in care, to flag hypertension, diabetes, and nicotine use among other risk factors, to develop individualized health programs for those at risk. The program was voluntary, but helped train those in the navigator program on how to improve health for a defined population.

They risk-stratified the group and high-risk individuals could opt in to certain health programs. Those employees were also offered wireless home health monitoring devices that reported readings to a centralized dashboard that the navigators could monitor and export to the person's primary care physician. The pilot program ran from July 2014 to August 2015.

"Population health is a new model of healthcare delivery that's very data-driven with appropriate interventions for high risk groups," Andrieni says. "Our most important mission is prevention. But we didn't know what was going to happen."

Results
Here's what did happen: Within the first six months, 50% of high-risk patients moved into the low-risk pool. The high-risk group represented about 7% of the total population, while those classified as "rising risk" were between 15% and 20% of the population.

So that significant reduction of the risk should pay off in myriad ways, and it should have some staying power.

"People who used those devices wanted to keep them, and they became engaged in their own health, which made this stuff sustainable," she says. "They became aware, and motivated by health."

This month, the program, no longer a pilot, will roll out to all six hospitals in the Methodist system.

As part of the rollout system-wide, Andrieni has worked to build up physician commitments by asking them to be "population health partners" for Methodist's employees and dependents. They have to agree to same-day access for employees and beneficiaries, but they have a reimbursement incentive based on the volume of people they take care of and their outcomes.

Andrieni says she structured the program like a commercial payer would. If physicians take high-risk patients, there's a multiplier added to their reimbursement. If employees enroll in the so-called "guided track," they get a premium discount.

"Other employers will be interested in this," says Andrieni.

She's thinking ahead because she says a health system can't simply flip a switch and do well under risk-based reimbursement arrangements.

"It's about readiness. You never know when you will have to go from one world to the next," she says. "We can live in the world where we live and still develop our strengths in population health. We can offer this to employers independent of insurers. And we expect to see decreases in hospitalization and ED use."

A Competitive Advantage
Sixty-seven percent of Houston is self-insured, most corporations have robust wellness departments, and most of their employees are in the low-risk group already, Andrieni says. But there's little or nothing for improving the health outcomes of people who have serious or risky health conditions.

"That's an opportunity for us," she says. "We want to become essential to these employers."

Andrieni says that if Methodist can prove its interventions have worked with its own population, she thinks other employers will be interested. Either way it may provide a competitive advantage.

"We're not feeling the pressure from payers, and maybe in time the landscape will change, but we will have developed these tools. One of the reasons our alignment model has grown so quickly is because independent physicians want to be part of something completely about improving outcomes and quality of care," she says. "This is completely clinical. I'm not talking to them about utilization."