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The American Journal of Accountable Care March 2019
Safety Net Representation in Federal Payment and Care Delivery Reform Initiatives
J. Mac McCullough, PhD, MPH; Natasha Coult, MS; Michael Genau, MS; Ajay Raikhelkar, MS; Kailey Love, MBA, MS; and William Riley, PhD
ACO Use of Case Mix Index to Comprehensively Evaluate Postacute Care Partners
Mark E. Lewis, MPH; and Avery M. Day, MPH
Improvement of Outpatient Quality Metrics in a Limited-Resource Setting
Carolina dos Santos, BA; Torkom Garabedian, MD; Maria D. Hunt, LPN; Schawan Kunupakaphun, MS; and Pracha Eamranond, MD, MPH
Improved Cost and Utilization Among Medicare Beneficiaries Dispositioned From the ED to Receive Home Health Care Compared With Inpatient Hospitalization
James Howard, MD; Tyler Kent, BS; Amy R. Stuck, PhD, RN; Christopher Crowley, PhD; and Feng Zeng, PhD
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Effective Population Health Care Delivery Under Medicare’s Merit-based Incentive Payment System: Realigning Accountability With Capability
Adam S. Wilk, PhD; and Sanjula Jain, PhD

Effective Population Health Care Delivery Under Medicare’s Merit-based Incentive Payment System: Realigning Accountability With Capability

Adam S. Wilk, PhD; and Sanjula Jain, PhD
Current population health efforts have been hampered by the misalignment of accountability. Thus, population health management will improve when shared accountability among stakeholders is achieved.

Medicare’s Merit-based Incentive Payment System and other value-based payment systems hold providers accountable for population-level measures that are driven by many factors, including those beyond the providers’ direct control (eg, psychosocial stressors, environmental hazards). In this commentary, we identify and illustrate this misalignment of accountability and capability at the individual clinician level and at the provider organization level, which can hinder population health improvement. We also envision the roles of administrators and frontline clinicians amid a new culture of shared accountability and rigorous evaluation, with the potential to accelerate advances in population health care delivery.

The American Journal of Accountable Care. 2019;7(1):28-30
The healthcare system’s ongoing transition from fragmented care and volume-based payment toward coordinated population healthcare and value-based payment has been slow. This transition has been hampered by the misalignment of measurement and accountability systems with population health care delivery goals. The Institute of Medicine report For the Public’s Health: The Role of Measurement in Action and Accountability articulated that a well-functioning accountability system for improving health must identify bodies “with a clear charge to accomplish particular steps toward health goals.”1 Current efforts to improve population health have been stymied significantly because it is not clear which entities—within the healthcare system or across the broader public health system—have such a charge and in what contexts.

Misaligned Accountability

When identifying where accountability for achieving population health goals should lie, a natural first choice is the individual clinician, given the importance of physicians, nurse practitioners, and other frontline clinicians in determining patients’ care pathways. Consequently, current value-based payment systems often integrate performance measures that hold the individual clinician accountable for patient outcomes. This is problematic, however, as these outcomes are often affected by numerous factors, many of which are beyond the clinician’s direct control.

To illustrate, Medicare’s Merit-based Incentive Payment System (MIPS) holds clinicians accountable for care practices such as major depressive disorder prevention and antidepressant medication management. Clinicians may reasonably be expected to screen patients for depression and administer Patient Health Questionnaire-9 (PHQ-9) evaluations to help reduce the percentage of patients remaining on antidepressant medications after a designated time period. However, the population-level impact of these efforts is likely to be small, whereas the potential impact could be much greater with better-coordinated, collective efforts—those integrating both medical and nonmedical actors—to manage the underlying psychosocial stressors and complex, multifactorial processes that drive depressive symptoms.

The term population health management (PHM) embodies the vision of achieving population health improvement by these means. Coordinated, multifaceted PHM interventions may include established models of chronic disease prevention and care management, as well as new collaboration with social services, improving the physical environment and safety, engaging in community education and outreach, and addressing food insecurity and other sequelae of poverty. Significant economies of scale are needed to efficiently perform most PHM interventions, such as geographic analysis of community-level health hazards and other sophisticated measurement and reporting functions,2 which require substantial investments in information technology and big data analytics. Moreover, it is beyond the training of most clinicians to prioritize, coordinate, and execute such multidimensional initiatives effectively. For both reasons, such outcomes-based MIPS measures place too much accountability on the individual clinician and thus may be ineffective in improving population health.

This misalignment is increasingly recognized among thought leaders, payers, and policy makers, as reflected in proposed redesigns of MIPS3 and the growing interest in new value-based payment models such as Accountable Health Communities, which emphasize managing attributed populations collectively.4 Provider organizations have begun to demonstrate how they may leverage their greater economies of scale to advance PHM goals, including through hospital leadership and shared services agreements among groups of smaller organizations.5

Still, skeptics worry that provider organizations are just as unprepared as individual clinicians for the challenges of implementing effective PHM interventions. Doing so may require undertaking tasks far removed from traditional modes of medical care, such as forging and maintaining relationships with social services agencies and other public health institutions across communities. Indeed, few healthcare provider organizations—let alone individual providers—have demonstrated the ability to undertake them effectively.

Provider organizations have also experienced challenges effectively coordinating PHM interventions internally. The system-level measures used to determine payments within value-based contracts (eg, use of certified electronic health record technology, diabetes screening rate) hinge on the actions of the system’s individual clinicians. For example, if an organization leverages its big data capabilities to microtarget screening interventions to a high-risk patient subgroup, the individual clinician must still identify the patient in his or her exam room as high risk and perform the screening. Yet, rarely have provider organizations’ leadership effectively articulated how their clinician employees benefit when the organization’s PHM initiatives are executed faithfully or made substantial efforts to cultivate buy-in and engender a culture of collaboration among clinicians and staff in support of PHM. Perhaps more importantly, provider organizations’ leaders typically have not passed along to or shared with clinician employees the financial incentives the organization faces under value-based contracts, nor have they provided organizational or financial guardrails to ease clinician employees’ transitions into population health–oriented delivery and payment models.6 Although provider organizations are indeed starting to build in PHM-oriented performance bonuses for their clinicians, the predominant compensation structures remain salary based or productivity driven, unlinked to population health improvement. Thus, although payment systems mislay accountability when focused on the individual clinician, it is unclear whether population health will improve when accountability for PHM rests with the provider organization instead.

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