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):28-30The 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.
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.
A New Culture of Shared Accountability
Individual clinicians and provider organizations each have important roles to play in improving population health care delivery: principally, in executing the organization’s PHM initiatives and in formulating and resourcing these initiatives, respectively. It is incumbent on administrators and frontline clinicians alike to understand these roles and coordinate the organization’s care delivery priorities together.7 Internally, such coordination must include, for employed clinicians, negotiated internal compensation models that align with the terms of the organization’s various payer contracts. Externally, provider organizations must coordinate with payers to negotiate payment contract incentives that can be easily passed along to or shared with their employed clinicians. Respecifying MIPS quality measures so that they focus on individual clinicians’ activities (eg, administering PHQ-9 evaluations) rather than downstream outcomes (eg, antidepressant medication management) represents one federal opportunity to foster providers’ internal coordination in this way. Provider organizations may also work with local payers to facilitate partnership agreements between network providers and entities (eg, social services) that can enhance their PHM initiatives’ capabilities and scale. Importantly, these arrangements must evolve over time with the community’s PHM efforts and as all involved parties identify opportunities to improve their effectiveness.
Robust scientific evaluations and evidence-building efforts are critical for overcoming barriers to improving PHM efforts, especially considering that it remains unknown what the most effective models of delivering population health are and how to apportion accountability for them. Given the multifaceted nature of the psychosocial determinants of population health, in most communities it may be critical that payers and other organizations traditionally ancillary to the healthcare industry (eg, employers, municipal health departments) participate in community-level deliberations to define the community’s population health goals, formulate plans and economic incentives for achieving them, and evaluate efforts. MIPS could foster this by modifying its Improvement Activities list to include, among other potential options, substantial (eg, 25%) representation from these community entities on the provider organization’s board or documentation of referrals and coordinated handoffs of underserved patients to local social services programs for nutrition or housing support. Moreover, each community must conduct its own evaluations, as coordinated PHM is a local endeavor. For instance, the set of organizations needed at the table to support achieving a particular population health goal may vary with the community’s sociodemographic and environmental characteristics and with the evolution of community organizations as they take on new roles and build up the “capacity to undertake the required activities”1 over time.
Throughout the course of a community’s innovation, intervention, evaluation, and evolution, effective PHM will accelerate when the coordinated networks of the community’s partner organizations expand and each partner is held accountable more precisely for achieving what it is capable of achieving in the interest of improving the population’s health. MIPS and other value-based payment systems will continue to significantly inform how shared accountability is defined, incentivized, and implemented in many communities. It is important that they do so deliberately, for until shared accountability is realized, our efforts to realize meaningful gains in population health will continue to lag.Author Affiliations: Rollins School of Public Health, Emory University (ASW), Atlanta, GA; The Health Management Academy (SJ), Washington, DC.
Source of Funding: None.
Author Disclosures: Dr Wilk is employed by Emory University, which engages in population health management efforts through Emory Healthcare, and owns stock as a minority shareholder in United Health Group. Dr Jain is employed by The Health Management Academy, which is a network of delivery systems.
Authorship Information: Concept and design (ASW, SJ); analysis and interpretation of data (SJ); drafting of the manuscript (ASW, SJ); critical revision of the manuscript for important intellectual content (ASW, SJ); and administrative, technical, or logistic support (ASW, SJ).
Send Correspondence to: Adam S. Wilk, PhD, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322. Email: firstname.lastname@example.org.REFERENCES
1. Institute of Medicine. For the Public’s Health: The Role of Measurement in Action and Accountability. Washington, DC: The National Academies Press; 2011. doi: 10.17226/13005.
2. Beck AF, Sandel MT, Ryan PH, Kahn RS. Mapping neighborhood health geomarkers to clinical care decisions to promote equity in child health. Health Aff (Millwood). 2017;36(6):999-1005. doi: 10.1377/hlthaff.2016.1425.
3. Medicare Payment Advisory Commission. Redesigning the Merit-based Incentive Payment System and strengthening advanced alternative payment models. In: Medicare Payment Advisory Commission. Report to the Congress: Medicare and the Health Care Delivery System. Washington, DC: Medicare Payment Advisory Commission; 2017:159-176. medpac.gov/docs/default-source/reports/jun17_ch5.pdf. Accessed July 6, 2018.
4. Accountable Health Communities Model. CMS website. innovation.cms.gov/initiatives/ahcm. Updated January 17, 2019. Accessed February 4, 2019.
5. Khullar D, Burke GC, Casalino LP. Can small physician practices survive? sharing services as a path to viability. JAMA. 2018;319(13):1321-1322. doi: 10.1001/jama.2017.21704.
6. Ryan AM, Shortell SM, Ramsay PP, Casalino LP. Salary and quality compensation for physician practices participating in accountable care organizations [erratum in Ann Fam Med. 2015;13(5):411. doi: 10.1370/afm.1791]. Ann Fam Med. 2015;13(4):321-324. doi: 10.1370/afm.1805.
7. Ganguli I, Ferris TG. Accountable care at the frontlines of a health system: bridging aspiration and reality. JAMA. 2018;319(7):655-656. doi: 10.1001/jama.2017.18995.