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Population Health Efforts Track Where the Money Goes


Michael Abrams, managing partner for Numerof and Associates, said regions where states have taken a lead in promoting value-based care are further ahead in moving away from fee-for-service.

There are a few lessons from a recent survey that looked at the nation’s progress toward value-based care. First, government efforts to push the systems in this direction matter. Second, while resistance from doctors has been part of the problem, so has a lack of incentives.

The American Journal of Managed Care asked Michael Abrams, managing partner of Numerof and Associates, whether the data from the recent survey, the State of Population Health, showed population health efforts are faring better in particular regions or among certain specialties. In an e-mail, Abrams said there are differences:

  • In regions where state governments have pushed the transition to value-based care, there’s more progress. New England is far ahead of the South, Abrams said.
  • While the past 2 Numerof surveys have not focused on doctors by specialty, they do ask health systems where they target efforts. Doctors who treat chronic disease—diabetes, heart failure, and chronic obstructive pulmonary disease—are getting the attention. So are orthopedists, no doubt because of CMS’ pursuit of bundled payments for joint replacement, Abrams said.

In April 2016, the Comprehensive Joint Replacement (CJR) model took effect in 67 markets, to reduce cost and quality variation for hip and knee replacements, which are among the most common and costly procedures for Medicare. Total expenditures per procedure ranged from $16,500 to $33,000 across geographic areas. CMS had finalized a new rule to expand CJR and to launch bundled payments in cardiac care, starting July 1, 2017.

In the most recent survey, 51% of respondents listed orthopedics as a therapeutic area of focus, Abrams said. “With CMS mandating bundled payments under CJR for much of the country, it’s no surprise that healthcare delivery systems are making cost and quality in this population a priority.”

Abrams sees potential for more care coordination by primary care physicians, if the incentives follow. “Currently, the challenge is that doctors don’t have incentives to coordinate care. As the payment model changes, we expect that the incentives will shift and primary care physicians will be paid for managing their patient populations effectively to maintain health, reduce costs, and achieve better outcomes,” he said.

“Whether incentive payments such as those implemented by CMS for managing chronic conditions are enough to move the needle (vs moving to population-based payments) remains to be seen,” Abrams said.

Starting this year, CMS has created incentives, including the collaborative care model, which calls for mental health care to be delivered within a primary care practice. Comprehensive Primary Care Plus, or CPC+, seeks to improve coordination on a regional basis across multiple payers in 10 states.

CMS also created an incentive to pay physicians a monthly fee to coordinate care for seniors with multiple chronic conditions, but it is unclear how well this is working.

Abrams said market-level differences affect how rapidly specialists embrace value-based care. “In markets where specific specialties have a great deal of market power and influence, groups may remain independent and resist influence over their practice,” he said.

Healthcare leadership makes a difference, too. “Savvy health system executives, regardless of their market, are finding ways to collaborate effectively with specialists to establish care paths and maintain adherence to them," Abrams said. "Incentive structures also are an important factor here.”

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