Health care reform: Possibilities &amp; opportunities for primary care

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Applied Evidence

Health care reform: Possibilities & opportunities for primary care

J Fam Pract. 2014 June;63(6):298-304

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References

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Moving toward population health management

New ACO-type models also make it easier to improve health care for specific populations, using strategies designed to organize, provide, and manage care for defined groups. In addition to controlling the cost of caring for specific groups, well-designed and implemented population health management strategies can increase continuity of care by ensuring oversight of patients across the spectrum of health care settings.

Five broad categories of population health management are most prominent: lifestyle management and demand management (both for relatively healthy people), disease management (for those with chronic conditions), catastrophic care management (for patients with rare or catastrophic illness or injury), and disability management (for groups of employees).⁸TABLE 2⁸ describes the population targeted and activities associated with each. It is important to remember, however, that no single strategy is mutually exclusive for a particular group.

Comprehensive Primary Care (CPC) initiative. In a collaboration made possible by the Affordable Care Act, CMS initiated the CPC initiative in 2012.⁹ A 4-year project designed to test and further identify the benefits of population health management and strengthen coordination of care for Medicare patients within primary care settings, the CPC initiative involves 497 sites and 2347 providers caring for approximately 315,000 Medicare beneficiaries.⁹ More information is available at http://innovation.cms.gov/initiatives/comprehensive-primary-care-initiative/.

TABLE 2
Population health management strategies⁸

Strategy	Target/goal	Key elements	Evidence of effectiveness
Lifestyle management	To help relatively healthy individuals make good choices about health behaviors and risks	• Prevention • Risk reduction • Self-care	• Adherence to guidelines for clinical screenings • Reduced costs resulting from prevention programs
Demand management	To help relatively healthy individuals take an active role in decisions about health and medical care; aims to reduce inappropriate demand for services	• Telephone triage • Advice and referrals • Decision and behavioral support • Education to promote self-care	• Reduced variation in care unexplained by morbidity • Improved understanding of perceived need for care • Improved access, better outcomes, lower cost
Disease management	To identify and target chronically ill patients (eg, those with diabetes, heart failure, or asthma) with specific interventions	• Clinical oversight/management of patients with chronic disease • Education and self-care • Coordination of care/providers	• Reduced costs for treatment of chronic diseases • Decreased complications associated with chronic illness
Catastrophic care management	To identify those with rare or catastrophic illness or injury and provide services needed to improve outcomes	• Immediate referral to appropriate providers • Coordination of care • Medical/care management	• Reduced hospitalizations and total claims costs • Reduced morbidity; improved QOL • Realistic, patient-specific goals
Disability management	To develop and deliver employer-driven initiatives for employees to reduce lost time from work, improve productivity, and optimize health and well-being	• Disability prevention programs • Return-to-work programs • Employer-based lifestyle management programs • Coordination of care/providers for employees with chronic disease, disability, and/or serious illness or injury • Absence management programs (ie, designed to control/limit unexplained, unscheduled, or excessive absenteeism) • Workplace rehabilitation	• Lower workers’ compensation/disability benefit costs • Reduced number of injuries • Reduced lost time from work • Increased productivity

^{QOL, quality of life.}

Building infrastructure and leveraging IT

ACOs and ACO-type models will take a variety of forms, depending in part on geographic need and local demographics. Yet, all share a common need for a strong infrastructure to support improved transitions, integration, and coordination of care. Incorporation of a strong health IT system is critical so that data regarding the process and cost of care, as well as outcomes, can be collected and put to optimal use.^10-13

Across health care settings, health IT innovations are being successfully implemented in efforts to enhance physician decision support, improve patient safety, increase guideline adherence, and improve chronic disease treatment.^11,13 In primary care, for example, an IT infrastructure can create disease registries so that data on patients with specific conditions can be tracked and acted upon—eg, a diabetes registry could be used to identify and contact patients who have an hemoglobin A1c >9 and have not been seen in 9 months or more.

Similarly, an IT system with the ability to identify patients at high risk for disease decompensation, hospitalization, and/or increased morbidity and mortality linked to progression of a chronic disease is needed. Identifying medical conditions associated with higher costs would make it possible to focus care coordination and chronic care management efforts on this targeted population.