How CMS can help hospitals succeed in providing sustainable pop health initiatives

Don’t wait for your EHR vendors to bolt on pop health features when CMS already offers programs, tools, financial incentives and a roadmap for integrated, coordinated care.
By Charles Coleman
06:07 AM

I think it’s fair to say that many of us who have been immersed in the EHR revolution of the past decade on a day-to-day basis most likely never expected to see the electronic health records systems functioning as population health platforms — for many reasons.

That said, EMR vendors seem to be suggesting that if you wait, they will build it, and so have apparently convinced some health care providers and systems to actually do just that — hold off until their EHR vendor adds population health to its existing implementations. But the wait for these holdouts may not be worth it in terms of lost opportunities to leverage evolving payer-provider-employer population health collaborations, incentives, shared savings, quality improvements and better resource optimization.

The wait, in fact, could be sadly reminiscent of Vladimir’s and Estragon’s painstaking sojourn waiting for Godot.

Having participated in numerous population health program designs and rollouts, which in some cases are very cleverly designed extensions of investments made in EHRs, over the past four years, it has become increasingly apparent that the sustainability and even the survival of population health as a strategy for managing sick, not so sick, and healthy lives coupled with evolving best practices and the inclusion of accessible social-determinants-of-health [to include mental (MH) and behavioral health (BH) factors] is just as critical for qualitative and quantitative outcomes today as it will be tomorrow.

Indeed, health care providers can and are fine-tuning new business models with the more enlightened among them designing collaborative value-based population health management programs with the payers at the table, including the biggest of them all: CMS.

The Centers for Medicare and Medicaid Services, in fact, currently has pop health initiatives underway that hospitals should understand. Let’s take a look.

New data sets enhance pop health effectiveness
These models are literally a work-in-progress and definitely dependent on the availability and condition of data perceived to be the most useful, actionable and beneficial in delivering on the promise of pop health. Of the sources of data being vetted for inclusion into more intelligent screening, stratification and outreach programs, data collected and maintained by many state public health agencies are now being adapted to fill in numerous gaps in what clinical-only (EHR) data cannot provide about the patient, member or person’s physical environment and identified pockets of known areas of deprivation, poverty, illiteracy, drug/alcohol/opiod addictions, air and water quality issues, elevated mortality/morbidity rates, vaccination compliance, mental health disorders, safety and crime, repeat ED utilization, and seasonal outbreak forecasts and warnings in keeping with their role of providing traditional CDC-like services.

CMS is beginning to support these efforts with the newly released Accountable Health Communities Screening Tool (2017) intended to provide standardized screening for health-related social needs in clinical settings to address this critical gap between clinical care and community services in the current health care delivery system. Designed by a panel of national experts, CMS developed this “10-item screening tool to identify patient needs in 5 different domains that can be addressed through community services (housing instability, food insecurity, transportation difficulties, utility assistance needs, and interpersonal safety), according to the National Academy of Medicine. “Clinicians and their staff can use this short tool across a spectrum of ages, backgrounds, and settings, and it is streamlined enough to be incorporated into busy clinical workflows. Just like with clinical assessment tools, results from this screening tool can be used to inform a patient’s treatment plan as well as make referrals to community services.”

Patient Centered Medical Home 2.0
In 2015, CMS introduced the most important broadly applicable change it has made to primary care to date: Payment for Chronic Care Management (CCM). Designed to accelerate the shift from office-based fee-for-services to value-based-outcomes, this program focused on supporting a “high-preforming primary care system that improves the value through increased emphasis on access, prevention, and care coordination by supporting care managers, patient communication, medication refills, and care provided electronically or by telephone,” said an article in the New England Journal of Medicine.

Over the last couple of years, the IT construct of the Patient Centered Medical Home has matured to a point where it can act as the central hub in a sustainable hub-and-spoke model of care coordination and delivery and, in some instances, has the ability to integrate new data into a more comprehensive care management profile of the patient at hand thereby allowing for more exactness and personalization in care plan design, intervention, and outcomes monitoring. Judith Baumhauer, MD, wrote in a different NEJM article that the end-game is to better understand and leverage the causal relationships between purely clinical (EHR) data and the other 80 percent of healthcare-related data such as mental and behavioral health, lifestyle choices, genetic, socio-economic determinants, device and patient-reported data (PROs).

CMS Looking Ahead: Medicare’s MACRA—QPP—2018
Last month, CMS released another proposed modification to the MACRA Quality Payment Program (QPP), which is slated to go into effect in 2018. Overall, the goal of these tweaks is to make the whole program less complicated and burdensome, primarily among the independent and small group practices. For example, the CMS “Year 2 proposed rule offers Virtual Group participation, which is another way clinicians can elect to participate in MIPS. Virtual Groups would be composed of solo practitioners and groups of 10 or fewer eligible clinicians, eligible to participate in MIPS, who come together virtually with at least 1 other such solo practitioner or group to participate in MIPS for a performance period of a year,” CMS explained. “Our goal is to make it as easy as possible for Virtual Groups to form no matter where the group members are located or what their medical specialties are. Generally, clinicians in a Virtual Group will report as a Virtual Group across all 4 performance categories and will need to meet the same measure and performance category requirements as non-virtual MIPS groups.”

For those eligible physicians who elect to participate in the modified program, two payment options are on the table: MIPS (Merit-based Incentive Payment System) and the Advanced Payment Model (APM).

Population Health Management 2020
In looking at the probable trajectory of some of the most thoughtfully designed population health programs supported by rigorously integrated data from multiple sources, the ability to measure, monitor, and manage discrete populations with one or more co-morbidities is beginning to move off the drawing board and into beta implementations is some PCMH 2.0/IDN provider systems that leverage the new CoCM model.

This marks a major milestone in providing a measures-based method for looking at the interactions between (in the example below) a patient’s mental health metrics (M3), blood pressure, BMI, and HgbA1c for managing a diabetic with symptoms of anxiety through interval testing to fine-tune treatment and outcomes.

Leading hospitals already paving the path ahead
Continuing to refine these care management models by working shoulder-to-shoulder with CMS also gives hospitals and outreach facilities the opportunity to provide input to CMS’s decision-making processes, to participate in pilots and studies, and to teach them how to support best-population-health practices and get their buy in along the way.

Contact Charles A. Coleman, Ph.D., Population Health Portfolio Solutions, Behavioral & Mental Health Program Integration Specialist at or 919-271-4359.