The shift from 'fee for service' to population health management will be a long but necessary road, health experts say.

For one patient in his late 40s, near-weekly trips to the emergency room were the norm this summer as he battled frequent asthma attacks in the New York metro area.

That is, they were the norm until Mark Rosenberg, the emergency department chief of St. Joseph's Healthcare System, found out what was causing the repeated visits: The patient lived right by a construction site, and the home's only air conditioner was tiny and "right on his face" in the bedroom.

"In middle of a summer day, as they're digging their ditches, this dusty dirt that's been in the ground for 150 years is now flying into his window and his house is caked with dirt," Rosenberg says. "It's no wonder he keeps having to go to emergency department."

So rather than continuing to provide medicine and remind the patient to use his inhaler, knowing he'd be back in the emergency room soon, Rosenberg's team took another approach: They asked the patient if he could stay with a family member or friend while construction wrapped up.

 

"No problem," the patient told Rosenberg. He hasn't been back to the emergency department since.

This is just one untraditional medical intervention of many taken by doctors across the country in the shift toward outcome-based care, which health experts say will in turn improve overall population health. As rising health costs strain communities and institutions, improving population health has become a focal point for health professionals who say simply treating patients in the doctor's office doesn't cut it anymore.

A population health approach examines how medical care, genetics, individual behavior, public health interventions and social indicators such as education and employment all play a role in determining the health of a population. For population health directors, the patient is an entire community – not just those who make it to the doctor's office or emergency room.

"Keeping somebody healthy sometimes requires some detective work and changes the way you think about people, one person at a time," says Rosenberg, who is also the chief innovation officer and former chairman of population health at St. Joseph's in Paterson, the third most populous city in New Jersey.

The trifecta of population health – dubbed the "triple aim" by the Institute for Healthcare Improvement – is to improve quality of care and health outcomes for groups while lowering per-capita costs. Such strategies are vital to improving health in communities with higher rates of chronic diseases and poverty and lower levels of health insurance coverage, particularly in areas where access to care is a challenge.

In Paterson, for example, where nearly one in three people lives in poverty and less than three-quarters of adults have high school diplomas, no primary care physicians are accessible via the major bus routes, but every route goes to the hospital, Rosenberg says. Lack of transportation can cause delays in care, which "may lead to a lack of appropriate medical treatment, chronic disease exacerbations or unmet health care needs, which can accumulate and worsen health outcomes," according to a 2013 study published by the National Institutes of Health.

"Health is much more than what's right in front of you," says Megan Tschudy, an assistant professor of pediatrics at Johns Hopkins University School of Medicine. "Health does not happen only in my clinic or the hospital. Health is also what happens in homes, health is also what happens in neighborhoods and schools – and that's what we need to think about."

Although the benefits of population health strategies may be most visible in underserved communities, proponents say it's important to integrate them in health systems trying to combat rising costs across the country. By 2025, U.S. spending on health care will account for just under 20 percent of gross domestic product, up from 13 percent in 2000, according to Centers for Medicare and Medicaid Services data.

The shift toward a population health approach requires all arms of the health care industry to work together to determine the best outcomes for each patient, taking their daily lives into account, which in turn leads to better outcomes for a population overall while driving down costs and improving individual patient experiences, says Trissa Torres, chief operations and North America programs officer at the Institute for Healthcare Improvement, a nonprofit based in Massachusetts.

"My son has diabetes, so what matters is his quality of life, and his care and outcomes over time, and how he can get through his day and how he can manage it longitudinally, on a day-by-day, year-by-year basis," Torres says.

But in the vast majority of interactions with patients, providers take an episodic standpoint, Torres says, with little coordination between primary care doctors, specialists, emergency room physicians and other providers.

Changing the way health professionals are paid would be the biggest push for the gargantuan health care system – providers, payers and vendors long accustomed to the fee for service model – to shift their focus toward health outcomes, Torres says.

"When you pay for individual visits, we create a system focused on what happens in an individual visit or episode," Torres says. "If we shift the payment system to focus on getting to a better outcome, the incentives change. So each individual provider or service doesn't just care what happens when they're doing what they do, they now need to work together to get better outcomes."

 

U.S. Is Many Different Communities When it Comes to Health
The Centers for Medicare & Medicaid Services is shifting how Medicare pays hospitals to reward those providing better quality care through several measures, including a "pay-for- performance approach" that affects about 3,000 hospitals across the country.

But shifting the entire health industry to a population health-centric model is a long process, Torres says, exacerbated by uncertainty surrounding federal health care policies such as the Affordable Care Act. As more providers take a population health approach with successful health outcomes and cost-effective bottom lines, others will follow, she says.

"I think the move from where we currently are toward population health is one of most important transitions our health care delivery system has made," Torres says. "Not only … should we be able to measure that and see improvement at a population level, but also we should really feel those differences at the individual level."

At St. Joseph's, Rosenberg's hospital in New Jersey, the emergency department has been integrating population health management strategies for nearly a decade. Since 2009, every senior who comes to the emergency room has been screened to identify ongoing primary care needs, Rosenberg says.

And more recently, the hospital has begun sending paramedics to the homes of some emergency room patients and utilizing alternatives to opioids for pain management, efforts Rosenberg says contribute to better population health for those groups.

"There are pieces of health care that need to be done that are actually more than just taking care of somebody's blood pressure, so we're talking to the patients and finding what their actual needs are," Rosenberg says. "We are getting decreased revisits to emergency department, which we believe translates to better health care."

 

By: Gaby Galvin

Gaby Galvin is a staff writer at U.S. News & World Report. You can follow her on Twitter and email her at This email address is being protected from spambots. You need JavaScript enabled to view it..