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How 3 programs are addressing chronic conditions and population health

Writing for the Harvard Business Review, Ryan Howard and Michael Englesbe of the University of Michigan explain how programs in Michigan, North Carolina, and England leverage specialty care visits to screen for chronic illness and other foundational health issues—programs that can serve as models for health systems around the country.

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Addressing population needs through screening programs

Millions of U.S. patients visit specialists who focus on a single health issue rather than chronic conditions that could significantly impact health and life expectancy, according to Howard and Englesbe.

"Today, a patient in the United States and other developed countries may see an array of specialists, undergo a variety of procedures, but never speak to a doctor about fundamental health behaviors such as smoking, diet, or exercise or chronic conditions such as diabetes, obesity, and stress," they write.

This is a missed opportunity, Howard and Englesbe write, because these "discrete care episodes with specialists" can be leveraged to "move the needle on our nation's most pressing population health needs"—and, in fact, some health care systems have already implemented programs to address this demand.

For instance, the Michigan Surgical Home and Optimization Program (MSHOP) at Michigan Medicine and the Preoperative Anesthesia and Surgical Screening (PASS) program at Duke Health are interdisciplinary programs that address longitudinal health at the time patients receive specialized care, such as surgery.

Under these programs, patients who undergo any type of operation also receive screening for chronic conditions, including diabetes, obesity, smoking, malnutrition, physical inactivity, frailty, and stress. Then, patients who have any chronic conditions are referred to providers who can help them establish longitudinal care for long term management.

In particular, Michigan Medicine has created a multidisciplinary clinic that tracks surgical patients' progress as they begin treatment for their chronic health conditions—an approach that so far has led to an eight-fold increase in referrals for long-term health management and helped patients make significant health improvements that persist long after their operations.

Similarly, the United Kingdom's National Health Service implemented the Making Every Contact Count (MECC) initiative to help patients make behavioral changes, such as quitting smoking and increasing physical activity, to improve their overall health. Under the initiative, patients receiving any medical service from a routine eye examination to a minor operation receive screening for chronic health conditions and are offered brief interventions and referral to treatment.

In addition, MECC trains caregivers at every level—including waiting room staff, medical assistants, and physicians—"to identify and engage patients in these brief interventions around health behavior change," Howard and Englesbe write.

How these programs impact population health

Overall, these programs can help reduce the cost of care, improve chronic medical conditions, and help patients identify and implement critical lifestyle changes, such as smoking cessation.

"Considering that 50 million surgical procedures are performed annually in the United States, such an approach is a powerful way to improve population health within current care-delivery pathways," Howard and Englesbe write.

In fact, there is a long-established body of evidence that suggests these types of programs effectively address foundational health problems within the U.S. health care system.

Over the past 20 years, research has shown that major life events, including surgery, ED visits, and receiving a new diagnosis can serve as "teachable moments," they write. "These are events that motivate individuals to make changes in their health that they had previously not considered or been unable to make."

For instance, while less than 10% of smokers successfully quit each year, more than 50% of smokers who undergo surgery for smoking-related diseases successfully quit after surgery. Even patients who undergo operations that are not related to smoking are more likely to quit.

"As surgeons, we see this phenomenon repeatedly: patients told they need surgery speak of a newfound motivation to do everything in their power to ensure the best possible outcome. Currently, however, few health systems have processes in place to transform that motivation into lifelong actions," they write.

However, they write, "even within the still-dominant fee-for-service payment structure in the United States, there are ways to align the delivery of specialty care with efforts to address the most salient health needs of the population."

While health care reform in the United States will likely continue to be a slow-moving process, Howard and Englesbe argue that "creatively embedding the kinds of efforts we have described into the health care system that we have—rather than waiting for the health care system that we want—may be our best bet for improving the health of our population." (Howard/Englesbe, Harvard Business Review, 2/10)

Advisory Board's take

The next chapter of population health involves specialists. Here's where to start.

Claire Wirth By Clare Wirth

A lot of population health management has focused on primary care, but the industry hasn't made significant strides in specialty care—even though it drives the bulk of health care spending.

That's because involving specialists in value-based care is hard. Not only is specialty care a more diverse space, but it's also more tied to traditional fee-for-service reimbursement and episodic care delivery. We've previously discussed how engaging specialists in accurate HCC capture is a 'no-regrets' opportunity in this hybrid financial incentive state—but what ambitious, yet feasible behavior changes remain for specialists?

Our team recently highlighted three near-term strategies to engage specialists in improving population health. These strategies aim to reduce low-value referrals to specialty care and ensure patients receive the right level of care at the right time.

Strategy 1: Evidence-based referral considerations

Strategy 2: Be accessible to referring physicians via e-consults

Strategy 3: Hand back patients to primary care once they're well-managed

We can't improve population health without specialists. The three strategies outlined in this series are ambitious, yet feasible behavior changes that work under hybrid financial incentives primarily by addressing the specialist-PCP communication gap. Building avenues for collaboration and a shared culture is at the core of referral considerations, e-consults, and hand-backs—and will remain central to future value-based care work.







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