Session on Population Management Highlights Shift Toward Value-Based Models in Diabetes Care

The shift from delivering healthcare one patient at a time to being responsible for a population requires both a new mindset and new payment structures. Both are hard, but both will be essential in diabetes care, for reasons of health and cost.

Four speakers at Friday’s symposium, “Population Management: Coordinating High-Value Diabetes Care in Diverse Settings,” discussed how this can happen at the 75th Scientific Sessions of the American Diabetes Association in Boston. Led by moderator Debra J. Wexler, MD, the panel moved from why diabetes measures are so central to population health management, to specific strategies deployed at state and even local levels.

Darren A. DeWalt, MD, MPH, director of the Learning and Diffusion Group at the Center for Medicare and Medicaid Innovation (CMMI) at CMS, shared the rationale for a population-based approach. “When I think of population management, it means taking care of patients and having accountability for their outcomes,” he said. This structure has been building over 20 years and is now taking hold across the country. It requires:

· The ability to gather analytics about patients, not only their health data but also “the context in which they live.”

· The ability to segment patients to identify those at risk.

· The ability to translate the information and use it in a meaningful way.

Use of contextual information, Dr DeWalt said, “forces us to say that medical care is no longer the 10 to 15 minute visit … it’s between-visit care.” Care occurs at home, in an email to the patient, and through community partners. Most of all, he said, “Patients need to be active participants in their own care, so they can make evidence-based decisions for themselves.”

But this transformation is very hard, especially realigning payment systems to match. Among other challenges, physicians don’t see a good return on investment by changing their approach. Dr DeWalt discussed 4 tools that CMS has deployed to promote its goals of better alignment of incentives, better access to actionable data, and more integration care for chronic illness and behavioral health:

· Starting this year, primary care practices have a new Medicare billing code for chronic care management; Dr DeWalt said practices can receive about $43 per patient per month, although there is a learning curve for documentation.

· The Comprehensive Primary Care demonstrations in 500 primary care practices nationwide are yielding mixed results, but CMS will examine why practices in some states are seeing savings and some are not.

· The Pioneer ACOs have been leaders in population segmentation and community partnerships, and unlike the Medicare Shared Savings Program, these groups have “two-sided” risk; they can lose money by failing to meet population health targets.

· The new Transforming Clinical Practice initiative seeks to support 150,000 clinicians over 4 years with an $800 million investment, “regardless of specialty.” Dr DeWalt emphasized that this program was not just for primary care physicians, but that endocrinologists, cardiologists, and others who see high numbers of patients with chronic conditions could benefit.

Julie Schmittdiel, PhD, a research scientist at Kaiser Permanente, discussed how the health system’s alignment with a research arm has given each a stake in the other’s success. The research section—which relies mostly on funding from foundations and the National Institutes of Health—provides evidence that affects healthcare across the country.

Dr Schmittdiel said Kaiser Permanente was among the early adopters of a population management approach to diabetes care: its diabetes registry dates to the 1990s, and for some time it’s had a team-based approach, with nurse case managers, pharmacists, nutritionists, and others involved in care.

Four principles are essential, she said:

· Population registries: “It seems so fundamental to know who has diabetes and how do we reach them.”

· Evidence-based practice requires knowing the right risk factors to target, and the right medications to use.

· Health systems must receive relevant feedback on performance of individuals and facilities.

· Leveraging efficiencies is essential.

The goal, Dr Schmittdiel said, “is to reduce micro- and macro-vascular complications by optimizing glucose control and cardiovascular risk factors at the population level.”

“We do this by providing team-based care for all diabetes patients,” she said. Everyone receives “light touches,” and those whose glycemic control is poor get more intense outreach.

Kaiser Permanente’s fully integrated electronic health record (EHR) is key to clinical practice and research. “It keeps everybody on the same page,” she said. But no matter how strong a population health management system is, Dr Schmittdiel said, “There will be people who fall through the cracks. You have to have tailored strategies for those patients.” This is especially true when there are language barriers or cultural issues, and health systems must have ways to address this.

Robert A. Gabbay, MD, PhD, the chief medical officer for Joslin Diabetes Center and editor-in-chief of Evidence-Based Diabetes Management, previously led the Penn State Institute for Diabetes and Obesity. His talk covered a Patient Centered Medical Home (PCMH) initiative that began during his tenure at Penn State, which is now bearing fruit. An article on the initiative appeared this week in JAMA Internal Medicine.¹

“Diabetes, in many ways, has been at the vanguard of the many changes in healthcare delivery,” Dr Gabbay said. The concepts of team-based care, promoting self-care, the early studies of the chronic care model—all started with the need to address diabetes. “It’s common, it’s increasing, and it’s expensive,” he said, so early on, it was a disease that healthcare leaders realized needed new approaches.

It has required the “paradigm shift” away from treating patients “when we see them” to the population management approach, which takes responsibility for patients “when we don’t see them.” This team-based approach “is well-accepted for diabetes, but it is a newer concept elsewhere,” Dr Gabbay said.

Enter the Patient-Centered Medical Home (PCMH), and the Pennsylvania Chronic Care Initiative, which transformed care across 150 practices in phases, taking one geographic at a time. The initiative involved 17 different payers, 1000 providers and 96,000 patients with diabetes. It began in 2009 and adopted a “learning laboratory” approach; as Dr Gabbay explained, lessons learned in each region were folded into the launch of the project into the next region. Elements of the initiative included:

· A quarterly learning collaborative, guided by facilitators.

· Practice coaches who worked on individual changes that were discussed.

· Practice-embedded data on care management, the “secret sauce.”

· Monthly quality outcome reporting.

· Supplemental payments from participating insurers, which varied by region.

As Dr Gabbay discussed, early on, the Pennsylvania initiative had some successes, but the evidence was mixed on whether it was saving any money. But by year 3, the lessons learned helped fine-turn the project as it moved into new regions; these regions have seen more rapid improvements. As the evidence accumulates, the PCMH model is making headway on increasing 4 measures of diabetes process care while reducing rates of all-cause hospitalization and emergency department visits,¹ and another recent study showed cost savings.²

What have researchers learned? Practices benefit from:

· Specific performance expectations

· Earlier supports for care management, with training

· Strong communication between practices and payers is key: payers may know right away, for example if a patient is in the emergency room; the practice may not.

· Understanding the shared savings methodology

Dr Gabbay said states can provide a “convening function” to promote payment reform on a regional basis, since antitrust laws would prohibit payers from gathering for such a purpose. As Medicaid providers, states are a large payer themselves. Finally, federal innovation dollars often flow through states, he said.

Marshall Chin, MD, MPH, serves as director of the Chicago Center for Diabetes Translation Research, part of the University of Chicago School of Medicine. He practices where theory meets reality: his patients have some of the highest rates of diabetes and its complications, but they don’t trust institutions. For Dr Chin, the roadmap to reducing disparities means earning patients’ trust before interventions can even begin.

Bringing change requires planning and steps: interventions take commitment to quality, planning, structure, and good design. They must be evaluated and adjusted as needed, and they must be sustained. He discussed the importance of understanding the population’s belief systems; that it wasn’t enough to just take traditional measurements like weight or blood pressure—the healthcare system must understand what motivates the population if it is to grasp the intrinsic and extrinsic motivators that will bring change.

For providers, financial incentives are changing quickly, as payment models based on population management take hold. This has given Dr Chin more ability to work with community partners, such as Walgreens, which has increased its healthy offerings in “food deserts” and hosts store tours to help clients select better choices. He capitalizes on opportunities like farmers’ markets and food pantries, bringing in medical students for blood pressure checks or education sessions. “We turn it from a good event to a health event,” he said.

From diabetes-friendly cooking competitions, to putting physicians on local radio programs, Dr Chin passes up no opportunity to connect with his audience. But the key, he said, is listening. “You have to talk to your patients.”

References

1. Friedberg MW, Rosenthal MB, Werner RM, Volpp KG, Schneider EC. Effects of a medical home and shared savings intervention on quality and utilization of care [published online June 1, 2015]. JAMA Internal Med. doi:10.1001/jamainternmed.2015.2047.

2. Neal J, Chawla R, Colombo CM, Snyder RL, Nigam S. Medical homes: cost effects of utilization by chronically ill patients. Am J Manag Care. 2015;21(1):e51-e61