What You Mean to Population Health
How will shifting health care models affect radiology's role in patient care?
Fifteen years ago, population health was a "relatively new term, not yet precisely defined." Today, population health — and more specifically population health management — is on most medical specialists' minds, even if they aren't sure exactly how it will affect their practices and their patients.
Population health refers to a number of social determinants that are the major predictors of the health of a certain population. Those predictors include items like education, income, nutrition, geography, social behaviors and interactions within a community, and access to technology. Populations could be defined by gender, age group, ethnic group, or health condition.
Enter population health management (PHM) as a sustainable health care delivery model aimed at delivering better patient outcomes at lower costs. The goal of PHM is to keep a patient population as healthy as possible while reducing costs by minimizing things like hospitalizations, emergency room visits, and unnecessary care (including imaging). While it sounds simple, implementing system-wide change of this magnitude will require the coordination of many moving parts. “The challenge of PHM is to do it in a way that scales to the population at large. There are so many people out there that it is difficult to apply individual practices and behaviors on a population scale,” says James A. Brink, MD, FACR, chair of the ACR Board of Chancellors.
A shift to PHM isn’t necessarily intuitive for radiologists. “It’s hard to change what you’ve been doing for 30 years,” says Richard Duszak Jr., MD, FACR, vice chair for health policy and practice at Emory University School of Medicine and affiliate senior research fellow at the Harvey L. Neiman Health Policy Institute®. “And PHM is the exact opposite of what many of us have been trained to do.”
Under the fee-for-service system, physicians are incentivized to focus on individual transactions. “When I think about PHM, I contrast it with what we have now, which is individual patient disease management. We look at what works for one patient and not holistically. We tend to wait until patients are sick before we take action,” says Duszak. Population health management transforms this approach into one of proactively considering cohorts of patients and their wellness.
For PHM to work in radiology, it’s going to take both transparency and accountability, according to David B. Nash, MD, an internist and dean of the Jefferson College of Population Health in Philadelphia. That means knowing how often and for which indications imaging studies are being ordered and executed. This is important because the overall cost of health care is directly related to the number of diagnostic tests, including imaging studies, being ordered every year. The literature shows, Nash says, that a lot of unnecessary imaging is being done. “And that’s bad for everybody,” he says. Historically, PHM has been on the shoulders of primary care physicians, for example, in managing diabetes control, weight loss, or asthma. But as PHM broadens to include entire health systems, radiologists now have a larger role to play.
Because PHM differs from conventional health care by emphasizing value rather than volume, radiologists need to question the value of each imaging study ordered, Nash says. Better utilization of services, more efficient and transparent report writing, ease of access to patient records, and more communicative relationships between physicians are all key elements of PHM.
Also critical in a radiology practice, says Brink, is identifying, reporting, and controlling variations that could improve the overall health of the population. “And if we can ensure consistent and appropriate use of our imaging resources before and after the discovery of key imaging findings, we can optimize health benefits while reducing costs,” he adds. “It’s about finding that sweet spot of appropriate utilization.”
Awareness and Partnerships
Radiologists won’t be as successful in reducing imaging, streamlining utilization, and communicating variations in findings until they recognize that change is upon them. “If I were a radiologist, I think I would welcome PHM,” Nash says. “It elevates the role of the radiologist as a true partner in patient care. As medical professionals, we all have an opportunity here to be a part of a bigger, more integrated delivery system.”
For PHM to work, forming new partnerships with hospitals and health systems and across departments and specialties is critical. Mergers and partnerships are anticipated side effects of population-based care. “The days of two- or three-radiologist practices are on the way out,” Nash says. More hospitals and health systems are moving toward managing population health, and that’s only going to continue to expand, he says. Radiologists will have to work within these systems, not alone. “There needs to be a framework in place to support collaboration among providers, payers, and community partners.” Community groups and public health agencies can play a valuable role in PHM by helping patients overcome non-clinical obstacles to care to improve health and wellness.
“Partnering translates into job security,” Duszak suggests. “Some radiologists think that their only job is to interpret images, when in fact people expect us to provide diagnostic information that is meaningful and relevant — and that includes much more than just putting out a report.”
Payment and Practice with PHM
Redefining a radiologists’ job in a PHM model is undeniably tied to payment. “Ideally, we are appealing to people’s altruism and professionalism with PHM,” Duszak says. “But even for the people with whom that message doesn’t resonate, this comes down to dollars.”
The Medicare Access and CHIP Reauthorization Act (MACRA) and the Merit-Based Incentive Payment System (MIPS) component set the stage for value-based payments and have already started putting some payment at risk. “Your salary with a penalty or bonus in 2019 under MIPS is contingent upon what you started doing on January 1 of this year,” Duszak points out. “That’s how MACRA was designed: to align behavior with payment.” By 2022, when a full-blown MIPS model is in effect, Duszak says, “the dollar differential between radiologists who are top performers and who maximize their bonuses and the poor performers who maximize their penalties will be about 20 percent of their Medicare pay.”
So as reimbursement moves toward value versus volume, and specialists find themselves being held financially accountable for patient health outcomes, reimbursement is going to revolve around infrastructure and improving care and wellness, Nash believes.
Using health information technology and promoting interdisciplinary teamwork are cornerstones to a successful PHM approach — and a healthier patient population. “We want to believe we’re making a difference,” says Duszak. “And there are resources to help you get there.” For example, radiologists need to use structured reporting to make their findings clear to both referring clinicians and patients. And they should participate in qualified clinical data registries to benchmark their facilities’ performance around specified clinical processes and outcomes (see sidebar). Registries allow practices to capture evidencebased data that helps radiologists make the best care and treatment decisions and compare the performance of other health care providers on patient outcomes.
“Radiologists need to roll up their sleeves and look at the resources the College has been providing on how to be successful under MACRA and alternative payment models,” says Duszak. Nash agrees, also suggesting that reimbursement will be obviated when people use a lump-sum payment to use technology in a different way. “We’re going to get paid if there is higher patient satisfaction.”
He envisions increasing use of technology tools to connect patients with their physicians. Online consultations are being used in some facilities, allowing patients to ask questions of their specialists in place of an in-person visit. Providers can also offer virtual follow-up using Skype or similar media platforms. Making electronic health records easily accessible also promotes transparency, can save time, and empowers patients to better manage their own health and wellness. And taking action to streamline services within a single facility improves efficiency and the patient experience.
Patient satisfaction as a metric is important now, says Duszak, when patient- and family-centered care is a focal point of how health systems and providers are evaluated. There is no substitute, Duszak says, for making the time to interact with others. “Radiologists are going to have to interrupt their time in the bunkers reading film,” he says. “They need to talk to referring clinicians and patients. They need to commit.”
Whatever steps you take, it’s important not to wait until the consequences of not changing are already upon you, Duszak cautions. “To be successful under PHM, your job is to provide the most meaningful and relevant diagnostic information available. You should interpret well and in a timely manner, but the information you report needs to be relevant and appropriate.”
By Chad Hudnall, managing editor