Peer Reviewed: Designing Vermont’s Pay-for-Population Health System

Vermont is developing a health care system that could offer a unique opportunity to test a new model for improving population health. Four lines of development converged for the system: 1) a published challenge to create a pay-for-population health system, 2) comprehensive state health reform legislation, 3) the Institute for Healthcare Improvement Triple Aim project, and 4) the concept of the accountable care organization (ACO). In phase 1 of pilot testing, 3 communities serving 10% of the population are using the system, which is based on the enhanced medical home model. Planning is under way for phase 2 of the pilot, ACOs that use incentives based on the Triple Aim goals. Vermont has created a conceptual framework for a community health system and identified some of the practical issues involved in implementing this framework. This article summarizes the design and implementation of the enhanced medical home pilots and the results of a feasibility study for the ACO pilots. It describes how one state is using a systematic approach to health care reform to overcome some of the implementation barriers to a pay-for-population health system. Vermont will continue to provide a statewide laboratory for a pay-for-population health system.     

Decision Making on Medical Innovations in a Changing Health Care Environment: Insights from Accountable Care Organizations and Payers on Personalized Medicine and Other Technologies

Background

New payment and care organization approaches, such as those of accountable care organizations (ACOs), are reshaping accountability and shifting risk, as well as decision making, from payers to providers, within the Triple Aim context of health reform. The Triple Aim calls for improving experience of care, improving health of populations, and reducing health care costs.

The application of triple aim framework in the context of primary healthcare: A systematic literature review

The Triple Aim framework is an increasingly popular tool for designing and assessing quality improvements in the health care sector. We systematically reviewed the empirical evidence on the application of the Triple Aim framework within primary healthcare settings since its inception almost a decade ago. Results show that primary healthcare providers varied in their interpretation of the Triple Aim framework and generally struggled with a lack of guidance and an absence of composite sets of measures for performance assessment. Greater clarity around application of the Triple Aim framework in primary healthcare is needed, especially around the selection and implementation of purposeful measures from locally available data. This review highlights areas for improvement and makes recommendations intended to guide future applications of the Triple Aim in the context of primary healthcare.     

Pursuing the Triple Aim: The First 7 Years

Context

In 2008, researchers at the Institute for Healthcare Improvement (IHI) described the Triple Aim as simultaneously “improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.” IHI and its close colleagues had determined that both individual and societal changes were needed.

Methods

In 2007, IHI began recruiting organizations from around the world to participate in a collaborative to implement what became known as the Triple Aim. The 141 participating organizations included health care systems, hospitals, health care insurance companies, and others closely tied to health care. In addition, key groups outside the health care system were represented, such as public health agencies, social services groups, and community coalitions. This collaborative provided a structure for observational research. By noting the contrasts between the contexts and structures of those sites in the collaborative that progressed and those that did not, we were able to develop an ex post theory of what is needed for an organization or community to successfully pursue the Triple Aim.

Findings

Drawing on our 7 years of experience, we describe the 3 major principles that guided the organizations and communities working on the Triple Aim: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time.

Conclusions

The concept of the Triple Aim is now widely used, because of IHI''s work with many organizations and also because of the adoption of the Triple Aim as part of the national strategy for US health care, developed during the implementation of the Patient Protection and Affordable Care Act of 2010. Even those organizations working on the Triple Aim before IHI coined the term found our concept to be useful because it helped them think about all 3 dimensions at once and organize their work around them.     

Registered Dietitian Nutritionists Bring Value to Emerging Health Care Delivery Models

Health care in the United States is the most expensive in the world; however, most citizens do not receive quality care that is comprehensive and coordinated. To address this gap, the Institute for Healthcare Improvement developed the Triple Aim (ie, improving population health, improving the patient experience, and reducing costs), which has been adopted by patient-centered medical homes and accountable care organizations. The patient-centered medical home and other population health models focus on improving the care for all people, particularly those with multiple morbidities. The Joint Principles of the Patient-Centered Medical Home, developed by the major primary care physician organizations in 2007, recognizes the key role of the multidisciplinary team in meeting the challenge of caring for these individuals. Registered dietitian nutritionists (RDNs) bring value to this multidisciplinary team by providing care coordination, evidence-based care, and quality-improvement leadership. RDNs have demonstrated efficacy for improvements in outcomes for patients with a wide variety of medical conditions. Primary care physicians, as well as several patient-centered medical home and population health demonstration projects, have reported the benefits of RDNs as part of the integrated primary care team. One of the most significant barriers to integrating RDNs into primary care has been an insufficient reimbursement model. Newer innovative payment models provide the opportunity to overcome this barrier. In order to achieve this integration, the Academy of Nutrition and Dietetics and RDNs must fully understand and embrace the opportunities and challenges that the new health care delivery and payment models present, and be prepared and empowered to lead the necessary changes. All stakeholders within the health care system need to more fully recognize and embrace the value and multidimensional role of the RDN on the multidisciplinary team. The Academy’s Patient-Centered Medical Home/Accountable Care Organizations Workgroup Report provides a framework for the Academy, its members, and key partners to use to achieve this goal.     

From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider

The Triple Aim—enhancing patient experience, improving population health, and reducing costs—is widely accepted as a compass to optimize health system performance. Yet physicians and other members of the health care workforce report widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs. Burnout thus imperils the Triple Aim. This article recommends that the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.     

How to evaluate population management? Transforming the Care Continuum Alliance population health guide toward a broadly applicable analytical framework

Many countries face the persistent twin challenge of providing high-quality care while keeping health systems affordable and accessible. As a result, the interest for more efficient strategies to stimulate population health is increasing. A possible successful strategy is population management (PM). PM strives to address health needs for the population at-risk and the chronically ill at all points along the health continuum by integrating services across health care, prevention, social care and welfare. The Care Continuum Alliance (CCA) population health guide, which recently changed their name in Population Health Alliance (PHA) provides a useful instrument for implementing and evaluating such innovative approaches. This framework is developed for PM specifically and describes the core elements of the PM-concept on the basis of six subsequent interrelated steps.The aim of this article is to transform the CCA framework into an analytical framework. Quantitative methods are refined and we operationalized a set of indicators to measure the impact of PM in terms of the Triple Aim (population health, quality of care and cost per capita). Additionally, we added a qualitative part to gain insight into the implementation process of PM. This resulted in a broadly applicable analytical framework based on a mixed-methods approach. In the coming years, the analytical framework will be applied within the Dutch Monitor Population Management to derive transferable ‘lessons learned’ and to methodologically underpin the concept of PM.     

Accountable Care Organizations: roles and opportunities for hospitals

Federal health reform has established Medicare Accountable Care Organizations (ACOs) as a new program, and some states and private payers have been independently developing ACO pilot projects. The objective is to hold provider groups accountable for the quality and cost of care to a population. The financial models for providers generally build off of shared savings between the payers and providers or some type of global payment that includes the possibility of partial or full capitation. For ACOs to achieve the same outcomes with lower costs or, better yet, improved outcomes with the same or lower costs, the delivery system will need to become more oriented toward primary care and care coordination than is currently the case. Providers of clinical services, in order to be more effective, efficient, and coordinated, will need to be supported by a variety of shared services, such as off-hours care, easy access to specialties, and information exchanges. These services can be organized by an ACO as a medical neighborhood or community. Hospitals, because they have a management structure, history of developing programs and services, and accessibility 24/7/365, are logical leaders of this enhancement of health care delivery for populations and other providers.     

Accountable Care Organizations: Roles and Opportunities for Hospitals

Abstract

Federal health reform has established Medicare Accountable Care Organizations (ACOs) as a new program, and some states and private payers have been independently developing ACO pilot projects. The objective is to hold provider groups accountable for the quality and cost of care to a population. The financial models for providers generally build off of shared savings between the payers and providers or some type of global payment that includes the possibility of partial or full capitation. For ACOs to achieve the same outcomes with lower costs or, better yet, improved outcomes with the same or lower costs, the delivery system will need to become more oriented toward primary care and care coordination than is currently the case. Providers of clinical services, in order to be more effective, efficient, and coordinated, will need to be supported by a variety of shared services, such as off-hours care, easy access to specialties, and information exchanges. These services can be organized by an ACO as a medical neighborhood or community. Hospitals, because they have a management structure, history of developing programs and services, and accessibility 24/7/365, are logical leaders of this enhancement of health care delivery for populations and other providers.     

老龄化社会下英国健康服务体系的改革及经验

英国是最早进入老龄化的发达国家之一,应对老龄化有较为丰富的经验。本文主要从英国的健康服务体系、健康筹资及支付模式、老年健康服务模式及整合服务模式探索案例对英国应对老龄化的健康服务体系进行介绍。从英国经验启示来看,我国应建立统一的资源配置规则,加强全科医生、初级保健和公共卫生建设,建立以数据、分析工具为支持的决策体系,以应对老龄化带来的健康服务体系的挑战。     

Quality Improvement in Healthcare Delivery Utilizing the Patient-Centered Medical Home Model

Despite the fact that the United States dedicates so much of its resources to healthcare, the current healthcare delivery system still faces significant quality challenges. The lack of effective communication and coordination of care services across the continuum of care poses disadvantages for those requiring long-term management of their chronic conditions. This is why the new transformation in healthcare known as the patient-centered medical home (PCMH) can help restore confidence in our population that the healthcare services they receive is of the utmost quality and will effectively enhance their quality of life. Healthcare using the PCMH model is delivered with the patient at the center of the transformation and by reinvigorating primary care. The PCMH model strives to deliver effective quality care while attempting to reduce costs. In order to relieve some of our healthcare system distresses, organizations can modify their delivery of care to be patient centered. Enhanced coordination of services, better provider access, self-management, and a team-based approach to care represent some of the key principles of the PCMH model. Patients that can most benefit are those that require long-term management of their conditions such as chronic disease and behavioral health patient populations. The PCMH is a feasible option for delivery reform as pilot studies have documented successful outcomes. Controversy about the lack of a medical neighborhood has created concern about the overall sustainability of the medical home. The medical home can stand independently and continuously provide enhanced care services as a movement toward higher quality care while organizations and government policy assess what types of incentives to put into place for the full collaboration and coordination of care in the healthcare system.     

Optimizing health care delivery by integrating workplaces, homes, and communities: how occupational and environmental medicine can serve as a vital connecting link between accountable care organizations and the patient-centered medical home

In recent years, the health care reform discussion in the United States has focused increasingly on the dual goals of cost-effective delivery and better patient outcomes. A number of new conceptual models for health care have been advanced to achieve these goals, including two that are well along in terms of practical development and implementation-the patient-centered medical home (PCMH) and accountable care organizations (ACOs). At the core of these two emerging concepts is a new emphasis on encouraging physicians, hospitals, and other health care stakeholders to work more closely together to better coordinate patient care through integrated goals and data sharing and to create team-based approaches that give a greater role to patients in health care decision-making. This approach aims to achieve better health outcomes at lower cost. The PCMH model emphasizes the central role of primary care and facilitation of partnerships between patient, physician, family, and other caregivers, and integrates this care along a spectrum that includes hospitals, specialty care, and nursing homes. Accountable care organizations make physicians and hospitals more accountable in the care system, emphasizing organizational integration and efficiencies coupled with outcome-oriented, performance-based medical strategies to improve the health of populations. The ACO model is meant to improve the value of health care services, controlling costs while improving quality as defined by outcomes, safety, and patient experience. This document urges adoption of the PCMH model and ACOs, but argues that in order for these new paradigms to succeed in the long term, all sectors with a stake in health care will need to become better aligned with them-including the employer community, which remains heavily invested in the health outcomes of millions of Americans. At present, ACOs are largely being developed as a part of the Medicare and Medicaid systems, and the PCMH model is still gathering momentum and evolving among physicians. But, the potential exists for implementation of both of these concepts across a much broader community of patients. By extending the well-conceived integrative concepts of the PCMH model and ACOs into the workforce via occupational and environmental medicine (OEM) physicians, the power of these concepts would be significantly enhanced. Occupational and environmental medicine provides a well-established infrastructure and parallel strategies that could serve as a force multiplier in achieving the fundamental goals of the PCMH model and ACOs. In this paradigm, the workplace-where millions of Americans spend a major portion of their daily lives-becomes an essential element, next to communities and homes, in an integrated system of health anchored by the PCMH and ACO concepts. To be successful, OEM physicians will need to think and work innovatively about how they can provide today's employer health services-ranging from primary care and preventive care to workers' compensation and disability management-within tomorrow's PCMH and ACO models.     

General practitioners’ views on the influence of long-term care reforms on integrated elderly care in the Netherlands: a qualitative interview study

This study explores the long-term care (LTC) reform in the Netherlands and its relation to the day-to-day integrated care for frail elderly people, from the perspective of general practitioners (GPs). We assessed GP perspectives regarding which elements of the LTC reform have promoted and hindered the provision of person-centred, integrated care for elderly people in the Netherlands. We performed case studies conducted by semi-structured interviews, using the Healthy Alliances (HALL) framework as a framework for thematic analysis. GPs reported that the ideals of the LTC reform (self-reliance) were largely achievable and listed a number of positive effects, including increased healthcare professional engagement and the improved integration of the medical and social domains through the close involvement of social support teams. The reported negative implications were a lack of co-ordination in the implementation of the reforms by the municipality, insufficient funding for multidisciplinary team meetings and the reinforced fragmentation of home care. In particular, the implementation of the system reforms took place with little regard for the local context. We suggest that the implementation of national care reforms should be aligned with factors operating at the micro level and make the following recommendations: use one central location for primary health and social services, integrate regional ICT structures to improve the exchange of patient information, and reduce fragmentation in home care.     

Achieving Population Health in Accountable Care Organizations

Although “population health” is one of the Institute for Healthcare Improvement’s Triple Aim goals, its relationship to accountable care organizations (ACOs) remains ill-defined and lacks clarity as to how the clinical delivery system intersects with the public health system.Although defining population health as “panel” management seems to be the default definition, we called for a broader “community health” definition that could improve relationships between clinical delivery and public health systems and health outcomes for communities.We discussed this broader definition and offered recommendations for linking ACOs with the public health system toward improving health for patients and their communities.WITH THE PASSAGE OF THE Affordable Care Act (ACA),1 the United States has turned its attention to improving the quality of health care while simultaneously decreasing cost. As we move toward alternative and global payment arrangements, the need to understand the epidemiology of the patient population will become imperative. Keeping this population healthy will require enhancing our capacity to assess, monitor, and prioritize lifestyle risk factors that unduly impact individual patient health outcomes. This is especially true, given that only 10% of health outcomes are a result of the medical care system, whereas from 50% to 60% are because of health behaviors.2,3 To change health behaviors, it will be necessary to engage in activities that reach beyond the clinical setting and incorporate community and public health systems.4The Institute for Healthcare Improvement (IHI), a leading not-for-profit organization dedicated to using quality improvement strategies to achieve safe and effective health care, has developed the Triple Aim initiative5 as a rubric for health care transformation. The three linked goals of the Triple Aim include improving the experience of care, improving the health of populations, and reducing per capita costs of health care.6 However, although two of the three aims–experience of care and cost reduction–are self-explanatory, there is little consensus about how to define population health. Words like “panel management,” “population medicine,” and “population health” are being used interchangeably. Berwick et al.6 describe the care of a population of patients as the responsibility of the health care system and use broad-based community health indicators as evidence of improvement. Other recent publications have attempted to describe population health from the hospital,7–10 primary care,11 and community health center perspectives.12 The “clinical view” identifies the population as those “enrolled” in the care of a specific provider, provider or hospital system, insurer, or health care delivery network (i.e., panel population).7 Alternatively, from the public health perspective,8 population is defined by the geography of a community (i.e., community population) or the membership in a category of persons that share specific attributes (e.g., populations of elderly, minority population). In either case, the context of a community and the existing social determinants of health, ranging from poverty to housing, are known to have substantial impact on individual health outcomes. Thus, ensuring the health of a population is highly dependent on addressing these social determinants and requires collaborative relationships with community institutions outside the health care setting.13,14Two key concepts that will greatly influence the definition and actualization of population health in the post-ACA era include the accountable care organization (ACO)15 and the patient-centered medical home (PCMH).16 The ACO represents an integrated strategy at the delivery system level to respond to payment reform.15 These integrated systems of care are poised to manage a population of patients under a global payment model. The PCMH is focused on transforming primary care to better deliver “patient-centered” care and to address the whole patient, including their health and social needs.17,18 Both models will need to identify, monitor, and manage their “population” of patients. However, their ability to extend their definition of population health to encompass the entire community will depend on resources, market share, and the strength and capacity of collaborating community and public health organizations. As integrated delivery systems are asked to do more than focus on their own patients, they will require additional resources. These may come from a realignment of existing programs (community benefits), a return on investment from effective preventive care, or collaborative relationships with existing community and public health organizations.In this article, we discuss two major points regarding ACOs and their approach to population health. First, ACOs should be committed to serving the health of the people in the communities from which their population is drawn, and not just the population of patients enrolled in their care to achieve the population health goal. Second, to achieve this expanded definition of population health, ACOs will need to engage in collaborative efforts with community agencies and the public health system. We describe a “community” definition of population health to be used in lieu of the “panel” definition and then outline the resources needed and strategies for collaboration. Finally, we offer recommendations to assist ACOs in realizing their population health goal.     

Accountable Care for the Poor and Underserved: Minnesota’s Hennepin Health Model

Hennepin Health provides integrated medical and social services to low-income Medicaid patients in a large county located in Minneapolis, Minnesota. Data sharing is critical to program operations along with care coordination provided by community health workers. Early evidence indicates fewer emergency department visits and increased use of outpatient primary care. By focusing on prevention, coordination, and team-based care, the county hopes to improve individuals’ quality of life while reducing costs through better care management and reductions in emergency department use.Hennepin Health represents a new model of integrated care targeted to low-income individuals with complex health and social needs—needs very similar to the Affordable Care Act Medicaid expansion population. The program is supported by enhanced data integration to better coordinate medical care with other needed social services in a capitated Accountable Care Organization (ACO) framework. The positive outcomes achieved and the ability to reinvest in the model have helped to garner political support and have motivated providers and care teams who see the opportunities to make a difference in the lives of a largely disenfranchised patient population. Hennepin Health provides an integrated care management model that other care plans can use to improve care and lower costs for the Medicaid expansion population under the Affordable Care Act.     

Key state legislative provisions on purchasing alliances

In order to function effectively in post-reform healthcare markets, behavioral healthcare professionals must understand and interact with health purchasing alliances. Healthcare reform initiatives based upon the principles of managed competition envision an important role for cooperative health purchasing organizations, or "health alliances," that collect premiums and contract with health plans for the provision of comprehensive health services delivered within the framework of a standardized benefit package. Health purchasing alliances have already been implemented in eight states, and this trend is expected to grow. The following article illustrates the structure and authority of the health alliances that are already in operation, and is presented here to give Behavioral Healthcare Tomorrow journal readers an up-to-date overview of reforming healthcare markets. This matrix arrays recent state laws which we identify as clearly including components of managed competition or purchasing alliances. Other states undoubtedly have elements of reform that include some aspects of these concepts. For example, under legislation, a Vermont health care authority was established and, among other things, charged with developing two comprehensive reform proposals, one of which will involve multipayors and the other a single-payor system. Options will likely embody many of the activities of alliances. Vermont is not included in this matrix because these provisions are still in the developmental stage.     

远程医疗:穿戴式生物医疗仪器

人口老龄化加速、人们保健意识增强等社会趋势将使得单纯的医院诊治模式逐渐转变到医院、社区、家庭与个人相结合的模式.可实现对人体非介入式、无创、连续医疗诊断的穿戴式生物医疗仪器将成为新型医疗模式下的重要诊断监护终端设备,它的广泛应用将极大地推动远程医疗和移动家庭保健系统的发展.     

公立医疗机构政府补偿与监管机制的研究框架

在补偿机制扭曲、政府监管滞后的背景下,科学设定公立医疗机构政府补偿标准和方式,改进政府监管手段和能力对保障公立医疗机构公益性具有重要意义。上海市闵行区开展了基于公益性绩效的政府补偿机制改革和基于信息平台的政府监管机制改革。文章以新公共行政理论为指导,总结闵行区政府补偿和监管机制的特点,评价改革的效果,并且探索分析补偿和监管机制改革对医疗机构运行绩效的影响,为深化公立医院改革提供决策参考。