MARCH 5, 2018

Advancing Quality

It’s said that strong lions survive by focusing on taking down large prey, like antelope. The weaker lions don’t survive because they spend significant time and energy hunting smaller animals. These weaker lions aren’t able to take down enough small prey to sustain themselves.

Anthem, Inc. and its affiliated Medicare health plans advise healthcare professionals we collaborate with to take a similar approach when implementing value-based population health management. We remind them not to get distracted by the smaller prey but, instead, proactively focus on the three antelopes that will lead to success: 1) identify and document burden of illness, 2) close all known care gaps, and 3) allocate resources to reduce avoidable treatment and lower cost of unavoidable treatment.

Identify and document burden of illness. Healthcare professionals must proactively know the burden of illness for their patients in order to effectively implement population health management. However, according to a Health Affairs article, only 53 percent of seniors in Medicare HMO plans receive a comprehensive wellness assessment in any given year. This is a missed opportunity for providers. Information obtained in these assessments related to medical, behavioral, social, and economic determinants of health is critical in improving a patient’s health outcome.

For example, spending the extra time with a diabetic to check the circulation and sensation in their feet can potentially avoid amputation and the patient eventually asking, “Wasn’t there a way to prevent this?” Conducting a complete diabetic assessment will also help avoid the significant costs associated with treating complications from uncontrolled diabetes.

Close all known care gaps. Johann Wolfgang von Goethe said, “Knowing is not enough; we must apply. Willing is not enough, we must do.” This quote is most relevant in regards to care gaps in the context of population health. When providers identify a patient’s burden of illness, they must work with the patient to design a care plan that manages and monitors their health condition and leads to better outcomes.

As an example, not knowing how many patients have hypertension is a care gap. Not following up with patients to ensure they are taking prescribed medications appropriately is a care gap. Not knowing if a hypertensive patient is controlling their blood pressure with the prescribed treatment regimen is a care gap. Closing care gaps such as these will further a provider’s commitment in delivering quality care and result in better patient health.

Allocate resources to reduce avoidable treatment and lower cost of unavoidable treatment. It’s generally accepted that 20 percent of a provider’s patient population is responsible for roughly 80 percent of a practice’s total care costs. Any effort to lower costs must address how treatment is delivered to this relatively small population while maintaining high-quality care. It may be the case that some of these high costs are due to avoidable poor health outcomes.

It could be the diabetic who is uncontrolled on conventional therapy or the medicated individual with persistent high blood pressure. The unique relationship that should exist between a patient and their healthcare provider can be of great value in these situations. It should help the provider understand the patient’s health goals and develop a care plan that meets the patient’s needs, while implementing the appropriate level of care.

When my own mother was in the late stages of advanced lung cancer, she found herself in an acute inpatient bed as a team of clinicians – myself included – contemplated extensive and costly treatment options. That is until her oncologist – a subject matter expert with superb patient engagement skills – outlined her condition, explained the available evidence-based treatment options, and discussed the benefits and detriments of those options. By engaging with her oncologist, my mother made the informed decision she believed was right for her. She spent her remaining days in the comfort of her home – in peace – under hospice care.

Throughout our experience with collaborating providers, Anthem and its affiliated Medicare health plans know firsthand that the transition to value-based population health management does not happen overnight. These three antelopes will help everyone involved stay focused on moving the organization in the right direction as quickly and efficiently as possible.

Michael Vincent Smith, MD is a Regional Vice President and Medical Director of Central Region Medicare at Anthem, Inc. Dr. Smith currently oversees Medical Management, Quality Management and Population Health Management for Anthem’s Medicare Advantage, Medicare Supplement and Medicare Part D Plan membership in Indiana, Ohio, Wisconsin, Kentucky, Missouri, Tennessee and Georgia. Dr. Smith is a board-certified cardiovascular and thoracic surgeon and former Chief of Cardiovascular Surgery and Vice-Chairman of Surgery of an academic medical center in Atlanta where he founded the first bloodless cardiac surgery program in Georgia. As the Director of a Cancer Center he also started the first lung cancer early detection program in the same state.