Population Health News: How does population health integrate with accountable care?
Katherine Schneider: My motto is that ACOs are all about the “C” part of the acronym. If we don’t change the care model at an individual level, then we will not achieve improvements in outcomes, which include the health of a population, the care experience and smarter spending. I also view population health as a set of tools that we are integrating into the delivery system for data-driven quality improvement and care coordination. It is a viewpoint that expands beyond the four walls and timespan of a provider visit to include what happens to/for/by people 24/7, 365 days of the year regardless of where they are.
Population Health News: How do you embed chronic disease management in a delivery system?
Katherine Schneider: While I get annoyed when people say it’s all about the incentives, it certainly is a foundational prerequisite to have meaningful incentives aligned with better chronic disease care processes and outcomes. But you also have to teach providers new skills and give them tools. I like to use the analogy of surgeons learning to use laparoscopes decades ago. Last but not least, you need to address what should be embedded directly in a delivery system. Successful “embedding” really means transformative disruption of historical workflows of clinical practice, such as redistributing tasks to multidisciplinary teams working at the maximal scopes of their licenses. If this level of change is required of clinicians, then ensure that the rest of the system is also expected to change to support better outcomes (i.e., benefit designs which promote adherence to chronic disease self management rather than the other way around). Ultimately, we need to make doing the right thing the easiest default choice for care teams and patients. We still have a lot of work to do.