Becker's Hospital Review

24 Clinical Integration & ACOs Health systems also have to reduce their obsessions with "programs" to suc- ceed in population health. Instead, they must get better at partnering with community organizations and nonprofits. As illustrated by Dr. Dinger's Venn diagram, health systems cannot improve health outcomes by themselves. Yet some still attempt to act as autonomously as they can, ignoring a wealth of expertise and resources. "When we talk to other population health managers, they have unearthed a number of unique challenges inside their populations, such as domestic vio- lence, elder abuse and other public health crises. Unfortunately, most respond by trying to implement their own unique program to respond to the issue," says Dr. Dinger. "We usually encourage them to first speak with the experts in their community who work on these issues every day. In many cases these are nonprofit organizations that can add great value to the population health effort but often have trouble engaging and integrating with a health system's efforts." In a qualitative study published in the Journal of the American Medical As- sociation and the British Medical Journal this spring, Dr. Casalino and his colleagues suggested that the narrow, ACO-centric definition of population health could lead ACOs to wrongly conclude they are addressing all aspects of population health and therefore do not need to form relationships with public health agencies. It's true that hospitals today are expected to do more with less, but by work- ing under a narrow understanding of population health, hospitals may per- petuate this expectation more than necessary. Population health does not lie on health systems' shoulders. By partnering with nonprofits, public health agencies and other organizations, health systems can play into their own strengths and benefit from the expertise and contributions of others. Finding space to innovate Fee-for-service is still the predominant payment model in healthcare, but some health systems have an easier time pursuing population health under this pay model than others. What sets them apart? First, population health pioneers have found ways to innovate around tra- ditional reimbursement. MissionPoint's physicians work under a modified capitated agreement, which has left the ACO with more flexibility to experi- ment with care delivery. Dr. Dinger says MissionPoint empowers pediatric groups to launch a fast-track system that treats patients who do not have ap- pointments, for instance. People and their children can be seen in 30 minutes or less by a nurse practitioner, who also reserves time in the appointment for parent or guardian education. "When you're getting monthly amounts for patients, your cash flow is smoother, and you can start innovating because you know what cash is com- ing in next month," says Dr. Dinger. "Many can now afford to do that, but in fee-for-service world they were unable to." MissionPoint also sees the value in taking on extra upfront costs for patients to reduce their healthcare costs down the line. The ACO doesn't know exactly when or where it will see that ROI, but this is all part of bearing risk. Mission- Point pays for certain memberships to The YMCA, for example. "We know that being able to help people develop healthy active living habits is crucial to some people in our population," says Dr. Dinger. "If we can get them to go to the Y, we'll save money elsewhere to offset the cost of the Y membership. By providing more support services, we're able to improve a member's health status and prevent their costs from escalating." Aside from the strategic complexity of population health, health systems must also overcome a workforce and staffing problem. Nearly 60 percent of health system and hospital CEOs ranked population health as the "hardest" skill set to find within the broader healthcare field, according to an American Hospi- tal Association survey. Further, 48 percent of executives identified community and population health management as a talent gap within their organizations, making it the second-largest talent gap recorded after experience in leading nontraditional health partnerships, which is closely related (54 percent). Conclusion ACOs are still in their early days, and now is the time for health system lead- ers to move their organizations in the right direction by clarifying their ACOs' responsibilities, defining their role in improving health for the greater community and establishing a willingness to partner with organizations that fall outside of the healthcare bubble. For as much as we hear it and read about it, population health is not a health- care-specific concept. It is something to be shared between public health agencies, social institutions and policymakers. Hospitals fit in there some- where. We shouldn't expect too much too soon, but hospital leaders need to start defining what their organizations can do in the broader picture of population health and explore opportunities that have, for years, gone un- touched. n What Are the Most Expensive Cities for Primary Care? By Dani Gordon I n Dallas, a patient can pay up to 23 times more than necessary for a lipid panel, according to a recent study by Castlight Health, a lead- ing provider of enterprise healthcare cloud software. Examining the cost of common outpatient services in different cities, the Castlight Health study illuminates the wide range of primary care costs across the United States. Something as simple as a preventative primary care visit can be extraor- dinarily expensive even within an insurance-approved network. According to Castlight Health, the top 15 cities with the most expensive primary care visits based on the average price per visit are as follows: 1. San Francisco — $251 2. Sacramento, Calif. — $219 3. Portland, Ore. — $216 4. Minneapolis — $209 5. Charlotte, N.C. — $199 6. Boston — $193 7. Seattle — $189 8. Chicago — $165 9. Atlanta — $147 10. San Diego — $145 11. Dallas — $141 12. Washington, D.C. — $141 13. St. Louis — $140 14. Detroit — $139 15. Pittsburgh — $139 The average was calculated by Castlight Health using a series of data including medical claims data, publicly available data, provider infor- mation and actual provider rate sheets that list the negotiated price be- tween a provider and an insurer. n

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