How Population Health is Making Strides in Maryland

The state's all-payer global budget model is helping hospitals justify investments to reduce avoidable utilization. Leadership from LifebridgeHealth's Sinai Hospital is in the forefront.

For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the message was lost.
For want of a message the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail. —Ancient Proverb

As the proverb says, minor actions can result in major consequences. Amy Perry, president of Sinai Hospital and executive vice president at LifeBridge Health in Baltimore can testify to its wisdom.

For want of a stove, a diabetic was unable to prepare proper meals. For want of a proper meal, this diabetic experienced problems that worsened her health. For lack of a ride to the doctor's office, this diabetic was unable to secure a regular supply of insulin. For lack of a regular supply of insulin, she frequently visited Sinai's emergency room, generating thousands in healthcare costs.

Population Health Challenges HIT, Quality Leaders

Since she's been enrolled in Sinai's revised community outreach program, which began in this year, she hasn't seen the inside of an emergency department.

"In this case, we have a center for health and active aging, and we were able to connect them with her so she could learn how to prepare healthy meals. We found a community organization that paid for a stove," Perry says. "Things like that can make an enormous impact. She has not been readmitted since enrollment and she [had been] near the top of our frequent utilizer group."

Though not a perfect analogy to the ancient proverb, Perry says many frequent visitors to her 504-bed hospital's ED could tell variations of the same story.

But things are changing. Part of the reason why is Maryland's unique approach to try to get healthcare organizations to integrate population health strategies that keep people healthy and away from expensive, avoidable utilization.

Because of the way LifeBridge Health and other health systems in the state are paid, they can quickly ramp up population health activities that range far afield of inpatient care. Unlike other payment systems that still feature a mishmash of contracts and difficult-to-decipher incentives and disincentives, the ROI for such work is abundantly clear.

'Global Budget Revenue'
Your organization has a budget determined at the beginning of the year. Revenue is already known. To the extent you can keep people healthy and away from the most expensive treatments and utilization, the bigger your margin. Simple.

"Our new agreement with the state at the beginning of this year, which we call 'global budget revenue,' is essentially a cap on the dollars they give to the health system, which accelerated our effort to reduce avoidable utilization," says Perry.

"So when we were looking at what we could do with population health, we wanted to start with reducing the health disparities in the communities we serve."

Maryland has long been an outlier in healthcare. For 36 years, the state operated under a Medicare waiver that allowed it to operate the nation's only all-payer hospital rate regulation system. Essentially, it allowed Maryland to set rates for hospital services, and all third-party purchasers paid the same rate.

But the state changed the system significantly in 2014, as CMS and the state announced a new "all-payer model" to better help hospitals make the transition toward management of the health of populations.

Essentially it requires the state, over a five-year period, to move away from its statutory waiver in exchange for a new "innovation center" model. In practice, it's essentially using a formula to determine hospitals' revenue from the beginning of the year, rather than tallying it at the end.

Capitation
The new model requires the state to limit its annual hospital cost growth to the 10-year growth rate of the state's gross product (kind of like state GDP, in economics terminology). If the state fails at this metric, it will have to transition back to the national Medicare payment systems.

"The state is really providing an accelerated way for our hospitals to engage in these kinds of proactive wellness programs and helping us bridge the financial challenge of moving from fee-for-service," she says.

And Perry couldn't be more excited about the jolt it's given to the organization's population health initiative, particularly its community outreach activities, which brings us back to the stove, and how Sinai's new care team even figured out that it was a problem.

Perry says the postal zip code where the hospital is domiciled was a great place to start, because of the health disparities within it.

"Our zip code, 21215, has a much lower life expectancy than its surrounding neighborhoods," she says. "With our goal of reducing health disparities, we looked at what resources we had and what we could develop to help us improve the health of the entire community."

So began an intensive effort on the 60 blocks or so that is commonly referred to as the Park Heights community. Perry says Sinai mapped out transit systems, youth services, employment, housing and community development, social services and religious organizations, and looked at movement patters of people who lived in those neighborhoods.

Building a Network
The broad goal is eventually to create a social services network that will consist of people who don't necessarily have clinical skills, but who can help provide support, even if it's transporting a patient to an appointment.

As part of the program, the hospital hired 22 outreach workers who keep in regular contact with high utilizers to make sure they are getting what they need in follow-up care. The program started with a diabetes outreach group that helps with education, insulin access, and yes, stoves and other household impediments to proper management of this chronic condition.

One of the largest untapped resources was houses of worship. There were 67 of those in the immediate area. In addition to the outreach workers, the hospital has also created an "ambassador" program for religious organizations and the hospital's employees who live in 21215 to help build trust, and integrate the hospital into the community's social services network.

"This is absolutely a grass roots engagement and that's one reason it moves slowly," Perry says. "We need to develop trust to make progress, and we are leading it with funds, infrastructure, and data, but if it's going to be successful, it needs an organic component where our neighbors will see the benefit of participating."

Some Quick Wins
Identifying the critical needs of the community based on health indicators helped the outreach team decide where it could make the most impact the most quickly.

"Getting that baseline info helped us target key health issues in our neighborhood and helped us make an early impact," Perry says.

The first initiative was a diabetes medical home extender program. The hospital sends coaches to people who are willing and who are frequent ED visitors because their diabetes is not well controlled. With home visits and phone follow-ups, trained outreach workers can identify other social pressures that are causing noncompliance and help solve them.

The woman with the stove problem, not surprisingly, had many other impediments to good diabetes management. She was on limited income, on disability, and had no sense of how to prepare healthy meals. She was given taxi vouchers to help travel to follow-up appointments, and Sinai was able to set her up with a primary care physician, who can help ensure regular insulin access.

The program is so new that Perry won't have outcomes data for another six months or so, but the anecdotal evidence that a significant difference is being made is compelling.

"Addressing these things can make an enormous impact," says Perry. "It shows what you can do when you get out into the community and leave our campus. That's really what population health is, and it's very rewarding to make a difference in people's lives."