Balancing Act: How Population Health Impacts Individuals

Physicians and health experts weigh in on the Affordable Care Act's emphasis on population-based care.

Brands and marketers are masters at mass customization. Companies are increasingly adept at delivering personalized messages at scale via automated systems and other technology. In healthcare, the push for mass customization is far more complicated. As patients, we expect our doctors to provide individualized care but the debate continues on how to provide as many patients as possible with the most effective treatments and services.

Under the Affordable Care Act, physicians' and hospitals' payments are increasingly tied to quality standards in an effort to improve patient outcomes while reducing costs. But are the individual needs of patients being undermined by a focus on meeting population-based quality metrics?

"Contracts for medical care that incorporate 'pay for performance' direct physicians to meet strict metrics for testing and treatment," write Pamela Hartzband and Jerome Groopman, physicians on the faculty of Harvard Medical School, in an op-ed published in The New York Times. "These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice."

By rewarding physicians for meeting testing and treatment metrics, Hartzband and Groopman argue, there is a risk that doctors will focus on goals that are not necessarily in the patient's best interest. For example, doctors are "rewarded for keeping their patients' cholesterol and blood pressure below certain target levels. For some patients, this is good medicine, but for others the benefits may not outweigh the risks," they note. Hartzband and Groopman did not immediately respond to a request for comments at the time of publication.

Other doctors acknowledged the potential downside of a pay-for-performance model, but argued the benefits outweigh the disadvantages.

"Quality metrics is an extremely positive trend in healthcare, but no trend is perfect," notes Dr. Jonathan P. Weiner, professor of health policy and management at Johns Hopkins University. "As we have more monitoring, sometimes people have to jump through more hoops and sometimes they don't get the services as quickly as they should."

Under the fee-for-services model, patients may have had easier access to tests and services, Weiner adds, but it led to a wasteful system in which doctors often ordered unnecessary services. The advantage of a pay-for-performance model that uses population health metrics is "it tries to balance efficiency with access, although it's a delicate process," he says.

Additionally, there is a misconception that population health is a "one-size-fits all approach, when in fact, population health is really based on doing the right thing based upon evidence," says Dr. Harry Greenspun, director of the Center for Health Solutions at Deloitte. The more information providers and hospitals have about patient outcomes increases their ability to provide more accurate treatments and services. Weiner agrees. "If I have a choice between well-done quality metrics, or just the doctor's judgment, I'll take the well-done guidelines," he says. "But no guidelines are perfect, and a combination of well-done guidelines and the doctor's judgment is superior to a doctor's judgment by itself."

Implementing quality-based metrics was already occurring in healthcare before the ACA brought it to the forefront, notes Dr. Timothy Carey, an active clinician and director of the Cecil Sheps Center for Health Services Research in the University of North Carolina. But even as the ACA accelerates the move toward quality-based incentives, the impact has been minimal, he says.

"In terms of patients who need specialized care in my own practice, I have not seen all that much difference yet," Carey comments. "We're seeing a somewhat greater need for pre-authorizations, but has it gotten in the way of patient care? Not that much."

At the same time, formularies (lists of medications that are approved by insurance policies to be prescribed) are becoming "more restrictive as part of the negotiations between payers, pharmaceutical companies, and the delivery systems," Carey adds. "Where we used to have three or four drug options, it's often down to one or two and that leads to more time on the phone with the payer or pharmacy intermediary, which increases providers' overhead."

One example is the tug-of-war that is taking place over new hepatitis C drugs that come with hefty price tags. Gilead Sciences developed two hepatitis C drugs, Harvoni and Sovaldi, and priced them at $95,500 and $84,000, respectively. The drugmaker's rival, AbbVie, then struck a deal with pharmacy benefit managerExpress Scripts to offer its own hepatitis C treatment, Viekira Pak, at a slight discount to Express Scripts members. The catch is that Viekira is the only hepatitis C treatment that can be offered to Express Script members.Gilead Sciences reportedly struck a similar deal with CVS Health.

The hepatitis C drugs are "causing sticker shock to every payer," Carey notes and forces him to "work out ways to negotiate with the payers so we can actually get the right drugs to the patients that need them most."

But Carey is optimistic that drug costs will be manageable. "If we're going to be a market-based economy, there are two sides to the market," he notes "and we're beginning to see consumers, both patients and healthcare systems, push back against high charges for some of these specialized treatments."

Carey also disagrees with the argument that incentives to meet general quality metrics put the specialized needs of patients at risk. "Studies have shown that giving providers appropriate prompts and reminders benefits patients," he says. "And reminders to check what proportion of my patients' blood pressure and diabetes is under adequate control and who has had a colorectal screening are good reminders."

Additionally, he acknowledges that physicians receive a bonus for meeting these requirements, but notes that it is a physician's job to ensure that each patient receives the necessary care to ensure the best possible outcome. Ultimately, "many guidelines are just that-guides-and are not hard and fast rules," says Carey. "And it's not as if I've felt the hot breath of regulation breathing down my neck."

Aggregating and analyzing more patient data through population health measurements is also important for generating insights that can be applied to subsets of patients by disease, gender, age or other categories, Carey adds. However, numerous challenges remain before providers can leverage insights from aggregated patient data. One problem is the uneven adoption of electronic health records (EHR). Even though the Centers for Medicare and Medicaid Services has offered nearly $27 billion in EHR incentive payments, nearly two-thirds of doctors have complained of poor functionality and high costs in digitizing patient records, according to a survey conducted by marketing and research firm MPI Group andMedical Economics.

Balancing patient demands with appropriate care is another challenge, notes Greenspun. "The customer is always right in retail, but not necessarily in healthcare," he says. "There's a fine line between giving people what they want and helping them understand what the better choices are for them." Greenspun points to cancer therapy as an example. Whereas one patient might prefer an aggressive procedure that treats the cancer, someone else might prioritize quality of life with less medical intervention. "It's still a struggle to create a system that balances individual choices and effective treatments," he says.

However, Greenspun is bullish that a paid-for-performance model and population health measurements will "open the door to innovation." On the surface, "we're dealing with population data, butother industries have been successful at the mass customization of approaches and healthcare can learn a lot from these industries," he says. "I think we'll see some interesting things in healthcare in the coming years."