As “value-based ”and “accountable care” healthcare models proliferate across the country, primary care physicians are feeling mounting pressures from new requirements to demonstrate improved patient health outcomes. No doubt providers feel like they are swimming against the tide as their responsibility for health outcomes increases. Treatment provided to patients with chronic diseases accounts for 75 percent of the nation’s healthcare spending, while two-thirds of the increase in healthcare spending is due to increased prevalence of treated chronic disease. It’s not surprising that population health management is getting so much attention these days.

Here are a few more alarming facts about chronic disease in the United States according to the Partnership to Fight Chronic Disease:

  • Chronic diseases are the No. 1 cause of death and disability in the U.S.
  • The doubling of obesity between 1987 and today accounts for 20 to 30 percent of the rise in healthcare spending
  • The vast majority of cases of chronic disease could be better prevented or managed
  • Many Americans are unaware of the extent to which chronic diseases could be better prevented or managed
  • Eight out of ten seniors has at least one chronic condition

According to “The State of Aging and Health in America,” a 2013 special report from the U.S. Centers for Disease Control and Prevention (CDC), by 2030, one in five Americans will be a senior citizen, nearly double the 12 percent in 2000. With eight out of ten seniors having at least one chronic condition, it’s no wonder that healthcare utilization and costs among seniors are at an all-time high. Often, doctors’ visits are sporadic and infrequent, so health problems are not addressed until the patient is in crisis or suffers irreversible damage. That’s one reason why automated, proactive patient engagement is so important. It’s the first step toward intervention to break the vicious cycle of patient self-neglect. NextGen® Population Health (NextGen PH) is fully integrated with NextGen® Ambulatory EHR, NextGen® Practice Management (NextGen PM), NextGen® Patient Portal and NextGen® Dashboard.  Using a stratified approach, practices can program automated alerts for a targeted group of patients.  As these patients schedule appointments, all encounters are documented and tracked in your EHR, from which you can generate quality reports as needed.

Improving, Tracking and Reporting Health Outcomes

As the onus for managing, improving, and reporting on patient health outcomes shifts to providers, particularly primary care physicians, your proficiency tracking and reporting these outcomes to the appropriate quality organizations will ultimately impact how, when, and how much you get paid. But here’s the catch; even if your patients do not follow their recommended treatment (more commonly referred to as patient “non-compliance” and medication “non-adherence”) as their provider, you are still responsible for improving patient health outcomes according to the value-based care model.

“Whose Life is it Anyway?”

So who is truly responsible for the patient’s health?…the doctor or the patient? or…perhaps it’s the “system.” Herein lies the dilemma. It’s tempting to question why some patients do not take better care of themselves.  However, there are multiple socio-economic and demographic factors at play that impact patient behavior, far too complex to address in this blog. One of NextGen Healthcare’s clients who is using NextGen Population Health, offered some valuable insight that I hadn’t considered. He said, “Chronically ill patients are truly suffering. Imagine what it feels like to be sick all the time, to feel tired, chronically weak and in pain. Imagine spending more time in the doctor’s office and hospital than doing the things you enjoy with friends and family, not to mention the emotional and economic strain associated with being sick all the time.”

So rather than ask who is responsible, we should ask, what should we, as a healthcare community, be doing? The answer is¾ exactly what we are doing.  Healthcare is moving in the right direction as we collaboratively evolve toward medical homes, accountable care organizations, care coordination, and a whole new way of engaging patients to be part of the solution instead of the problem.

To learn more about NextGen Population Health,check out our latest Population Health demo and much more.