Walgreens model takes aim at population health

How can health systems simultaneously improve population health and patient satisfaction, yet reduce per capita costs - the three goals of the “Triple Aim”?

The Institute for Healthcare Improvement, a nonprofit center based in Cambridge, Mass., has been working on this question with organizations around the world since 2008, when Don Berwick, former president and CEO of the Institute, and his colleagues first introduced the Triple Aim concept.

At a population level, the Institute has encouraged organizations to explore interventions such as the promotion of greater use of primary care, enhanced communication between doctors and patients through e-mail correspondence, and self-management of disease. Some organizations have tried a targeted approach, going after specific groups of patients with limited means, those without insurance, or those who have chronic medical conditions.

However, health-system success may require both population strategies and more targeted strategies at the individual level, according to Ian Duncan, vice president, clinical outcomes and analytics, Walgreens. Duncan and his former Walgreens’ colleague, Geraint Lewis, outlined a new approach for health systems trying to achieve the Triple Aim in their article, “How health systems could avert ‘Triple Fail’ events that are harmful, are costly, and result in poor patient satisfaction,” in the April issue of Health Affairs.

The Walgreens executives suggest that a stratified approach should be used to identify subpopulations of patients who are at risk of health events - described as “triple fail” events - and who could possibly benefit from preventive measures. A triple fail event is defined as a suboptimal health outcome that is too expensive and results in patient dissatisfaction. Some examples include unplanned hospital readmission within 30 days, untimely nursing home admission, and overmedicalization at the end of life.

While many organizations have relied on predictive modeling to identify individuals at high risk for one of these events, they have not stratified the population to determine which subset of patients to put their resources behind. A stratified approach not only identifies individuals who are at high risk; it identifies those who represent an opportunity for improved care and lowered healthcare costs, Duncan said.

“Our findings suggest that if [health systems] expand their thinking around how to classify patients in order to take a more predictive approach aimed at preventing triple fail events before they occur, the potential benefits for all stakeholders would be significant,” said Duncan. “Ultimately, this model could become a model for how to address population health and how to help meet the needs of patients, health systems, payers, and providers.”

How to begin

Accountable care organizations (ACOs) are in a good position to employ the stratified approach, because they are responsible for the health of a specific population and have access to historical data to determine which individuals are at high risk for different triple fail events, Duncan explained.

The process would begin with the ACO’s analysis of patient data from electronic health records, medical claims, and pharmacy claims, in order to identify the high-risk pool of patients. The ACO then would estimate the likelihood that patients would benefit from specific preventive measures and assign patients to programs if they are good candidates.

“It is a very straightforward process to find that subgroup which is not compliant and in which you might be able to change behavior,” said Duncan. 

How to help the Triple Aim

With the introduction of its WellTransitions program last October, Walgreens is able to help health systems reduce hospital readmission rates and overall healthcare costs, and to improve patient health outcomes and medication adherence, Duncan said.

“It all begins with the identification of that subset of patients who are likely to have beneficial outcomes,” he continued. “At the time of hospital admission, pharmacists would perform a medication reconciliation, and at discharge, all patients would get their medication delivered to the bedside. For the subset of high-risk patients, they would also be followed up once they get back into the community by their primary care physician or a pharmacist.” 

Implementation of a stratified approach within an ACO does have challenges - the largest one being a change in mindset. For example, physicians have been trained to save lives at all cost. Yet end-of-life care often involves overmedicalization, Duncan said.

“It is difficult and challenging to design a program that is sympathetic to the patient’s needs and their families’ needs, and ethically sensitive to all the issues that you need to take into account, but which you know will improve the Triple Aim,” he said.

The stratified approach, however, can be a real game-changer for ACOs, helping them to focus on not just closing gaps in care, but by focusing on high-risk patients who will benefit from additional preventive care, he concluded.