The second half of our conversation with Christopher Stanley, M.D., MBA, the president of Henry Ford Health's Populance and the newest member of the Managed Healthcare Executive editorial advisory board.
Second of two parts
Christopher Stanley, M.D., MBA, president of Populance, a population health subsidiary of Henry Ford Health, a health system headquartered in Detroit, has joined the Managed Healthcare Executive editorial advisory board. Stanley has more than 30 years of experience in healthcare leadership, including population health positions at Sutter Health and the Catholic Health Initiatives. He is a former Army major and was trained as a pediatrician.
You can find the first part of our conversation with Stanley
This transcript has been edited for clarity and length.
Let’s turn to Populance, which, as I understand it, is a wholly owned subsidiary of Henry Ford Health. It seems to have grown out of the health plan that Henry Ford has, Healthcare Alliance Plan [now branded as Health Alliance Plan by Henry Ford Health], but why a separate entity here? You could be the population health chief for Henry Ford and be talking about care coordination and all that good stuff. But maybe what's different here is that Populance is set up as a separate entity.
That's a big unique driver, and it was very purposeful.
I was recruited after they had already decided that they were going to be forming a company, so I can't take too much credit for it. But I would say my experience at Catholic Health Initiatives and Sutter is that trying to do it inside of a larger organization, or inside of a division, a department or an area like the health plan side, is kind of like the treadmill turning up faster and faster as you're trying to run. It's hard to get a whole lot of traction because if you're doing it under the auspices of the health plan, the provider side, the physician side, says, "Well, I don't need to listen to you,” or “I don't agree with that model, because you're just doing this for the health plan.”
Similarly, if you're doing it under the department of the physician side, the health plan would say, "Well, doctors don't know anything about managing utilization. They just overuse and overspend,” right?
I knew from my experience; it would be very beneficial to have a separate legal entity with our own board and our own leadership team and that we have customers. Our customers are with the health plan and with the provider side; we're equally there to serve both of them, so we're not seen as the enemy on either side.
Another big reason — a huge value — is when we think data analytics and all of the appropriate safeguards from HIPAA [Health Insurance Portability and Accountability Act] and other regulations regarding privacy, health plans have a particular view and access. Providers have another access, but typically, they cannot and should not be able to see each other's information for various reasons.
We, by being a separate independent entity, can serve as Switzerland, so we can actually get claims information from a health plan because they're our customers, [as well as] the full clinical information from the provider side. We can mix them together for a full, 360-degree view of the patient. We still have certain safeguards on what information we can share back, but it actually has opened up a huge opportunity for information, insights and services that we provide as well, because we do have that level of independence.
The last piece, or one additional piece, anyway, is that we are able to move with a speed and a nimbleness that would be unheard of on a large provider side of the organization. They take months and years and 20 different committees to make a simple decision. The plan does, too. We can actually do things in a month or two that may take them a year or two to do on their side.
How many customers do you have? If I'm understanding correctly, you're set up as an entity by Henry Ford, but you're supposed to be working beyond the Henry Ford system, right?
I'll be very transparent with you on this. We really only have two contracted customers: our provider side — the clinically integrated network side of the organization — and our health plan. We have provided some work with other external provider organizations in the state, but we don't have any ongoing customers beyond that.
There are various reasons for that. We started off with certain assumptions, but it has been more challenging [and] complex to serve our internal customers than we expected.
We also didn’t know when we first started up Populance that the Ascension southeast Michigan medical groups and hospitals were going to be coming into Henry Ford Health. We’ve roughly doubled the size and maybe tripled the complexity of our provider side. Our health plan roughly doubled in size as well. So even though the customer number has not increased, the complexity and the work have really, really increased.
We've made the conscious decision to primarily focus over the next one to three years on our internal customers and then maybe start to go more external.
So that was a change. The original vision was to be out there, corralling customers.
That's a pretty new pivot for us — I would say over the past several months. So that may be different than what's been out there in my public statements. But again, it's a conscious strategic pivot … because of how much we have grown within our system.
In plainer English, Henry Ford has gotten bigger, so it seems like you have enough on your plate just dealing with the internal customers.
Very well stated. Yes, exactly.
Are you concerned that that’s viewed as a setback, that you had this ambition of being out there gathering customers and then pivoted back to the home team?
Very fair question. My quick answer is I'm not concerned about it. The reason is [because] Populance and Henry Ford Health never got into this to build a rapidly large business and then sell it off. We were always doing this to try to provide more benefit to the communities we serve, and we're doing this now in a different way because when we first started, as I shared with you, we didn't expect to double the size of our hospitals. We're still meeting our mission. We're just doing it through a different … path. We're increasing the number of people we're managing [and] serving and improving their lives. We're just able to do that now through our more direct family. At some point in the future, we'll probably be maximizing that and may very well be ready to do it with others.
What is the number on the attributed patients?
As of January 2027, it is going to be roughly around a million. It's a sizable number of patients.
Could you explain the relationship between the ACOs [accountable care organizations], Henry Ford and Ascension, and what Populance is doing? ACOs have one of the main vehicles for population-based health.
Legally, in our family, there are three ACOs as defined by a Medicare-based contract, in some of those advanced payment models: Henry Ford Health now has Mosaic ACO; St. John Providence ACO; and Genesys ACO. The contractual terms, what models they are in are all slightly different and have their own complexities. All of them, though, do have downside financial risk, so they're more advanced ACOs.
From a population point of view … the activities and services to manage an ACO population are largely the same as what we're doing for our commercial populations, for Medicaid, Medicare Advantage and even some direct-to-employer programs. We use our ambulatory care management capabilities within Populance for ACO patients, CIN [clinically integrated network] patients, Health Alliance Plan patients. It's essentially the same capabilities that we deploy for each one of those.
Understandably, in an ACO population and Medicare Advantage, we are dealing with older, more chronically ill patients that, therefore, need post-acute management — SNFs [skilled nursing facilities] and other kinds of care — so that is more important for that population than a younger population.
How those services are deployed may look different, but we count all of that into the roughly 1 million managed members as of January 2027.
Population health — you mention it in the same breath as value-based care. They are generally seen as one supporting the other. In rough terms, rather than thinking about individual patients, you start to think about populations, and there's an emphasis on prevention, partly because the payment for value-based care is supposed to work on a capitated basis at some level. It's care management and prevention and coordination of care, all this good stuff, with a little social determinants of health thrown in for good measure. But those ideas have been around for more than 10 years. So how are you seeing this notion of population health changing? Or is it just that it was such a lofty aspiration that it’s not the ideas that need changing; it's just trying to get to them and realiz[e] them?
I think most of my time — and most of the industry’s time — is spent on how to operationalize it in a sustainable way: the services, the components and the funding to achieve the quintuple aim as defining population health. I don't think there's been, to a large degree, any refinement, significant shifts or changes of population health as a concept. Frankly, pretty much everybody … sort of agrees with the triple and quintuple aim. Their language may vary a little bit or change here or there, but everybody sort of agrees to it.
The challenge is how we pivot … from a payment model and operations that are primarily set up around “the more activity you do, the more you get paid, and the better you do, too” — not the other end of the extreme of just value-based payment models or alternative payment models, but [to] that middle space. That's where most of Populance, most of my time and, I think, most of the industry is trying to balance, based on their geography or their strategy as a system.
Capitation is the far end of the spectrum. But we're in a lot of other alternative payment models, from pay for performance to up[side] and downside risk still on a fee-for-service chassis — the LAN [Health Care Payment Learning and Action Network] 2, 3, 4 framework. What are the right services and the right scale of services in each one of those steps? How do we run them on a day-to-day basis? And how does it best get incorporated into care delivery models in primary care and hospitals and health systems?
Henry Ford is very committed to that journey and to that destination, whereas some other organizations are saying, "Well, we've tried it, but we're losing money,” or "We don't really have it. We're not fully into it, so we're going to … back up and just stay in fee-for-service."
We're committed because we think that's the right thing to do for the community, and we're long-standing in our community.
The question really is more about the gradation. Do we spend a million dollars or $100,000 or $10 million on this type of activity or suite of services of the activity? Is it generating the outcomes that we want? Because it's very easy to do conceptually great things, but if you're not generating the output, the results, the readmission reductions, then it's not dollars well spent, and you need to use those dollars in a different way.
You're still in relatively early days at Populance. Are there some successes that are informing what you're going to do in the months and days ahead?
I'll give you at least a couple examples.
One of the reasons why we even formed or felt the need to form the company is [because] we were performing many of these activities in a highly distributed and variable way across our system. In Dr. Stanley's practice, we may have a care manager, and on the health plan, we had a care manager, and at our hospital, we had a care manager, and in this geography, we had a care manager — [all] using different tools [and] different processes. Sometimes those people were all contacting the same patient. It was very disjointed. In our first six months, when we brought everybody onto the same team, we started doing things the same way — the same tools, the same data — so we could collect the data, [and] we were able to roughly double the number of people we were contacting for activities with the very same number of staff because we weren't duplicating and triplicating efforts. And importantly, for us internally, we could also now measure all of that because it was a single methodology.
Our approach was not to say we're going to downsize or … get rid of care managers. We just increased the number of people we were able to contact with that number of care managers.
A more recent example would be because we now have data, information [and] insights, and because we have tools and processes in place, we identified that musculoskeletal issues were a big cost utilization driver for the populations where we have downside financial risk. We already knew that we had a startup by one of our doctors in our medical group that provides virtual physical therapy to patients. We matched those things up to say, “We have a need, we have a tool, so how do we marry those together?”
We've now enrolled in this program thousands of patients with back pain, with knee pain, with hip pain. My wife, who had a torn rotator cuff, enrolled in it. What we're seeing in this program is that we’re able to provide physical therapy to prevent or slow down the process where you would actually have to have surgery done on your knee or your hip or your shoulder.
So instead of just saying, "Oh, we're just going to accept that a lot of people [may be] getting unneeded procedures,” let’s get ahead of it. We'll provide a very patient-centered tool for every patient who enrolls in this program. On average, we save … about $10,000 in medical cost spend over the next year because they're avoiding hospitalization, surgery and therapy afterward. Functionally, they're actually much better not only than their baseline, but they're functionally about as good as if they were to have had surgery done, and the patient experience is through the roof.
We have done the same sort of thing on diabetes. We're saving thousands of dollars for every patient enrolled compared with a matched cohort of individuals. We're doing it at scale. We're doing it efficiently. But the real benefit is we're able to do things that we wouldn't be able to do if we were doing it piecemeal … and weren't doing it at scale.
Is virtual physical therapy one-on-one, or are people in classes?
This one is one-on-one. The diabetes has both a one-on-one component and a group component because we found, especially when you're dealing with a chronic disease, you're talking about nutrition, you're talking about lifestyle, and you're talking about exercise. You get a lot of benefit in being part of a cohort or … group.
In terms of the cost savings, are you developing the evidence in the way a researcher would, where you're looking at the people in the program, matching them to people who are not in the program? Are you developing the evidence base with research-like rigor?
I would say it's more in the research-rigor mode. That's one of the benefits of being embedded within a care delivery system that also has an academic mission and an academic component. We are looking at it from a matched cohort, not just a pre-, post- or historical trend. We have some publications or some online medical journal-style articles. We need to strike a balance because sometimes rigorous medical studies may take five or 10 years. We want to get our experience out there when it can really make a difference.
Stepping back a bit, I think there is some fatigue with value-based care and population health. I've attended some webinars, the gist of which is that the promise hasn't been met. It had a lot of intuitive appeal — that we were going to manage groups of people with an eye toward prevention and low-cost intervention to prevent downstream expensive intervention. Of course, CMMI [CMS’ Center for Medicare and Medicaid Innovation] had all those models. Some of us tried to keep up with all those models, and they proliferated. I think the research is divided. But I think it's fair to say that, at least in terms of the CMMI models, the savings have been modest. I'm just wondering, where do you see us now with population health? And do you see population health joined at the hip with value-based care?
I am definitely a big believer in population health, conceptually, and value-based payment models that help with incentives. It is not perfect, not the panacea, and all trials, all pilots, all tests definitely have not been successful. I do think that many of them have been, but certainly not all of them.
CMMI was built to test and to innovate and then to stand down programs that didn't work or to make improvements. And some have now gone from CMMI to become part of the standard CMS-based programs.
I think the literature does support that downside-risk Medicare Shared Savings Program [MSSP] models work. However, I believe as a leader in this space, they still need to continue to be improved and modified.
I will step back, though, and say, we as a system and me as a leader, that it's foolish to build a capability, a business or a strategy around a model, or even just around Medicare programs. I think that's foolish because you're going to constantly be chasing your tail, whether it's every three years when you're up for renewal or only based upon those incentives that are in place. Then you end up with this incentive from your Medicare business, this incentive from your Blue Cross Blue Shield in your state, or this one for something else.
I, instead, firmly believe that the system or the organization needs to have its strategy and align, accept and participate in the products that will align with that strategy. Coming back to my earlier comments, the services that we offer apply not just to MSSP but to all of those different programs.
The million members or so that we’ll have in January are covered by probably 20 different contracts. If we were to do it 20 different ways, or to have entered … each one of those individually, it would be foolish. … But to say, "Let's aggregate it all together; let's find the consistent tools [and] consistent management," then it's less important whether this program is just going to be here for a year or two or three.
What we're looking to do is fill the vessel with the membership that we can, be an appropriate size and walk away when … it doesn't make sense or the tools we have built are not the right tools for that project that we're trying to drive.
One of the biggest determinants of success or [failure] is the ability to manage culture change — moving from fee-for-service, heads in beds, every patient being seen as a revenue generator — moving from that mentality to [a] balance. We need to do what's right for the community, but we also need to stay in business.
That’s difficult for many health systems to balance, or to go through that culture change, and they still operate in a fee-for-service payment model and mentality and then hope that they get a bonus at the end. Then when they don't, they say, "See, it was because the program was wrong,” rather than "We didn't drive the culture change."
Value-based care has been something that's operated in the background, between providers and payers of various sorts. I think the ACO model was developed in a way that patients were attributed to, and that they didn't even know they were in an ACO program.
Correct.
Do you have thoughts about how to get the patient and the public engaged here? Is Populance doing anything to get your patients and the public on board with this?
Yes, but probably not in the way that you would think. As far as patients are concerned, or members of the health plan or beneficiaries, they don't understand — nor, I would argue, should they understand — all of the complexities of how doctors get paid and what the contract terms are.
They have medical issues and health needs. Hopefully, they have a relationship with a primary care physician, or at least physicians. I think that is the center of, frankly, what population health should be: that doctor-patient relationship.
Our approach — and what I think works the best in my experience — is that we provide support for physicians to work across their whole panel and across individual patients. Here's what the patients' gaps are. Here's information that you would not have known outside of a population health program. You know that your patients aren't taking their medication. They're not taking their insulin. Their hemoglobin A1c is 11. You may not have known that because they may not be telling you, or they may not be coming in to see you in the office.
The patient doesn't have to know that it was done by Populance or that it was a population health activity. They just need to know patients are coming in to see me when they need to see me, that and we offer them tools such as our Diabetes Care Connection program.
My patient has a hemoglobin A1c of 11. They can't afford their medication very well, they don't know how to inject, or they're not eating very well. I'll just refer them to the Diabetes Care Connection team, who are diabetes educators and health coaches. The patients don't have to know that those are Populance people. They don't have to know that it's funded out of this complex, byzantine CMS program.
How does this relate to all the discussion about healthcare affordability? It's become so expensive to have insurance and expensive to use care.
It is very connected. Our evolving term, beyond just affordability, while that is very important, is about value, which also includes what their health is and what the patient's … perceived view of their health is. So not just cheap care, but are they getting good value out of that? Is the experience good? Can they get in to see doctors?
Everything we do is directly built on affordability. That's partly why we track and publish the results of our musculoskeletal program and our diabetes program, which saves money. At an individual's level and at the level of health premiums, they help bend the cost curve.
For our employees, we had planned for a moderate single-digit increase in healthcare benefit cost from 2026 to 2027. Our current projection is about half of what that projected trend was going to be, partly because of the things that Populance and our system are doing. That directly translates into affordability. We don't have to pass on higher coinsurance or the higher costs of deductibles, or other types of costs to individuals as out-of-pocket expenses.
