Unsustainable costs, combined with widespread care coordination and quality gaps, have led to the inevitable large-scale efforts currently underway to redesign U.S. healthcare delivery systems and how care is funded. The traditional fee-for-service payment system, with its built-in incentives for more care, more testing and more expensive intervention has resulted in little provider alignment and accountability. Under recent federal legislative healthcare reform programs, most recently the Patient Protection and Affordable Care Act of 2010, all new levels of physician-provider-payer alignment will be required in order to reduce healthcare costs and ensure improved quality outcomes.
One of the relatively new approaches healthcare providers are taking to fulfill the federal requirements is Population Health Management (PHM). This is an industry term that means healthcare providers are responsible for caring for the health outcomes of defined groups (or populations) of patients. Physicians can no longer dwell in the mindset of caring only for individual patients in their waiting rooms. It’s not just about the sick in this new era of reform. The objective is to keep everyone healthy, but to do that requires healthcare providers to pay close attention to their entire population of patients and coordinate their care. And that’s what population health management is all about – the healthcare provider utilizing the right people and right resources, including technology, to provide better organized, more personalized and proactive care to all patients.
While there are many pieces that play a role in achieving population health management, three key highlights are:
- Risk Stratification of the High-Utilization Population
- Technology Platform for Care Coordination
- Patient Involvement
Risk Stratification of the High-Utilization Population
Risk-stratified care management begins with a periodic and systematic Health Risk Assessment (HRA), using criteria from multiple sources to develop a personalized care plan. So as the industry shifts the focus from sickness to wellness, it will be essential to identify the chronically ill, high-utilization population and place them into meaningful categories for care management. Although the number of such diagnostically-related populations is endless, a few illustrative examples would include patients with Alzheimer’s, unstable diabetes, asthmatic children with recurring ED visits or hip replacement patients on Coumadin.
According to the Agency for Healthcare Research and Quality, five percent of patients are responsible for almost 50 percent of U.S. healthcare spending (2005). In order for healthcare provider networks to maximize their shared savings opportunities, it is essential to reduce the number of unnecessary in-patient admissions, emergency department visits, and interventional care and imaging services.
Technology Platform for Care Coordination
With the Primary Care Provider (PCP) as the nerve center of coordinating care management services for their entire panel of patients, a very robust IT system will be required in order to derive meaningful quality metrics and care guidelines. It will be crucial to have data management, analysis reports and performance dashboards to help providers enhance their care delivery, along with online portals with medical information for patients and clinicians to access.
Unlike other industries that are highly reliant upon the implementation of meaningful data analytics, healthcare continues to be in its infancy with regard to quality metrics. Although mandatory data elements have been reported for the last decade on a limited group of diagnosis-related group (DRG) categories, there remains a lack of scientific confirmation that improved patient outcomes are directly related to the metrics and subsequent patient care guidelines selected over past years. The appropriate weighting of each metric and the many DRGs with no related reporting requirements are just a few of the challenges of population health analytic science and business intelligence in healthcare.
Historically, healthcare payers have only had access to patient claims data while the provider relied solely upon the individual patient’s electronic medical record information. As we improve our ability to overlay population-level electronic medical records (EMR) and claims data through a robust technology platform, we will continue to see a more scientific understanding of the impact of our collective efforts around population health.
In next week’s post, we’ll look at the areas of patient involvement and best practices.
Contact Intalere now to find out how we can help your organization with population health management.