Improving efficiency, quality through population health

Most managed care executives believe they will recoup their investments in population health management (PHM) within four years, but many don’t have a clear vision of the pathway to success, according to a recent KPMG survey of nearly 300 executives.

The survey was conducted during a webcast "Enabling New Payment and Service Delivery Models through Technology."

PHM may be a “fuzzy term" for those in the industry, according to Paul Taylor, MD, chief medical information officer at Wellcentive, which offers population health management and data analytics solutions to providers and payers. Rather than waiting for patients to come through the door, or worse, present at the emergency room with a crisis, PHM gives providers a tool to reach out and initiate contact and, if necessary, intervene with patients who might be at risk before their condition deteriorates, says Taylor, who is also a practicing physician in Michigan.

“It's looking across every access point in a healthcare facility or healthcare system at patients who need care, and doing proactive management to increase the quality, reduce the cost and make sure the patient is accessing the most efficient point in the system," he says.

PHM is a blend of care and case management that allows caregivers to look across their entire panel of patients to tease out which of them are at risk for specific health concerns, while providing a framework act on that information, says Taylor.

Data driven, action oriented

Before joining Wellcentive, Taylor recalls doing something similar to a PHM process, although on a smaller scale, in his practices as a physician about a decade ago. He ran spreadsheets tracking small panels of diabetes patients, or flu shot candidates to monitor their treatment and needs. “We did that with a very basic registry and a spreadsheet. But as a doctor, I'm responsible for hundreds of outcomes by payer contract and there are lots more pieces of information to deal with. You'd quickly run out of the ability to put more data on the spreadsheet.”

PHM today entails using computerized risk algorithms coupled with extensive patient data, says Hadi Kharrazi, MD, assistant director, Center for Population Health Information Technology at Johns Hopkins Bloomberg School of Public Health. He says PHM allows caregivers to locate and focus on the patients who are most at risk of being low quality and high utilizers of the system. Once identified, providers can intervene in a primary care, or other setting, at a fraction of the cost.

“The more data you have, the better the data, the more relevant the data the better you can predict outcomes,” says Kharrazi.

Next: How it works

How it works

PHM systems can ideally handle in the range of 50,000 parameters, covering everything from blood glucose or blood pressure and case history, to social factors, such as family structure, access to transportation, or nutrition.

PHM service providers typically gather health data from numerous EHRs and other access points such as lab reports and real-time claims information. Then, they employ risk algorithms and other computerized analytic processes to sort that data according to their clients' requirements and objectives. For example, they might provide information that can be used to guide patient management at the physician’s office or other relevant points in the health system.

Closing the gaps

Deborah Rumsey, executive director of the Children's Health Alliance in Portland, Oregon, believes the drive toward PHM started with the insurers. "They'd say only 70% of your patients have received a particular recommended care, but what we do is look for the patients who didn't," she says. "By having a population tool rather than just a number, we can find who is being missed and look into them.”

According to Rumsey, PHM encourages “collaboration between physicians, nurses, social workers, pharmacists-it's a team.” PHM tools allow caregivers to target interventions to the most appropriate staff persons, or when necessary, “to social work and agencies beyond the walls of the institution.”

A fresh approach

Bolstering the business case for PHM capabilities, the Department of Health and Human Services has set a goal of tying 30% of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as accountable care organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50% of payments to these models by the end of 2018.  HHS also set a goal of tying 85% of all traditional Medicare payments to quality or value by 2016 and 90% by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs. 

Reflecting on shift from the fee-for-service model to value-based payment, Kharrazi says, “If I was a provider under the old model I'd love to see the high-cost patient-the high utilizer.” However, he says, “With value-based purchasing, if you start visiting someone more and more you are losing money. How well you can manage the patient before they get to the hospital determines profitability. If the patient doesn't need to go to the hospital, that's where you get the most money.” For Kharrazi, PHM is a way to “manage your population in an efficient way given the resources you have.”

Taylor agrees, “It's a complete metamorphosis of the managed care idea of the 1990s which was geared toward limiting care. With PHM, sometimes, to keep people from having a bad outcome they may be getting more care, but different types of care.”

David Richardson is a writer based in Baltimore.