Readers Write: What Separates Winners from Losers in Population Health Management? Three Lessons

What Separates Winners from Losers in Population Health Management? Three Lessons
By Billie Jo Nutter

Billie Jo Nutter is CEO of Chordline Health.

There’s an alarming range of success and failure in population health management initiatives, with an ROI that spans from -$244.65 to $1,592.48 per year. As healthcare providers and health plans accelerate investments, ensuring organizations have the right data, tools, and processes to improve risk identification, care management, and value will be vital.

One area of untapped opportunity, according to pwc: driving payer-provider collaboration with a single care plan that is customized to each patient’s needs.

To get there, health plans and health systems must understand where breakdowns in population health management typically occur, how to evaluate their approach, and ways to drive better results.

Breaking Down Population Health Pain Points

Lack of trust and cynicism are two of the biggest factors that get in the way of payer-provider collaboration around population health, according to healthcare C-suite leaders who attended an HFMA population health colloquium last fall. Transparency  around population health data, analytics, outreach, and referrals can help unlock collaboration, but only if the data used to inform population health analyses and care management response are credible and actionable.

One way to build trust in population health data is by aggregating data from multiple sources, including community service organizations, to gain a whole-picture view of the patient, including the patient’s health-related social needs. Another is to tap into another organization’s data to compare a population against a similar population. This process can help uncover best practices in care management for a specific group. In instances where providers and payers are collaborating around population health management, it can also help to:

• Align resources for more effective care management.
• Point to opportunities to better manage multiple chronic conditions.
• Uncover instances where medication management could be streamlined, avoiding adverse effects and unnecessary costs.

Trust also comes down to the ability to use the data at the point of care to improve patient outcomes and to demonstrate the impact that was made in ways that all key stakeholders can understand. This is an area where the data must not only be credible, but also be delivered in such a way that clinicians can determine, at a glance, the health risks that a patient faces and the interventions that offer the best chance to improve health.

In addition, clinicians and value partners, like health plans, need to see the impact that they have made, such as the number of people for whom they have helped to avoid hospital readmissions or progression of disease. This level of clarity reinforces professional satisfaction. It also motivates all stakeholders to do more to strengthen the health of a population.

How can healthcare providers and health plans collaboratively develop a population health management approach that delivers clear wins for both stakeholders and their patients?

• Use shared data to develop a single care plan. Just as some providers leverage data from academic medical centers to better understand what works and what doesn’t in strengthening the health of specific populations, access to health plan data gives providers a more complete view of a patient’s healthcare utilization and care costs. From there, data scientists can not only analyze and forecast a population’s health needs, but also strengthen patient engagement in ways that improve overall health. That’s especially important for adults with chronic conditions, whose risk of hospitalization is two to eight times higher than that of adults without chronic disease.
• Explore innovative approaches to managing chronic conditions, especially within managed Medicare populations. When high-risk patients are identified, bring care managers from the health plan and the health system together to design and implement strategies for care coordination. Then, leverage technology for remote monitoring and support. One essential element for success: a population health analytics platform that can integrate with any data system. This ensures that no matter where a care manager or clinician works, that person has the same data view to make care decisions and view progress.
• Make it easy for clinicians to view population health data directly within their workflows. Intuitive patient dashboards can put population health data at clinicians’ fingertips, empowering them to understand the top factors that influence the patient’s health and population health. Such dashboards can also point to opportunities to reduce care costs, such as by highlighting medication prescribing trends for a particular population and ways to bring these patterns in line with evidence-based practices. One tip for success: make sure the dashboard offers flexible data filtering options to support the clinical team’s needs and enable the team to report on progress and opportunities in a variety of ways.

By taking a collaborative approach to population health management, health systems and health plans can more effectively improve the health of target populations while enhancing clinical workflows, patient outcomes and professional satisfaction.