Does your healthcare organization help people with diabetes manage their appointments, prescriptions and diet? If so, it is engaging in population health management (PHM). PHM combines traditional preventive care with new technologies to keep communities healthy.
Population Health Management Defined
Population health management refers to the steps healthcare organizations take to improve the health outcomes of a defined group of individuals. They may focus on a specific hospital’s patient population, a geographic area, a specific disease or some other unifying characteristic. This patient- and wellness-focused approach uses data to uncover gaps in care, allowing healthcare organizations to develop plans to close those gaps and improve health outcomes.
PHM aligns closely with public health. Public health aims to improve and protect community health through public policy, health education and injury prevention. But while public health focuses on creating and maintaining healthy conditions for the larger community, population health concentrates on the health of a targeted group of individuals.
PHM also aligns with value-based care, the payment model increasingly used by public and private payers, accountable care organizations (ACOs) and healthcare organizations. The value-based care model and PHM both emphasize providing quality care in ways that lessen the financial burden on the healthcare system.
What is the Main Goal of Population Health Management Programs?
The overarching goal of PHM is to improve patient health. In a 2016 study from HIMSS Analytics, healthcare organizations reported that they typically focus their PHM programs on one or more of the following initiatives:
- Chronic disease management. Healthcare organizations use PHM to manage patient populations with chronic conditions such as diabetes or chronic obstructive pulmonary disease (COPD).
- Wellness and preventive health. Healthcare organizations launch initiatives that promote healthy lifestyle habits to both youth and adult populations. Weight loss and smoking cessation programs fall into this category.
- Clinically integrated networks. Primary care physicians, specialists and hospitals create networks together to improve patient care. These networks share health record systems and track data to provide high-quality care and to lower costs. Under Federal Trade Commission requirements, an ACO, by definition, is considered a clinically integrated organization.
- Patient-Centered Medical Home (PCMH). A PCMH takes a team-based approach to care. In this model, the primary care doctor serves as the hub in a wheel of coordinated services and communication between the organization’s providers, the patient and his or her family.
- At-risk payment structures. This initiative refers to ACOs, bundled payment structures and programs such as the Medicare Shared Savings Program. (MSSP). These structures focus on improving quality of care for their members and offer payment incentives for doing so.
- At-risk cost structures. This initiative covers programs such as Medicare Advantage plans, Medicaid managed care and self-insured employee plans. Medicare Advantage plans receive payment from CMS based on beneficiaries’ Medicare Risk Adjustment Factor (RAF) scores. The various diagnosis codes that providers submit help determine Medicare RAF scores. The model, in theory, motivates providers to keep patients healthy, thereby improving RAF scores.
Why is Population Health Management Important?
The United States spends more on healthcare per capita than any other developed nation, according to a study out of the Johns Hopkins Bloomberg School of Public Health. As our population ages—the number of Americans age 65 and older is expected to double from 52 million in 2018 to 95 million by 2060—the need for reform is critical.
A successful PHM program helps healthcare providers better manage populations with chronic diseases, which already cost the healthcare system billions. A preventive care approach helps reduce the odds of patients developing more serious (and expensive) conditions in the future.
PHM programs also help providers identify gaps in care. When they fill those gaps, patient volume increases, which improves profits. An increase in preventive care may help reduce emergency room visits, lower hospital admissions and readmissions, and shorten hospital lengths of stay, all of which help control costs.
Population Health Management Strategies
How can your healthcare organization implement a successful PHM program? Suggested strategies include the following:
- Data. Electronic health record (EHR) data and claims data can help healthcare providers identify patients within their network who have advanced or chronic illnesses and may need more focused care. Depending on the goal, providers may also need access to patients’ social and economic information, cost data and other data. Socioeconomic and demographic data may help identify neighborhoods with the most smokers, for instance, or populations without a nearby hospital or clinic.
- Predictive analytics. Powerful analytics tools help healthcare organizations make sense of the data they collect. For example, after gathering data to identify patients with advanced diseases, analytics can determine who among those patients faces the highest risk of complications or hospitalization. Providers can then target those patients to provide at-home monitoring, medication management or palliative care, depending on their condition.
- Value-based care. According to a report from the U.S. Department of Health and Human Services’ Health Care Payment Learning and Action Network, 34 percent of healthcare payments in 2017 were tied to value-based care, up from 23 percent in 2015. The report indicates a steady trend toward patient and value-centered care.
PHM strategies work best within a value-based care model. By implementing value-based care, healthcare organizations can better understand the total cost of care and the risk they currently assume—and will assume—for their patients.
- Care management. This strategy requires healthcare organizations to think about supporting patients across the continuum of care. For example, a healthcare organization may launch a multipronged approach to identify and offer more focused care to high-risk patients to lower readmission rates. Or it may partner with its community to develop a plan to provide preventative care for homeless and/or uninsured patients, with the goal of lowering the number of emergency room visits.
Healthcare organizations can develop their own PHM strategy using a combination of data, analytics and support staff. By targeting patient populations that need more focused care, healthcare organizations can help improve outcomes for those groups, which lowers costs for patients and providers alike.
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