Why population health reminds me of Reuben Feffer

“I have a .013% chance of being hit by a car on my way home. Or a one in 46,000 chance of falling through a subway grate. So I try to manage that risk by avoiding danger and having a plan and knowing what my next move is.”

I’d like to say that’s all you really need to know about population health, risk stratification and data analytics relative to today’s dynamic healthcare climate, because that statement gets right to the heart of the matter.  But, like everything else in healthcare today, nothing is that easy.

So here we are, well into the Accountable Care Act (ACA), and it’s clear there’s no turning back. Healthcare jargon infiltrates our dreams. Terms like ACO, collaborative care, medical homes, best practices, MU, CQMs, outcomes, cohort management… have become “household” words. Providers across the healthcare spectrum, including health IT professionals, practice managers, and ancillary health service providers are feeling the pressure as they adapt to the changing “rules of healthcare engagement.”

All this talk about “population health management,” begs the questions: what does it mean? How do we implement it? And why is it important? The simple explanation is that as accountable care becomes the new “normal” in healthcare, providers will need to know more about their patients as a whole and then figure out the best and most cost effective ways to treat them. While the focus is primarily on high-risk patients ¾ those with chronic conditions, (who also happen to be the highest utilizers of healthcare services and resources), preventive care and proactive intervention is also a significant aspect of population health management.

What the data tells us

Population Health is not a new science; its close cousin, disease management, has been around for decades. However, one major difference is that now with digital health records and an interoperable solution, providers can obtain and aggregate patient data from multiple sources. In the past, disease management initiatives were mostly performed by payers and their case managers and were based on claims data because that’s all they had to work with.  As we shift from a volume-based care model to value-based, providers need to be equally concerned with healthcare utilization, costs, and outcomes.

What would Reuben do?

Back to “Along Came Polly.” what would Reuben Feffer do if he was the CMO of a large multi-specialty healthcare practice instead of a Life Insurance risk analyst? The easy answer is: “He would try to manage that “risk” by avoiding “danger” and having a “plan” and knowing what his “next move” is.”

Translated into population health terminology, Reuben would identify and define the following as such:

Risk

  • The increasing prevalence of chronic disease and comorbid conditions, such as obesity, heart disease, and diabetes
  • Aging population of baby boomers (born between 1946 and 1964) extremely high utilizers; for instance, in 2010, there were 40.3 million people, age 65; by 2050 projected 88.5 million; eight in 10 seniors suffer from at least one chronic condition
  • About 25 percent of seniors are obese
  • 20 percent have diabetes
  • 70 percent have heart disease
  • Projected physician shortage
  • Patient non-compliance with treatment

(Source: Wu, S., & Green, A. Projection of Chronic Illness Prevalence and Cost Inflation. In RAND Corporation)

Danger

  • Poor health outcomes, sicker patients, higher utilization of services, inefficient and fragmented care delivery
  • Patient non-compliance with treatment and medication adherence
  • Unsustainable costs
  • High potential for significant decrease in practice revenue

The Plan

Reuben will partner with an EHR vendor with an integrated population health program that will provide physicians and staff with an automated proactive patient engagement and communication solution. Ideally, the population health solution will give him easy access to useful patient data on all his patients’ healthcare utilization and performance.  The ability to stratify the patient panel by specific criteria helps identify and address problem areas, allocate resources effectively, and improve patient care and outcomes. Delivering better care in lower cost settings will help to:

  • Reduce avoidable ER visits and hospitalizations
  • Reduce hospital re-admissions
  • Significantly improve patient health outcomes
  • Generate new opportunities for practice revenue

Reuben’s next move

Once his population health solution is operational, Reuben will want to take his analytics capabilities to the next level. Advanced data analytics will not only help him identify treatment opportunities and report those outcomes, he will be able to better evaluate how well the practice is managing a specific disease(s) in accordance with evidence-based guidelines. With these capabilities we can more effectively manage our population health program, mitigate clinical and financial risks, and better negotiate with payers for risk sharing agreements.

Mitigating risk is the name of the game

Regardless of the industry, mitigating risk is important to the success of any enterprise. In life insurance, an insurer is less likely to insure a professional skydiver than a writer. In healthcare, the more accurate data providers have about our patients’ health risks, utilization and costs, the better positioned they are to effectively manage patients and also negotiate with payers for better shared savings arrangements. Ultimately, an effective population health management system will provide the level of analytics capability to stratify the patient population, and provide actionable data, from which providers can make better clinical decisions and develop shared care plans for the care team to implement.

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