As payers seek to define their individual approaches to population health management, there is much to consider, ranging from outside influencers to the payer’s strategic priorities and membership mix. It’s important to understand all the factors to create a successful strategy based on best practices.
Economic pressures and heightened regulatory requirements are shaping the population health conversation. One of the leading influencers is the Affordable Care Act, which expands access to care and incents organization to take responsibility for improving cost and quality. Many payers are experiencing a shift in their membership risk profile through ACA and Medicaid expansion, which creates a population that can be challenging to engage.
In addition, government innovation and value-based care models are intended to advance performance-based and risk-sharing agreements. Beyond the evolving regulatory environment, payers’ expectations of population health programs are also changing. They’re seeking results based on outcomes, as opposed to operational measures. As a result, program optimization is a key priority.
What should a payer focus on, given these influencers?
With the shifting of risk from payers to providers, more payers are focusing on engaging and equipping providers with responsibilities, incentives, tools and resources to take on a broader role in population health management. New population health models have evolved. One example: embedded population health management in the community, which has been shown to provide additional value beyond call campaigns. However, these programs can be expensive and aren’t always cost-effective, depending on the population the plan is trying to reach. In response, IT systems and analytics, and their related processes, have to be sophisticated enough to support these new models so that payers can identify the right people to engage and engage them optimally.
So what exactly is population health management?
Establishing a common understanding to enable effective collaboration
Population health management means many things, depending on who is defining it. It’s perhaps most useful to compartmentalize its different components based on payer functions and the membership mix that is supported by the population health goals.
Consider a health continuum categorized from lowest risk to highest risk: healthy, chronic, catastrophic, terminal. This provides a way to categorize potential cohorts based on inputs such as claims, pharmacy, lab, behavioral assessment and clinical data. Programs can then be developed to address each cohort’s needs. For example:
- At the health promotion end of the spectrum, the focus is on broad population models encouraging healthy behavior and closing care gaps. As a member case becomes more complex, the programs focus on a broad but tailored set of interventions to promote the right care, the right provider, the right medication and the right lifestyle.
- Episodic management takes a different approach to focus programs around utilization management, such as prior authorization, concurrent review and clinical claims review. Goals are typically focused on ensuring that medical events are contractually allowed, performed by preferred providers and evidence-based.
- Quality management is a broad category that typically focuses on things like Medicare Advantage quality, Medicaid quality, Stars, HEDIS, accreditation through NCQA and vendor oversight.
- Finally, coding completeness and accuracy is important for several reasons with Medicare Advantage risk adjustment among the top priorities.
Developing the capabilities to support core functions
What do all the programs have in common? Each shares the Triple Aim of: better care for individuals, better health for populations and lower per capita costs. It takes a diverse set of capabilities to achieve the Triple Aim’s ambitious goals. In addition, each program needs to be individually robust and optimized. For optimal performance, we believe they also need to be well integrated with one another.
How can these capabilities be optimized?
Click here to read and download the full article.