Motivating Change in Population Health Management


Improving member health through physician collaboration

The goal of population health management (PHM) is to help a specific population achieve and maintain their best health. Achieving the best health for a given population involves reducing expensive interventions, hospital and emergency department (ED) admissions, tests and procedures for those with acute or chronic conditions. It is also important to provide continued health and wellness support for population members without serious health concerns. Taken together, in a comprehensive strategy, both efforts can effectively lower costs.

The traditional payer approach to PHM has focused on telephonic disease and case management, which offers individuals greater access to health advice and education, especially for underserved populations, in a manner that’s convenient and inexpensive. However, the reliance on remote care management teams and the potential for disconnect when programs aren’t aligned or integrated with the patient’s doctor can present several challenges. These may include low engagement, attrition and limited effectiveness due to inconsistent metrics across providers and a lack of real-time data.

Given the significant changes in healthcare, from how doctors get paid to consumers taking on a greater share of costs, the retrospective one-to-many approach of traditional PHM no longer matches the way people want and expect to engage in conversations about their health. A key task for payers is to find new and innovative models that will allow them to more effectively support members, focusing on their individual needs, service expectations and timing.

A New Approach to PHM

For the North Carolina State Health Plan for Teachers and State Employees (NCSHP), the rising costs associated with caring for a large population of individuals with chronic conditions was a growing concern. NCSHP serves a highly diverse population of more than 700,000 members, including active plan members, COBRA, pre-65 retirees and retirees. More than half of its members face chronic or catastrophic health challenges, and these individuals drive about 76 percent of the plan’s health costs. Moreover, NCSHP’s members reside in all 100 counties across the state. Taken together, NCSHP faced the monumental challenge of creating a program that could meet the needs of its members.

NCSHP sought to extend the impact of its more traditional PHM program, by engaging providers in the care of plan members through a data-driven, coordinated support to achieve better health outcomes and improve members’ experience in a complex healthcare environment. To accomplish this, in 2015, in collaboration with its population health vendor, NCSHP launched a two-year Patient Centered Medical Home (PCMH) practice support pilot project. The two organizations worked with participating provider groups to continuously evaluate the impact of the program by developing targets for improved health outcomes, including the use of national standard clinical outcome measures, to gauge its impact.

The Patient Centered Medical Home (PCMH) pilot strategy aimed to improve member health quality and lower cost by:

  • Recruiting practice groups interested in collaborating to participate in the pilot
  • Increasing member engagement by promoting the provider/patient relationship
  • Sharing data, care management workflows and training needs to support population health activities
  • Exploring alternative provider payments that promote a value-based quality improvement program
  • Applying best practices for expanding value-based programs statewide.

A New Framework

NCSHP collaborated with four practice groups representing more than 20,000 members, 60 practices, and 942 physicians across multiple health service areas in the state to pilot the program.

Based on initial assessments of practice interest and capabilities, each group was placed into one of four payment tiers. NCSHP provided a per-member-per month quarterly payment based on the level of integration and support to be provided. Members were attributed based on the number of claims attributed to a specific provider or if there was a tie in the number of claims with two providers, to attribute the member to their most recent health care provider.

Each practice group worked to first flag NCSHP members in their electronic medical record (EMR) systems, and then to identify and stratify specific members for care coordination services. The practices and the Plan’s PHM vendor integrated workflows to better share information and resources to meet each member’s needs. In addition, the practices provided clinical metrics from their EMR and have focused on improving member engagement, member health and patient satisfaction.

The program leveraged advanced technology to help drive patient identification and engagement, including clinical analytics, care management applications and software, and data-mining capabilities. These technologies and analytics also supported reporting on key quality metrics and ongoing assessments of practice success, including comparative analysis to regional percentiles.

Evolving the Mode: Sharing Lessons Learned

One key to success has been the ability and willingness of participating physicians to dedicate time to sharing best practices. Early feedback on the pilot is extremely positive from the practices, with clinicians and management staff praising the close collaboration with NCSHP and the PHM vendor. The ability to improve and evolve requires recognizing challenges. The three most important lessons learned from this pilot initiative apply to any payer-provider collaboration:

  1. Define engagement: Effectively measuring engagement across multiple channels and stakeholders requires a standard definition, something that health care organizations have yet to address as an industry. Agree to engagement standards as a part of the strategy and planning process to eliminate later struggles around measurement and reporting.
  2. Use data to build a patient-centric profile: Sharing data across multiple sources is critical to improve care coordination and requires thoughtful integration. Coordinate information to ensure data is being used to build a patient-centric record that includes gaps-in-care intelligence, information from referral lists and quality measures.
  3. Expand patient communication: The patient experience further benefits from improved communications to help individuals become better educated about the tools and resources available to them through these collaborations. Informing patients about the value of completing a Health Assessment or the availability of health coaches for additional care management support, creates added value and drives more meaningful engagement.

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About Author

Jonathan Rubens, MD, MHPE
Jonathan Rubens, MD, MHPE

Senior medical director of ActiveHealth Management.

Scott Money

Business projects program manager of ActiveHealth Management.

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