Since healthcare has moved to value-based reimbursement and downside risk, provider groups and payer organizations have named population health management (PHM) a top priority. The anchoring principles of value-based care is delivering high-quality care while reducing costs and preventing unnecessary admissions for defined patient groups. These groups can be based on contracts, chronic conditions, event types, or any other commonality.
Over the last few years, healthcare IT vendors have responded by introducing new applications and capabilities to the marketplace that enable providers to deliver high-quality care to high-cost, high-risk populations at scale. Population health management is hitting its tipping point, and as evidenced by market dynamics:
- Population health management technology is spreading from executive and analyst reports to the entire healthcare organization, including front of office, back of office, and the point of care. New C-level and director titles with “population health” are being created around the industry.
- More traditional healthcare organizations (not just early-adopters) evaluate and purchase population health technology to support their provider and patient engagement efforts.
- Large vendors, such as Apple, Salesforce, and Microsoft, have entered the healthcare IT space.
Population health management consists of the variety of interactions that providers have with their patients and executive teams in concert with managing value-based contracts with payers. Population health management enables provider and payer organizations to deliver high-quality care to different groups of patients efficiently. Three significant areas make up population health management, as defined above:
The technology, where data insights are uncovered, is fundamental in determining the other major areas of strategy and people. Population health management technology (often referred to as a “platform”) is an enterprise data warehouse that stores and organizes data from multiple sources. It can be transformed into insights and then acted upon with the intent of improving patient outcomes.
What Makes a Population Health Management Platform Work?
The population health management platform consists of six key areas, each building on the other area.
- Data Sources — Data sources are where population health efforts begin. When considering all of the interactions a patient has with the healthcare system, the primary data sources include both clinical data (mostly from electronic medical records) and claims data (from commercial and government payers).
- Interfaces — Interface technology is responsible for pulling data from various sources and putting it into a staging area, where it will later be merged and normalized. Interfaces are necessary because they are the highway system for data to flow from one database (the original source system) to the PHM platform. What makes PHM vendors stand out is their ability to consume data from disparate sources.
- Data Processing — Data processing is where all the data that has been collected is harmonized and merged to create a single patient profile that includes insights from all available sources. Processing is the most critical part of the process because it determines the quality of reports and information that the end-user can access.
- Internal Rules — Internal rules organize data for action. The PHM platform can run internal algorithms to stratify the patient population by cost, risk, condition, etc. The data has been collected, aggregated, and cleansed. Virtually any combination of search criteria can be applied to the patient data to create custom lists or find insights, otherwise impossible without combining all data available on a single patient.
- Enterprise Data Warehouse (EDW) — The EDW is a second staging database where the cleansed patient data is copied to. Now, the end-user applications can populate with information and insights based on their role.
- User Applications — User applications drive engagement between providers, patients, care managers, and analysts. These are the applications the end-user will leverage to identify, assign, engage, and measure their population health strategy. A PHM platform is the critical driver of performance in the value-based care market.
The Power of Technology in a Pandemic
The COVID-19 pandemic is a prime example of concentrating focus on the groups most impacted. In the Centers for Medicare & Medicaid’s latest data release blog, Administrator Seema Verma reveals that, according to Medicare data, over 325,000 beneficiaries tested positive for the novel coronavirus, with 110,000 hospitalized. The CMS snapshot also revealed the top five chronic conditions of hospitalized fee-for-service beneficiaries were hypertension, hyperlipidemia, kidney failure, anemia, and diabetes.
Thorough PHM, however, is only possible with complete visibility beyond the exam room. Social determinants of health (SDOH) continue to impact the data, and is also something we continue to observe during the COVID-19 pandemic. It was just released that African Americans are hospitalized at the highest rate for the virus, approximately 465 people per 100,000, and Hispanic persons 258 per 100,000, while whites are at 123 persons. According to Healthcare Finance, CMS interprets these numbers to be yet another indicator of socioeconomic disadvantage. These facts reinforce the need for large healthcare organizations to invest in the technology and advisory services to help their providers engage with patients to achieve success in PHM and value-based arrangements. With this technology, segmenting patients at the highest risk during the pandemic will be an easier feat.
Insights generated by a PHM platform must also be aimed towards a target, be it clinical, financial, or administrative, which is where targeted population health strategy comes into play. In my next post, I will review population health strategies and dive into the various population health initiatives that healthcare organizations are deploying to deliver proactive care to high-risk patients.
Josh Patten is the Vice President of Operations at Lightbeam.