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Why Population Health Management Matters

Population health is likely something you’ve been hearing a lot about in the healthcare industry lately. The shift from fee-for-service to value-based payment has everyone focused on improving health outcomes for patients, and one of the main avenues toward this goal is that of focusing on population health management. This eBook will provide an overview of population health management beginning with what exactly it is and how it works. From there we’ll look at the goals of population health and how practices can approach it. Finally, we’ll discuss the role technology plays in population health management, challenges you may face and how to overcome them, how population health relates to incentive programs, and why all of this even matters. Let’s get started.

What is population health management and how does it work?Population health management (PHM) is a practice within the healthcare industry in which care delivery is studied and facilitated in relation to a group of individuals, or population, with the goal of improving patient health outcomes overall. The groups who are studied are often part of a larger group which could consist of all the patients of a particular medical practice, individuals living in a certain area, or patients who all suffer from a certain illness or share another characteris-tic that has an impact on overall health, such as socioeconomic status or geographic location. Today, population health management involves using data analytics to define patient groups, often stratified by the individuals’ risk of experiencing a certain outcome, in order to deliver the best possible care. By meeting the needs of the individuals in those groups practices can ensure quality of care and accountability on the part of both the providers and the patients.

The single most important piece of successful population health management is data gathered through the utilization of healthcare IT. This data, covering clinical, operational, and financial information, is used to determine actionable steps that can be taken for the benefit of the patient population. For best results, the healthcare technology used by a practice should be able to not only gather, but also summarize and analyze data about the population of that practice in order to draw conclusions about what the data shows. This will give a clear picture of the health of the patient population overall, as well as point to best practices to manage the diseases most prevalent within that population.

Stratification of Patient PopulationsThe main way data is used in relation to population health management is for the stratification of patient populations which involves dividing patients into risk groups based on clinical conditions and lifestyle characteristics. The goal of patient stratification is to group patients with like conditions together in order to draft a standard care plan for those groupings in an effort to improve health outcomes overall. Data that is useful for patient stratification includes the number and type of diseases, especially chronic illnesses, the patient has; any substance abuse or mental health diagnoses; any history of frequent hospitalizations; if the patient lives in an underserved community; and if the patient is of an advanced age. Using this data, each patient is assigned a risk score which is essentially a standardized metric that indicates the odds that a given patient will experience a certain outcome. The outcomes a practice may want to predict include emergency room visits, hospital admissions, or the development of specific diseases and illnesses, such as cancer, heart disease, sepsis, or diabetes, as these outcomes have the most drastic effect on well-being and account for some of the highest healthcare costs. To put it simply, the process for risk stratification is as follows:

• Compile the full list of patients in the practice. • Sort those patients by condition, both number of conditions and the type of conditions. • Stratify those patients into groups based on the number and type of conditions per patient. • Design care models for each group.

Once patients have been put into groups according to their risk scores, providers can identify the ideal level of care and services for those groups with the goal of improving overall health outcomes.

Many practices will stratify their patients into the following groupings:

• Highly complex: This group of patients, likely comprised of less than 5% of the total patient population for a practice, has the greatest care needs. They have a number of complicating factors, including many complex illnesses and socioeconomic barriers. Proactive, intensive care is required for this grouping, and the goal is to achieve better health outcomes through the use of lower-cost services with the hope of preventing unnecessary emergency services.

• High-risk: This group of patients, usually about 20% of the total population, is made up of patients who have numerous risk factors that could land them in the highly complex group if they are not managed properly. For this group, providers will use a structured program for care management that provides one-on-one support to make sure patients receive preventive services along with appropriate management of their chronic diseases.

• Rising-risk: This group is made up of patients who vary between stability and instability with their chronic conditions and other risk factors. The best plan of action for this group is to manage risk factors such as obesity, blood pressure, smoking, and cholesterol levels. As these factors are the root causes of multiple chronic illnesses, patients can be kept out of the high risk and highly complex groups by managing these issues. • Low-risk: This group is made up of patients who are generally healthy. They may have minor conditions that are easily managed, allowing the goal for this group to be keeping them healthy and engaged in their own well-being.

Once patients are compiled into groups, a unique care model and strategy is designed and executed for each group.

Highlycomplex High risk

Management of Chronic Illnesses within a Patient PopulationAccording to the Centers for Disease Control and Prevention (CDC), chronic illnesses make up seven of the top 10 causes of death in America, with about 86% of our country’s annual healthcare spending going toward the management of these illnesses. This is why managing chronic illnesses is one of the most important things a medical practice can do for its pa-tient population, and population health management allows a practice to do this efficiently and equally across all patients dealing with specific illnesses. Some of the illnesses that many practices focus on managing through population health first are diabetes, opioid addiction, hypertension, depression and other mood disorders, and respiratory illnesses such as Chronic Obstructive Pulmonary Disease (COPD) and asthma.

Remote Patient MonitoringOne important factor in population health management that is also very useful in managing those chronic illnesses is remote patient monitoring. Remote patient monitoring (RPM) is a practice in healthcare in which patients are able to use a mobile medical device, or even their own smartphone or wearable, to send health data to their provider in real-time. RPM is especially useful for the elderly and the chronically ill, two groups who need more regular monitoring in order to best manage their healthcare, but can also have a difficult time making frequent visits to the practice. Through the use of RPM, physicians are able to closely monitor the patients’ conditions regularly, not just when the patient comes in for an appointment, and they can also intervene if anything seems out of the ordinary.

One facet of remote patient monitoring is telemedicine, which is the practice of providing healthcare from a distance using telecommunications technology. Telemedicine is particularly useful for closing gaps that would otherwise exist in patient care by allowing patients to obtain care by their provider without having to rely on their otherwise scheduled visits. Most people have experienced a situation in which they needed to see a provider but there were no appointments available or a personal situation presented a barrier to it to the office. Telehealth reduces the wait for appointments and allows patients to receive care much more quickly and less expensively. Additionally, with telemedicine available, many patients will utilize that service as opposed to visiting the emergency room or an urgent care. This greatly reduces healthcare costs, as an average telemedicine visit costs $50 compared to the average $200 for urgent care or $2,000 for the emergency room. Finally, telemedicine helps to improve care coordination and also allows providers to reach broader markets by making care readily available to patients in rural areas and underserved communities.

Wellness checks are important to a patient’s overall health and they’re made much more efficient through the use ofremote patient monitoring. With the ability to check in on patient compliance with treatment plans as well as patients’ ability to send data on vitals, it’s easy to monitor a patient’s wellness without having to schedule an office visit, making this facet of care much more convenient for both patient and provider.

With such a focus on chronic illnesses in population health management, it’s no surprise that Chronic Care Management is an important component to this initiative. Chronic Care Management (CCM) includes education and oversight activities performed by providers outside of traditional office visits in order to aid patients who suffer from chronic illnesses and health conditions. Some of the most common illnesses addressed by CCM are hypertension, diabetes, multiple sclerosis, lupus, and sleep apnea. The goal of CCM is to motivate patients to remain compliant with their care as well as to monitor the efficacy of that care with the ability to intervene when needed. In addition to improving patient health outcomes, CCM allows providers to increase reimbursement by billing for CCM activities, essentially making for a win-win situation of better patient care and increased financial stability for the practice.

Much of the goals of remote patient monitoring can be achieved through the use of wearables, technology that includes fitness trackers, smart and sport watches, and medical devices such as glucometers. Patients utilizing this technology can record personal health data on their own and then transmit that data to their providers in order to allow for a greater understanding of their overall health picture as well as the ability to enhance their treatment plans.

TELEMEDICINE

$50.00AVERAGE VISIT COSTS:

URGENT CARE

$200.00AVERAGE VISIT COSTS:

EMERGENCY ROOM

$2000.00AVERAGE VISIT COSTS:

Using Patient Generated Health DataPatient Generated Health Data (PGHD) refers to health data that is created, recorded, or gathered by patients or a care-giver other than medical personnel. This data can be used to supplement the data that is gathered by physicians during office visits and hospital stays, allowing for a more complete picture of a patient’s health on an ongoing basis. Using PGHD can allow for more accurate stratification of a given patient within the population by providing a more consistent stream of information about that patient’s condition.

Creating Actionable Ways to Approach DataGathering all of this data is great, but data alone isn’t going to improve health outcomes. In order to achieve your population health management goals, you have to be able to take action on what your data tells you. In order to make sure that you’re making the most of your data, the first thing you need to do is closely examine how your practice approaches data analytics. Take a look at the relationships between data sets and how you aggregate your data. From there you can analyze the data in such a way that you know what needs to be done to best care for your patients.

The next thing that’s important to do is to make sure that your practice is using the right tools. Technology is your friend here, and while your EHR is a great start, it’s likely that investing in additional technology will help you as you work to extract and present the information you’re getting from your data input in a meaningful way. The final step is to create a plan for how you will use healthcare IT to inform patient care. An important thing to remember is to make sure you’re familiar with all the different government regulations that surround the capture and use of patient data, most obvious of which is to be sure that you’re always well within the HIPAA guidelines.

Promoting Patient AccountabilityAn important piece of the overall healthcare puzzle that is too often neglected is that of patient accountability. A doctor can provide all the information, resources, and treatment in the world, but if a patient isn’t compliant and doesn’t take responsibility for his or her own health, it won’t make any difference. This is where the increased contact of population health management makes a real difference. By continually encouraging patients to make necessary lifestyle changes to improve their condition, as well as reminding them of things such as follow-ups, vaccinations, and needed tests, patients are held accountable to their own responsibility for their health outcomes.

What are the goals of population health management?As with anything else in the healthcare field, there are specific goals to population health management for both patients and providers. For patients, population health management is used to seek ways to improve patient health outcomes as well as control the overall cost of healthcare. This can be accomplished by determining ways to fill in care gaps and creating treatment plans specific to each patient’s issues. Another goal is for PHM to help patients to be proactive with their treatment as well as prevention of further disease. This can be achieved through an increase in patient engagement which occurs through regular communication from the patient’s provider as prescribed in the care plan for the patient’s grouping.

For providers, population health management is helpful in the quest to transition to the new, value-based payment models. One goal of PHM for providers is to gain the ability to make evidence-based medical decisions informed by data analysis in order to choose how best to allocate resources. Along those lines, another goal for the use of popula-tion health management in a medical practice is financial improvement. Population health management programs help to keep costs lower by allowing providers to focus on utilizing services most appropriately in order to efficiently manage patient care. Also, by working to manage chronic illnesses more effectively, as well as prevent their occurrence, this mitigates unnecessary healthcare costs. Finally, clinical proficiency is another goal of population health management for providers. This is achieved by identifying and filling care gaps and improving care overall by clearly seeing the health picture of not only individual patients, but the overall practice.

Approaches to Population Health ManagementIt’s important for practices to realize that, as overwhelming as population health management might sound, it’s likely that you already have all the data you need to begin stratifying your patients in your possession. With that in mind, these are the basic steps a practice should take to begin a PHM program:

• Stratify your patients into key groups. You can do this using the patient data you have now in your EMR. • Fill in any gaps you find. If you find that you’re lacking in data, focus your efforts on collecting the missing information from your patients so that you can be sure you’re accurately establishing your population groupings. • Analyze your data and determine root causes. Knowing which patients suffer from which conditions is great, but the best way to provide outstanding care is to see if you can determine what might be causing those issues. Don’t forget to look at things such as a patient’s socioeconomic status, where they live, and how engaged they are in their own care. • Take action. Once you’ve properly stratified your patient population, it’s time to execute your care plan for each group.

More generally, for a practice just beginning a population health management program, it’s important to first take stock of your practice. Identify the reasons why you want to start this program, the goals you hope to achieve, and the conditions that are most prevalent in your practice that you think you should focus on to start. Remember, population health manage-ment requires changing the way you think about patient care as well as what you actually do to care for your patients on a daily basis. It’s a worthy cause, but it’s okay to begin slowly and work your way up to a more robust program.

How does healthcare technology come into play?Healthcare technology is essentially important to three factors that are central to population health management: data governance, data aggregation, and data analytics. Data governance refers to how data is managed by an organization for as long as it’s in that organization’s care. Healthcare technology’s role in data governance is to keep the data organized and easily accessible, as well as ideally providing for the analysis of that data in order to improve patient outcomes. When practices have solid policies related to data governance, they’re able to improve the patient experience, improve the health of their patient population, and reduce the overall cost of healthcare in their practice.

Data aggregation is the process of gathering data and summarizing it in order to prepare for analysis. In order to properly aggregate data, the purpose of the data must be clearly defined, as well as what should and shouldn’t be included. This is important in order to ensure that the data analysis that comes next will give meaningful insights that allow your practice to take appropriate actions to reach your goals.

Data analytics refers to the science of drawing insights from raw data. Simply put, once the data has been appropriately managed and summarized, that data is studied to find patterns and trends that allow practices to make decisions about care and treatment for patients in each grouping.

What are the challenges to population health management?As with anything, there are challenges that come along with population health management. The first of those challenges is the reliability of the data that is collected by patients. As we mentioned earlier, patient generated health data (PGHD) can play a large role in getting a complete picture of a patient’s health status and being able to properly stratify them into a patient grouping for your population health management program. Unfortunately, the reality is that at this point when patients collect data about their health status themselves, often through the use of wearables or smart phones, it can’t be 100% verified that this data is accurate. This creates a challenge in that inaccurate data could lead to patients being placed into the wrong grouping and being included on a care plan that isn’t ideal for their condition. To combat this concern, any health data submitted by a patient that seems to be out of the ordinary compared to their usual condition should be followed up on to see if there is an inaccuracy in the data or a change in the patient’s condition that may necessitate further attention.

Another challenge with regard to population health management is that of a standardized way to approach data. With such a focus on interoperability in healthcare, there’s been quite a lot of talk recently about the importance of working to standardize data. While there are strides being made to this end, there’s still a long way to go. This means that without standardization of the data that you collect in office as compared to what patients submit through their own collection, and even what you might get from other members of a patient’s care team, it may be more difficult to interpret and analyze the data from these various sources. This is something to take into consideration and even to talk to your technology vendors about in order to look for a solution.

Finally, stratifying patients by risk score can be a challenge in and of itself. While this is an integral part in population health management, that doesn’t mean it’s easy. Beginning this process can be quite the detailed process as well as time consuming. To overcome this challenge, it’s advised that practices determine the populations that need the most atten-tion in their practice and try to establish their care plan first. It’s also important to regularly revisit your patient groupings to make sure that no one’s condition has advanced to where they need to be placed into a more intensive grouping, as well as to see if any patients have had such an improvement in their condition that they can actually move to a grouping that requires less attention.

How does population health management relate to incentive programs?Current incentive programs, such as the Quality Payment Program, are focused on improving patient health outcomes, lowering healthcare costs and burdens, and moving from a fee-for-service model to one that is value-based. Population health management is uniquely positioned among big data analytics, health IT, improved efficiencies, value-based reimbursement, and an increase in patient engagement, essentially making it an ideal companion program to participation in incentive programs. By providing the type of focused care that a practice can offer through the use of population health management, reaching the goals of incentive programs becomes easier than ever before.

So why does all this matter?The landscape of healthcare is changing. The focus today is on lowering costs while improving outcomes. The way we do this is by providing the best possible care to individuals by intentionally engaging groups of patients with similar health statuses. Doing so not only provides a better patient experience, it also allows providers to receive higher reimbursement and to be successful in incentive programs. And perhaps most important, providers who engage in a population health management program are at the forefront of what is current in the healthcare industry and not at risk of being left behind in the past.

ConclusionPopulation health management likely isn’t going anywhere. As healthcare becomes increasingly focused on paying according to the value of the care provided, practices will continue to find ways to provide that high level of care efficiently. Population health management is one of those ways. Getting started might sound overwhelming, but with the right tools, it doesn’t have to be. Technology can make starting a population health management program in your practice a breeze. Henry Schein MicroMD offers one such technology in Vivify Health.

Vivify allows practices to increase patient engagement as well as successfully run population health management plus Chronic Care Management. This incredible tool is integrated in MicroMD EMR and is automatically populated with your patient data so that you don’t have to worry about double entry work. Patients can interact with your practice direct from their own mobile devices, and time spent on CCM is automatically tracked to make claiming it for reimbursement easy. If you want to be successful in population health management, look no further than Vivify. Ready for more information? Visit micromd.com/eservices/chronic-care-management or call 1-800-624-8832 to get started.

About Henry Schein MicroMDHenry Schein MicroMD, a subsidiary of Henry Schein, Inc., provides simple yet powerful EMR and Practice Management solutions that facilitate the delivery of superior patient care, automate incentive and quality reporting activities, and streamline operations for today’s busy providers. Full-featured, time-tested, and budget-friendly, MicroMD EMR is 2015 Edition CEHRT certified software that helps small practices, large medical groups, community health centers, and billing services accelerate progress toward a paperless environment and health information exchange with minimal disruption and stress. Learn more at www.micromd.com.

Learn more about Henry Schein’s solutions provider by calling your local representative or visiting HenryScheinSolutionsHub.com.

Discover. Connect. Transform.