Population health management: A key driver of value-based care

Dr. Sarah Matt, Vice President of Solution Strategy, NextGen Healthcare

The industry is abuzz with talk about population health management, but there is some confusion about how to practically work within these kinds of programs to achieve broader value-based care initiatives. A strong population health effort can deliver both clinical and financial value to a physician practice, serving as a key mechanism for value-based care. When designed well, a population health program can proactively identify high-risk patients and transition them into preventive care – which can not only improve patient outcomes but also remove costs from the system.

Organizations that look at population health management as part of an integrated value-based strategy will realize the most success in delivering better health outcomes for lower costs.

How can organizations make sure that their population health programs facilitate value-based care? Here are three steps to keep in mind. 

Obtain stakeholder agreement

Success with any population health management program begins with stakeholder agreement. Clinical and financial leaders must identify, agree to and buy into the program’s specific definitions and goals. Since population health definitions vary widely across the industry, reaching agreement may require educating organization leaders on the options and discussing what the practice itself wants to achieve. For example, some practices manage populations within the parameters of incentive and reporting programs, while others take a broader approach to improving overall practice health. Still others are acutely focused on reducing the costs of care for specific populations, such as individuals with diabetes.

Stakeholders should discuss how the population health program will support value-based care and what specifically that relationship will look like. Once a vision is clearly articulated, providers can then make strategic choices regarding resources, tools and processes for effectively leveraging available data, minimizing risk and building strong patient-provider alliances. Limited resources necessitate that providers make informed decisions that deliver the greatest return on investment. As such, healthcare organizations must sort through all the chatter and identify the best strategies and technologies for achieving the specific goals that are relevant to their needs.

Look at what you’re already doing

A physician practice may already have the building blocks of a population health effort in place depending on the regulations or requirements it follows for current quality reporting programs. For instance, if a practice is a Patient Centered Medical Home (PCMH), it is already collecting data for and reporting on quality measures. By aligning population health efforts with PCMH requirements, organizations can stand up a population health initiative to further power its value-based care efforts. For instance, a population health strategy targeted at improving the rates of hemoglobin A1c and eye exams for diabetes patients can not only improve the health of that population but it can serve as a catalyst for achieving PCMH incentive payments, delivering notable ROI in a relatively short timeframe.

In the same way, the recent finalization of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provides a significant opportunity for alignment. Building population health management programs around the same measures and clinical focus areas outlined in MACRA is a reasonable and rational tactic – especially considering the increased financial risks introduced by the regulation. Leveraging a consultant like NextGen Healthcare to help your practice draw the parallels between MACRA and population health initiatives can bring these efficiencies to light.

Establish a technology infrastructure

Once an organization agrees on the goals of a population health management program and determines where to start, it should make sure it has the tools in place to support the program. This is important not only in terms of capturing and reporting information but also in helping deliver more proactive and cost effective care.

For the organization to get the most out of the technology, it must get its physicians and patients excited about using it – otherwise the ROI potential is minimal. The right approach engages all stakeholders in the process early, educating them on the goals of the overarching programs, the value of the technology and how to use it, as well as soliciting feedback along the way. When physicians are on board, implementation plans can create excitement around new workflows. This enthusiasm will naturally spread from physicians and staff to patients as the organization begins using the technology to further the program.

Once physicians and patients embrace the program, a practice can fully leverage patient engagement tools. Instead of waiting until a patient has a problem, for example, the practice can use the various tools to send reminders that prompt preventive care. The reality is that even chronic patients are only seen by their providers every couple of months, limiting the ability of physicians to effectively manage day-to-day health choices. Thus, patient-provider communication tools are critical to circumventing the potential for adverse events and improving outcomes.

Consider a practice that has identified a population health initiative centered on flu prevention. A variety of messaging techniques – including everything from direct mail and automated phone messaging to email, patient portals and text messaging – can be used to remind patients to get a flu shot. Taking it a step further, automation can then enable patients to schedule an appointment to comply with the request in real-time. With these techniques in place, practices can ensure that staff work at the top of their license. For instance, nurses don’t need to spend time reminding patients to come in but can actually staff the flu shot clinics, allowing more patients to receive vaccinations and avoid acute care visits. Not only does this help with overall population health, it also opens up physician schedules to focus on more at-risk patients, aligning multiple value-based goals.

Moving forward together

The idea that an organization can improve the overall health of its population is exciting, and frankly, it is what most clinicians got into medicine to do. By aligning all stakeholders in a common pursuit, marrying population health initiatives with current value-based work and fully leveraging a strong technology infrastructure, organizations can take a significant step toward better population health and greater value.

MARCA, Medicare Access and CHIP Reauthorization Act of 2015, NextGen Healthcare, Patient-Centered Medical Home, PCMH, Population Health Management, value-based care


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