An Exciting Journey: Four Phases to Population Health Management Maturity

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An Exciting Journey Four Phases to Population
Health Management Maturity
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• American healthcare system is undergoing change
  at an unprecedented pace.
• New care models are directed at preventive care,
  proactive chronic disease care, and utilization
  management and are being implemented in
  conjunction with payment models that incorporate
  financial risk-taking and incentive management.

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• Emerging provider-driven, practice-based
  population health management (PHM) programs open
  up exciting opportunities that build on the
  physician-patient relationship and demand
  accountability for outcomes.

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• PHM is not a new concept.
• Predominantly driven by payers, it has been
  practiced piece-meal over the last 20 years, with
  generally unsatisfactory results as measured by
  healthcare costs.
• In most cases, payer-driven PHM programs
  consciously avoid the physician role due to
  conflicting incentivesthe more services
  clinicians provide, the higher their payment.

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Four-Phase Model

• Despite their promise, provider-led PHM programs
  do not just form overnight.
• Medical Groups must transition from the
  traditional siloed payer-driven PHM program to a
  provider-driven model that is patient-centric and
  payer-agnostic.

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• As organizations make this journey, they will
  travel through four phases of maturity (Figure
  1)
• The Pilot
• Care Program Development
• Physician-Driven Services
• True Patient Engagement
• Increasing financial returns from shared savings,
  performance-based, or risk-based rewards follow
  each phase.

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• Figure 1 Physician-Led Population Health
  Maturity Cycle

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• Each phase has its own challenges across multiple
  dimensionsleadership, care management processes,
  information technology (IT)/data analytics,
  physician alignment, and patient engagement.
• These challenges change as groups progress
  through the four phases of PHM maturity.

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Factors Impacting PHM Growth
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Phase 1 The Pilot

• The pilot is when an organization will apply to
  become an accountable care organization (ACO)
  with the Centers for Medicaid Medicare Services
  (CMS) or a patient-centered medical home (PCMH)
  with commercial payers and negotiate its first
  risk-based or pay-for-performance contract.
• In the pilot phase, the organization assesses its
  capabilities and the potential benefits of
  developing a PHM program.
• Based on the findings of the readiness
  assessment, an organization could start on the
  path to a PHM program as an ACO or PCMH with one
  payer for a small population of 10,000 to 15,000
  members.

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• Leadership
• Executive leadership (e.g., CEO, president) sets
  the priority by communicating a vision of the PHM
  program for the organization.
• Care Management Processes
• In Phase 1, most of the PHM processes are driven
  by the payer. The payer will want to dictate
  quality performance reporting needs, patient care
  protocols, and provider incentives.

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• A typical PHM process in Phase 1 is illustrated
  in Figure 3
• Figure 3

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• IT/Data Analytics
• During Phase 1, technology requirements for the
  new care processes are identified and a roadmap
  for future infrastructure and applications needs
  is developed. The priority at this stage is to
  get the pilot program rolling with minimal
  investment.
• Physician Alignment
• On the clinical side, most of the challenges in
  the pilot will stem from attempting to garner
  physician alignment.
• Physicians are asked to focus more on preventive
  care and use clinic visits as opportunities for
  proactive chronic care management in order to
  identify and address any gaps-in-care. Initially,
  most of these processes will be ad hoc, episodic,
  and not systematically followed across the
  provider network.

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• Patient Engagement
• Patient engagement in Phase 1 is very basic and
  also driven by payers. Most of the proactive
  patient involvement relates to educating patients
  about managing their chronic diseases.

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• Challenges/Recommendations
• The consultant trap
• IT stickiness
• Naysayers
• Divided attention

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Phase 2 Care Program Development

• After experiencing financial benefits from the
  initial pilot, the organization gears itself for
  Phase 2 of the maturity cycle of the PHM
  initiative.
• This preparation is reflected in increased
  budgets for staffing, care management processes,
  and technology, whose scale-up costs are
  estimated from the pilot phase.
• To be successful in phase 2, an organization must
  undertake more risk-based contracts and manage a
  larger population under different payment
  modelsPCMH, ACO, shared services, bundled
  payments, etc.

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• Leadership
• Phase 2 requires a strong PHM leadership to
  maintain focus on the long term. Providers will
  create a management level position.
• Providers will also start developing their own
  standardized care management process based on
  their experiences during the pilot phase.
• Care Management Processes
• Phase 2 starts with most of the care management
  processes still driven by the payer. Each payer
  will want to dictate its own quality performance
  reporting needs, patient care protocols, and
  incentives. In most cases, the payer provides the
  resources for the dedicated care coordination
  services care coordinators may operate within
  provider facilities, but will still be under the
  payers payroll.

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• A typical PHM process in Phase 2 is illustrated
  in Figure 4
• Figure 4

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• IT/Data Analytics
• Goals within IT move from basic quality reporting
  to population analytics capabilities to identify
  gaps in care, risk stratify populations,
  determine which physician patient populations are
  meeting quality and cost targets, and report
  outcome measures.
• Physician Alignment
• Phase 2 starts the shift from anecdotal-driven to
  data-driven performance management. Organizations
  use the data to identify disparities of care
  costs and outcomes at the physician level.
  Performance metrics are outcomes based (e.g., ER
  visits, hospitalizations, re-admissions,
  utilization, etc.).

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• Patient Engagement
• In Phase 2, the trust between the physician and
  patient is leveraged to implement PHM programs
  more effectively. Providers start identifying
  population cohortshigh cost, high risk, high
  utilizers, etc. Patient engagement is proactive,
  involving outreach programs and physician visits
  to ensure care compliance and medication
  adherence.
• The end of Phase 2 is where power starts shifting
  to the provider the provider knows what actions
  need to be taken to start driving the PHM
  process, but also recognizes the organizations
  gaps in capabilities and need to build internal
  competencies to start taking control of the
  process.

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• Challenges/Recommendations
• Clinical integration chaos
• Over investing in IT
• Limited resources
• Data disorder

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Phase 3 Physician-Driven Services

• The key in Phase 3 is designing and incorporating
  PHM processes with physician-led, practice-based
  care management processes.
• Phase 3 puts even greater focus on provider
  accountability as most of the PHM processes are
  now driven by provider organization resources.
• Managing populations starts to become
  payer-agnostic.

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• Figure 5 shows the changing influence of payers
  and providers as organizations progress towards
  becoming a high-performing PHM organization.

Figure 5
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• Leadership
• The priority of executive leadership is to
  transition from developing to operationalizing
  PHM processes.
• Care Management Processes
• By Phase 3, the provider organization has more
  than 30 percent of business under risk-based
  contracts PHM care processes are also extended
  to the practices entire population with the
  mindset that all patients are under
  pay-for-performance contracts.

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• A typical PHM Process in Phase 3 is illustrated
  in Figure 6
• Figure6

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• The provider organization now employs their own
  care coordination team led by physician
  leadership, establishes the standardized
  evidence-based care protocols, and starts
  leveraging the EHR data for predictive modeling
  and risk stratification.
• For the first time, the providers are able to
  marry clinical data from the EHRs with claims
  data and demographics to get a 360 degree view of
  the patients risk. Providers now understand
  clinical and non-clinical risk factors by patient
  and which factors can be controlled and which
  cannot.

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• They are able to continually stratify the
  population into risk categoriescritical (high
  risk, high cost), high utilizers (low risk, low
  cost), hidden (high risk, low cost) and
  relatively healthy/unknown (low risk, low cost)
  on a monthly basis.
• Providers start tracking the mover population
  cohorts as they move from low-cost to high-cost
  categories (as shown in Figure 7).

Figure 7
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• IT/Data Analytics
• Required infrastructure in Phase 3 includes an
  internal data warehouse to collect data from
  disparate sourcesEHR, payer claims, practice
  management system, health risk assessments etc.
  Tools must also include flexible quality
  reporting engines to enable reporting of
  different measures for different risk programs.
• Physician Alignment
• In Phase 3, physician alignment is completed.
  There is transparency of performance data by
  physician, facility, program, and patient cohort.

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• Patient Engagement
• Every patient encounter is leveraged to address
  the care gaps identified by the analytics and
  seamlessly reported to the physician at point of
  care through the EHR. Each patient is treated
  with the same care protocols irrespective of the
  health plan.
• The physician and care management teams work as a
  team and are evaluated by their PHM metrics.

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• Challenges/Recommendations
• Information technology trap
• Non-champions
• Shifting accountability

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Phase 4 Patient Engagement

• In Phase 4, PHM becomes the normal course of
  business.
• The patient is now treated truly as a healthcare
  consumer and patient engagement becomes a
  round-the-clock effort.
• Patient care becomes integrated care, with
  hospitals, physician groups, skilled nursing
  facilities, and community health services all
  working together to provide a continuum of care.

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• Leadership
• Leadership requirements in Phase 4 are totally
  different from requirements in Phase 1. Every
  discussion and decision about care is data
  driven.
• Strategic leadership skills include the ability
  to work in collaborations with other providers in
  the integrated network and learning to manage
  partner assets (e.g., imaging/diagnostic
  equipment) without owning them.

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• Care Management Processes
• Irrespective of the payer and risk contract, the
  business of care is driven by a systematic
  process that can be broken down into these steps
• Analyze the total population and micro-segment it
  into cohorts based on clinical and non-clinical
  risks.
• Identify the drivers of each risk and whether
  they are controllable or non-controllable in the
  short or long term.
• Design optimal care management programs with both
  provider-driven and patient engagement components

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• Prioritize the care programs based on costs,
  complexity to execute, available competencies,
  and time to realize value. Execute the programs
  by aligning the incentives for caregivers and
  patients
• Track ongoing performance to measure program
  effectiveness, provider performance, and patient
  adherence. Tweak the programs to fix any gaps.
• Report the performance in terms of the impact and
  trends on outcomes (hospitalizations,
  re-admissions, ER visits) and per member per
  month costs.

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• The PHM process become very sophisticated with a
  closed-loop continuum of care as shown in Figure
  8.

Figure 8
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• IT/Data Analytics
• An organization in Phase 4 is in the race to
  become a world-class healthcare leader.
  Technology and data provide the foundation for
  how care management is designed and delivered.
• Physician Alignment
• On the clinical side, care management functions
  are decentralized to physician clinics to
  increase access. Leadership needs to focus on
  keeping physicians engaged and ensure there is
  minimal performance burn out.

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• Patient Engagement
• Patients start operating as active healthcare
  consumers by becoming more involved in their own
  health decisions and understanding their risks
  and how they can engage with providers.
• Health plans have significant incentives and
  disincentives for patients to adhere to best
  practices and keep healthy.

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• Challenges/Recommendations
• Failure at the top
• Data security
• IT systems integration

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• Population health management that keeps the
  population healthy and lowers healthcare costs is
  a journey.
• The time it takes an organization to move from
  one phase to the next depends on leadership will
  and commitment, organization willingness to
  change, financial resources, external market
  demands, and flawless execution.

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• Figure 9 shows a representative balanced
  scorecard that can be used to determine the
  progress of an organization along the PHM
  Maturity Cycle.

Figure 9
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• For the organization to inculcate the values and
  vision of the retooled care delivery system, the
  CEO and senior executives must embrace the new
  model of care early on.
• The velocity of change will differentiate the
  winners from the losers in the race for market
  leadership in the changing healthcare delivery
  ecosystem.

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• Authors
• Dr. Michael (Mike) Deegan, Clinical Professor for
  Healthcare Leadership and Innovation in the
  Naveen Jindal School of Management at The
  University of Texas at Dallas.
• Karen Kennedy, CEO of Kangent Consulting, Inc.
  Former CAO of Medical Clinic of North Texas (1999
  -2012).
• Jay Reddy, Founder CEO of VitreosHealth, a
  leader in predictive population analytics.

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• Read full article here
• http//www.vitreoshealth.com/index.php/population-
  health-management-maturity
• For any query please contact Sandeep Misra at
  smisra_at_vitreoshealth.com