An Exciting Journey: Four Phases to Population Health Management Maturity - PowerPoint PPT Presentation

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An Exciting Journey: Four Phases to Population Health Management Maturity


American healthcare system is undergoing change at an unprecedented pace. While past transformations were driven by discoveries in medicine, treatments, and procedures, the need to keep the population healthy is driving the current transformation. 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. The article written by Karen Kennedy, MichaeI Deegan & Jay Reddy shows about different phases an organization travels through Population Health Maturity, challenges faced by them and how to overcome those challenges. Read full article here: – PowerPoint PPT presentation

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Title: An Exciting Journey: Four Phases to Population Health Management Maturity

An Exciting Journey Four Phases to Population
Health Management Maturity
  • 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.

  • 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.

  • 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.

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

  • As organizations make this journey, they will
    travel through four phases of maturity (Figure
  • 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.

  • Figure 1 Physician-Led Population Health
    Maturity Cycle

  • 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.

Factors Impacting PHM Growth
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

  • 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.

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

  • 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
  • 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.

  • 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.

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

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
  • 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.

  • 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.

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

  • 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.).

  • 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
  • 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

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

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

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

Figure 5
  • 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.

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

  • 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

  • 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
  • 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.

  • 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.

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

Phase 4 Patient Engagement
  • In Phase 4, PHM becomes the normal course of
  • 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.

  • Leadership
  • Leadership requirements in Phase 4 are totally
    different from requirements in Phase 1. Every
    discussion and decision about care is data
  • 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.

  • 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
  • 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

  • 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
  • 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.

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

Figure 8
  • 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.

  • 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.

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

  • 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.

  • 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
  • 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

  • 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
  • Jay Reddy, Founder CEO of VitreosHealth, a
    leader in predictive population analytics.

  • Read full article here
  • http//
  • For any query please contact Sandeep Misra at
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