Strategic Quality Improvement Imperative: Population Health Management
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Strategic Quality Improvement Imperative: Population Health Management
Despite spending more on healthcare than any nation, the U.S. health system ranks last or next to last on high performance dimensions when compared to health systems of six other developed nations — Australia, Canada, Germany, the Netherlands, New Zealand and the United Kingdom (Davis et al., 2010).
Although there are many reasons for this ranking, one is the fact that Americans receive only half of recommended care. Another is poor management of the more than 40% of Americans afflicted with chronic diseases such as heart disease, stroke, cancer, diabetes, arthritis, and obesity that often are preventable. These types of chronic conditions contribute to 7 out of 10 deaths per year accounting for more than 75% of health costs in the United States (CDC; The RAND Corporation).
The Centers for Disease Control and Prevention recently found the prevalence of two or more of nine selected chronic conditions (hypertension, heart disease, diabetes, cancer, stroke, chronic bronchitis, emphysema, asthma, and kidney disease) increased significantly from 1999 to 2000 and from 2009 to 2010. Over that 10-year period, the percentage of adult men and women aged 45 to 64 with two or more chronic conditions jumped from 16.1% to 21%. Meanwhile the percentage of those aged 65 and over with two or more chronic conditions rose from 37.2% to 45.3% (Freid et al., 2012).
These statistics explain why hospitals, health systems, physicians, and policymakers increasingly are considering using population health management (PHM) programs to improve quality and mortality, minimize disease progression, reduce readmissions, and bend the cost curve.
Under PHM programs, providers stratify large populations to ensure high-risk individuals and groups receive the quality of care that they should. Providers focus on identifying high-risk chronic patients, applying appropriate and coordinated interventions that proactively impact care across the continuum at both the individual and population levels, and tracking and monitoring clinical performance.
The rapidly aging population is also driving hospitals toward PHM as the risk of developing one or more chronic conditions rises with age. For example, the percentage of adults aged 65 and over with hypertension and diabetes increased from 9% to 15%; hypertension and heart disease from 18% to 21%; and hypertension and cancer from 8% to 11% over the past decade (Freid et al., 2012).
The push toward the PHM concept is being driven by several factors: healthcare payers’ urgent demands for providers to manage and reduce rising prevalence of chronic diseases, the extension of health insurance to 30 million uninsured Americans in 2014, meaningful use of electronic health records (EHRs), the emerging shift from fee-for-service to outcomes-based reimbursement, and growing movements to create care delivery transparency and accountability.
Three Building Blocks
PHM today is still in its infancy because most providers are still struggling with the development of the following three foundational components required to launch such initiatives:
• Organizational vision, leadership and commitment
PHM fundamentally alters the way organizations deliver care. This transformation requires a health system’s leadership to develop a clear and compelling vision to mobilize their organization to a proactive, patient-centered, coordinated, collaborative, and multidisciplinary care model.
To achieve that approach hospitals and health systems must communicate and explain their vision and objectives to win over employees and physicians inside and outside their enterprise. It also will be essential for them to establish a governance structure (e.g., policies and procedures) to coordinate medical services; define and manage information for analytics, reporting, and continuous quality improvement; and drive shared decision-making and accountability with unaffiliated providers as well as patients. All of these initiatives will require significant leadership, commitment, and investment from hospitals (Cassell et al., 2012).
• Information technology (IT)
IT is key to effective PHM. Providers will need EHRs, clinical decision support, registries, analytic tools, data warehouses, health information exchange (HIE), and predictive modeling software (Cassell et al., 2012). These solutions will enable hospitals to collect, store, and analyze patient data; generate actionable information to support appropriate and timely interventions; optimize adherence to clinical guidelines; monitor the results from those interventions; and ensure the most effective and informed treatments possible are dispensed to patients. These technologies also will help organizations predict potential outcomes and manage resource utilization and risk more efficiently.
Healthcare facilities will also need to build or join health information exchanges to share data with external health systems and use tools such as patient portals to empower patients to become more involved in the management of their medical problems. With consumers and clinicians rapidly adopting smartphones and tablets in their personal and professional lives, it will be critical for providers to incorporate one or more mobile devices into their PHM effort.
• Cultural change
Shifting focus to health, wellness and prevention, care collaboration, provider accountability and patient engagement will require deep cultural change and commitment across all levels of an organization.
Enterprises must build a new culture on three fronts. First, they need to change the mindsets of nurses, physicians, and employees within the organization. A PHM program has little chance of succeeding if individuals fail to embrace and execute the innovative care model.
Second, providers will have to engage patients to improve clinical outcomes and decrease deaths. They can accomplish this by working with individuals to increase adherence to the care plan and come in for recommended screenings, and manage and encourage people to exercise, eat better, cease smoking, and reduce alcohol consumption—all to help prevent or reduce chronic conditions.
Third, facilities will need to overcome their mistrust of insurers. It will be critical for hospitals to partner with payers to ensure patients receive appropriate treatments; promote healthier lifestyle behaviors; and support early detection and diagnosis of chronic diseases. Cooperation between the two parties will accelerate provider implementation of PHM initiatives and lower start-up costs by giving providers access to analytic tools and information. Payer and hospital collaboration is beginning to occur. Last October, for example, Cigna and Banner Health Network announced an accountable care organization (ACO) initiative to expand patient access to health care, improve care coordination, and manage population health. Effectively managing population health is a necessary requirement of an ACO in order to minimize effects of chronic diseases and prevent onset of certain diseases.
Pioneering health systems such as Banner Health Network are starting to tackle the organizational, technological and cultural barriers impeding PHM. However, most providers are waiting for the federal government to define objectives for Stage 3 meaningful use of EHRs before implementing PHM programs. Stage 3, intended to emphasize outcomes improvement, population health, and patient engagement, is expected to begin in 2016. But with the immense pressure to provide proactive high-quality care and value-based outcomes and the number of people with chronic conditions climbing sharply, health systems are recognizing that they cannot afford to wait four more years to implement PHM programs. Providers taking action toward PHM now will gain significant competitive and financial advantage as health reform advances to new reimbursement models and Stage 3 becomes a reality.
Nalin Jain is delivery director of Healthcare Advisory Services at CTG Health Solutions and a healthcare information technology services leader with more than 25 years of executive, operational, and consulting experience in the provider and payer segments. Jain may be contacted at Nalin.Jain@ctg.com.
Robin Keeney is delivery manager of Healthcare Advisory Service at CTG Health Solutions. She has more than 30 years of experience in the healthcare industry including 15 years of consulting experience in revenue cycle, health information management, clinical documentation management, and EHR optimization. Keeney may be contacted at Robin.Keeney@ctg.com.
References
Cassell, C., Kontor, J., & Shah, L. (2012). Population health management: Leveraging data and analytics to achieve value. Retrieved at http://www.ctg.com/industries/healthcare-providers/thought-leadership/white-papers/).
Centers for Disease Control and Prevention (CDC). Chronic Disease Prevention and Health Promotion. Retrieved from http://www.cdc.gov/chronicdisease/overview/index.htm
Davis, K., Schoen, C., & Stremikis, K. (2010, June). Mirror, mirror on the wall: How the performance of the U.S. health care system compares internationally, 2010 update. The Commonwealth Fund. Retrieved at http://www.commonwealthfund.org/Publications/Fund-Reports/2010/Jun/Mirror-Mirror-Update.aspx
Freid V. M., Bernstein, A. B., Bush, M. A. (2012). Multiple chronic conditions among adults aged 45 and over: Trends over the past 10 years. NCHS data brief, no 100. Hyattsville, MD: National Center for Health Statistics.
The RAND Corporation. The First National Report Card on Quality of Health Care in America. Retrieved from http://www.rand.org/pubs/research_briefs/RB9053-2/index1.html