Leveraging an Integrated Population Health Model to Improve Costs, Quality, and Satisfaction

“Looking at cost versus quality as it relates to life expectancy, we are number 1 in one thing, and that is cost,” said Cary Shames, DO, CHCQM, ABQAURP vice president and chief medical officer, Sharp Health Plan, during a session on population health management at the National Association of Managed Care Physicians 2019 Fall Managed Care Forum, held October 10-11 in Las Vegas, Nevada.

Shames began by outlining the well-known problem that the US healthcare system faces: Healthcare in the United States comes with a higher cost but not always with better outcomes. In fact, according to Shames, healthcare in the United States is 2 to 3 times more expensive than that in any other industrialized country. At the same time, life expectancy is considerably worse than those countries, he added.

For example, a colonoscopy in the United States comes with a price tag of $1185 and costs nearly half that ($655) in Switzerland. It’s also well-known that the issue carries over to drugs, as well. Lipitor in the United States costs $124 while it costs just $6 in New Zealand.

Additionally, the United States, compared with other industrialized countries, has a problem with medical, medication, and lab errors, said Shames.

According to Shames, taken together, these factors underscore the need for a population health management model that encompasses 3 pillars, which offer a health system the ability to analyze big data of a population in order to best manage the individuals within that population:

1. Know what is happening and predict what will happen
2. Engage providers and patients in the health and care delivery
3. Manage health and care to improve the quality of lives

“Simple, but not as easy to do,” said Shames, who took a step back and said that the idea of moving to a population health strategy is a seismic change in how health systems view and deliver healthcare.

But, the strategy reaps benefits, he said. For example, a 2018 survey from the Healthcare Intelligence Network found that 71% of responding organizations said patient satisfaction has increased as a result; 64% of organizations said that medication adherence has improved; and 61% of organizations attribute a decrease in emergency room visits to population health management initiatives.

Before digging deeper into the different aspects of such a strategy, Shames emphasized the need for these efforts to focus on healthy and at-risk patients the same way they focus on the sickest patients that account for the majority of healthcare costs, because as time goes on, if efforts are not spent on these healthy and at-risk patients, they will move toward the sicker end of the spectrum, and their costs will accrue significantly.

Shames then offered a look into the population health management model implemented by Sharp Health Plan, which offers health insurance to more than 149,000 people in San Diego, California. The model is built on an approach that encompasses data aggregation, comprehensive care, and measuring performance, all of which is based on a value-based reimbursement model.

Aggregation of data and population assessment

The health plan collects and aggregates a wide range of data sources and then passes that information to the point of care, which Shames said allows proactive management of their populations. These data include clinical data, administrative data, and program data.

This information is then fed into a predictive tool, which stratifies patients as healthy members, members with emerging risks, members with acute care illness, members with chronic illnesses, or members at end-of-life care. Within these categories, patients are further stratified to get a more granular look at where they are in terms of their current health and predictive health.

Integrated care

Once a patient is enrolled in a plan, they choose or are assigned to an in-network primary care provider, who directs the healthcare of the member; is part of an integrated care team that partners with specialists, hospitals and the health plan; has prescription drug responsibilities; and is increasingly addressing behavioral health.

Care interventions include member-targeted interventions, such as health coaching and diabetes case management; integrated-system collaboration interventions, such as those for social determinants of health, member—practitioner interaction, and hospital communication and information sharing; and community resources, such as food banks.

The health plan also implements patient safety initiatives, which include polypharmacy reporting, opioid misuse monitoring, and readmission prevention.

The final portion of integrated care includes an expanded access network of not just primary care, specialty care, and hospitals, but also telehealth services, urgent care facilities, CVS minute clinics, worksite wellness, and emergency travel services

Measuring effectiveness and impact

On a monthly, quarterly, and yearly basis, the health plan offers providers measurements on their clinical, cost/utilization, and member experience. Providers also have access to a physician dashboard that provides monthly assessments of patient outcomes and other performance measures, as well as a point-of-care reporting tool to help physicians manage the patient in front of them.

Value-based reimbursement

Arguably the most important aspect, according to Shames, is that the model is based on value-based reimbursement, in which all other parts of the integrated delivery system fall under. Under the capitated, fully delegated model, all providers that touch the patients within the health plan provide coordinated care—sharing both data and outcome goals.