Most physician practices contract with multiple private payers along with Medicare and Medicaid. Historically, each of those payers requested different quality measures, even using different criteria for ostensibly similar measures, and offered a variety of pay-for-performance programs. The result, one patient has Payer A, measuring success one way, while another has Payer B, who will measure it differently. Clinicians must approach each patient thinking about doing their best for that person, and not about the differences in how insurers measure quality.
Today, as the industry continues its shift to value-based care, clinicians continue to struggle: How do we do what’s best for the patient while still getting paid for the services we provide under an outcomes-based structure that is the core of value-based care? The answer is—population health management.
Defining your Patient Population
To effectively manage the health of a patient population, providers must be able to define the population as is most appropriate for their practice. Possibilities include, dividing patients into groups by payer, geographic area, or, perhaps, people with a specific condition.
"To effectively manage the health of a patient population, providers must define the population as is most appropriate for their practice"
No matter how providers define their populations, electronic health records (EHRs) and population health tools must be able to help them identify members of the population and turn the available data into information clinicians can use to direct care while continuing to refine the data over time.
The information needs to be presented in an efficient manner to help address two essential questions from clinicians:
• What to do for the patient who’s in front of me?
Every office visit is an opportunity to deliver more complete care for patients. However, when primary care physicians are going from patient to patient, seeing them for an unrelated condition, it’s easy to miss chances to ensure that patients are current with all their preventative care such as vaccines, mammography, or colonoscopy.
• What to do for the patient who’s not being seen?
Under value-based care, providers will be responsible for the outcomes of an entire population. Providers and health systems need to utilize both EHR and claims data to identify those patients who are rarely seen, and then need a mechanism to reach out to them. In this way providers can ensure the entire population is up to date on vaccines, or the diabetic population is regularly reporting blood sugar levels along with receiving annual foot and eye exams.
Heart failure patients are a significant proportion of hospital readmissions and, despite significant efforts, hospitals have not seen much success in reducing that number. According to a study in Circulation Heart Failure (Circ Heart Fail. 2016; 9e002594.) looking at the American Heart Association get with the Guidelines registry data, the 30-day readmission rate for heart failure patients remained at 19 percent in 2012 down slightly from 20 percent in 2009. Sudden weight gain can signal a patient’s worsening condition and need for intervention. If clinicians can track someone’s weight daily—say with an internet-connected scale—then they can see 1) patients that experience weight gain, or 2) patients who aren’t submitting weight measurements. A follow-up phone call along with early intervention can potentially help keep those patients out of the hospital and lead to better outcomes. The key in managing the data is in enabling the system to identify the patients at risk versus a manual review to keep the overall workload manageable.
Flexible Systems to Facilitate Change Across the Continuum of Care
Advanced analytics are making it increasingly possible to slice and dice the data providing a variety of views of patient populations. The importance of this capability will continue to increase as the shift to value-based care continues.
Technology must help enable providers to manage patients across the entire continuum of care. Patient information and care plans must be securely accessible to multiple providers to ensure coordination throughout our fragmented system as helping maintain a healthy population is not limited to any individual care setting.
We’ve come a long way, but there is more change to come. We continue to see new requirements in the reimbursement system, most recently with the Medicare Access and CHIP Reauthorization Act (MACRA) and its associated Quality Payment Program. That’s why it will be important to build systems flexible enough to respond to clinical and payment needs in a constantly changing industry.
As value-based care continues to evolve, no one is exactly certain what to expect other than continued change. However, there is general agreement on how the U.S. healthcare system structures reimbursement will continue to drive many of the decisions about what, when, and how care is delivered. Throughout, it is critical to remain focused on one fundamental priority to maximize the likelihood of making the right decisions: What’s best for the patient?