Unless you haven’t read any news over the past few years about healthcare, you’ve undoubtedly come across many pieces about top industry trends. Most publications list population health. 

Why has population health so seemingly quickly been catapulted to the forefront? One of the primary reasons is the transition to value-based care. As we mentioned in a recent blog, value-based care programs are those that reward healthcare providers with incentive payments for the quality of care they give to people with Medicare and support the agency’s three-part aim of better care for individuals, better health for populations and lower cost. These programs focus on patient-centered care with the goal of improving outcomes by reducing hospital admissions and readmissions, improving preventive care and delivering more personalized care for chronic care patients.  

Managing population health isn’t only for healthcare providers, though. Payers also are focused on initiatives to address chronic care management. In fact, many payers in the United States have over the past decade or so implemented some type of population health management (PHM) program. 

The Integration of Population Health Management Programs with Value-Based Care 

Like those of their provider counterparts, healthcare payers’ population health management programs must address problems that contribute to poor health conditions in specific populations. Although most payers previously utilized only claims-based risk stratification to assess which members were the highest users of various healthcare services, most programs now employ ones that also account for and address social determinants of health (SDOH). 

For population health management programs to be successful for payers, they’re tasked with developing and implementing ones that net them the biggest clinical and financial gain — without a hefty investment. As with healthcare providers, common population health management goals for payers consist of:

  • Reducing the number of diagnosed diabetics with uncontrolled blood sugar (A1C greater than 9)
  • Increasing exercise rates among children and adolescents with higher BMI measurements
  • Reducing costs of avoidance emergency department utilization
  • Increasing the number of weekly “Healthy Days” experienced by patients diagnosed with depression
  • Improving the number of adults who receive vaccinations for pneumonia, shingles, and other preventable diseases
  • Encouraging smoking cessation and reducing any type of tobacco use among adolescents and adults 

What role does value-based care play in these payer population health management programs, though? Models that promote value-based payment aid in aligning provider and payer incentives. The result is effective population health management. 

What metrics do payers use to define value and gauge provider quality? There are many from which to choose, but a majority of payers select from areas such as inpatient admissions, emergency department visits, laboratory and pathology services, medical and pharmacy drugs and radiology. 

Without these metrics and other necessary data, payers will most likely fail in the transition from fee-for-service to value-based care. They won’t be able to effectively improve patient health outcomes or lower healthcare costs. 

Advantages of Payer-Based Population Health Management 

When population health management programs are developed and implemented correctly, they can have a marked impact on quality of care, costs and patient health outcomes. By investing in advanced analytics to tailor population health management initiatives to support their members, they also increase member satisfaction while addressing existing health disparities. 

In addition to the use of analytics, automation assists healthcare payers in closing gaps in patient care, promoting preventive care through numerous screenings and removing access barriers that prevent members from receiving the care they need. Other technologies enable them to aggregate and share electronic medical record data among all members of the extended care team. These tools combined allow them to utilize a population health management program that helps them prosper under the value-based care model. 

Population Health Management Program Challenges for Payers 

If utilizing population health management offers so many advantages, why don’t more payers engage in such programs? According to PwC, the biggest challenges facing payers in care management are that approximately 60 percent of adults have at least one chronic disease, and adults with chronic conditions have a two to eight times greater likelihood of hospitalization. 

Along with these obstacles, payers often are challenged by conducting appropriate levels of care coordination, patient outreach and disease management. And, those quality metrics we mentioned earlier in the blog? There are so many of them that sometimes payers aren’t able to adequately keep up with them. 

At Providertech, we know that your members are more likely to follow recommended care, including seeking preventative care, when they’re engaged in their own health. We collaborate with you to help you achieve clinical and quality goals using HIPAA-compliant text and voice messages that are delivered based on what works best for your business. Our CareCommunity platform helps you reduce wasted time by 75 percent and automatically identifies target segments to support your personalized population health campaigns. Schedule a demo with us to learn more! 

Connect with Lisa on LinkedIn to learn more about population health management.