There are roughly 900 health insurance companies in the United States. The five most popular payers — UnitedHealth Group, Anthem, Kaiser Permanente, Ambetter and Humana — comprise 50 percent of health insurance enrollment

Although they vary by size and the number of members served, most payers face similar challenges, including managing costs while dealing with the rising cost of care, developing operational efficiencies, improving member satisfaction and aligning incentives with providers. They also encounter a growing demand for access to real-time data, uncertainty over healthcare reform, workforce shortages and outdated administrative systems. 

Many payers are now developing population health management (PHM) strategies to address chronic care management and meet the goals of value-based care. By driving strong PHM, health insurance companies have the potential to excel in this value-based care model that relies on quality measures and patient outcomes to define successful care. 

Common population health management goals for payers often include:

  • 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

Components of a Successful Payer PHM Program 

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

For PHM programs to be successful for payers, they are tasked with developing and implementing ones that net them the biggest clinical and financial gain — without a hefty investment. A key component to achieving this is collecting and analyzing real-time patient data. 

By having access to such data, payers are better able to target interventions, improve resource allocation and achieve more informed decision-making. Data also enables health insurance companies to better define value and gauge provider quality. 

Popular metrics payers utilize to measure provider quality include 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 will not be able to effectively improve patient outcomes or lower healthcare costs. 

Perks of Payer-Based Population Health Management 

When PHM programs are developed and implemented correctly, they can have a marked impact on quality of care, costs and patient outcomes. By investing in advanced analytics to tailor PHM 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 PHM program that helps them prosper under the value-based care model. 

The Providertech Approach to PHM 

At Providertech, we know that your members are more likely to adhere to care plans and seek preventative care when they are 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 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!