Population Health Management: A Path to Value

This report is based on a webinar presented by John Moore, CEO and Founder of Chilmark Research, on August 7, 2019, titled, “Population Health Management: Path to Value.”

Regulatory changes demand that providers take on more risk and have the appropriate IT infrastructures to do. Thereforevalue-based care(VBC) and population health management (PHM) are increasingly integral to future healthcare technology and market trajectories. Meeting PHM goals requires significant investment, and organizations are still seeking better understanding of the PHM landscape, how to derive benefit from it, and how to achieve positive ROI from investments in PHM strategies.

Defining Population Health Management: A Strategy, Not a Product

人口健康管理是一项主动的、以数据为驱动的战略，重点是通过与社区合作实现的有财务联系的确定的提供者网络来改善特定人口的健康。针对2010年通过的《平价医疗法案》(ACA)和人口风险从支付人向提供者转移所引发的全国范围内基于价值的倡议，围绕PHM的组织努力已经升级。服务提供者正在转向更积极主动的护理模式，以降低成本和提高质量。

Health systems need four core elements to enable PHM:

1. The enterprise data warehouse to leverage analytics/algorithms and visualization tools to understand, track, and report on population activity and measure improvements.
2. An interoperability engine to extract data from EHRs and other sources and deliver insights into the clinical workflow.
3. 护理管理，以解决慢性护理在门诊部门的目标，以降低利用成本。
4. Patient engagement to enable self-care (another means of lowering utilization cost).

按照上面的四个支柱，人口健康是一个参与系统(图1)。记录系统(基本软件/托管过程)往往是分层的，基于事务，响应慢，部署周期长，关注内部。另一方面，参与系统以面向患者的信息形式提供从临床工作流程到人群的延伸。参与系统方法帮助患者做出适当的卫生决策，最终扩展到卫生系统如何管理一个区域或社区内的人口。

How Is Population Health Management Evolving?

Population health management capabilities have steadily expanded over the decades from PHM 1.0 (mid 1990s) to PHM 2.0 (around 2012) through PHM 3.0 (2020 and onward):

• PHM 1.0: Initial, incomplete solutions (1.0) primarily served payers with claims-driven analytics for reporting, had limited visualization and analysis and no patient or community engagement capabilities.
• PMH 2.0: With PHM 2.0, solutions started coming to the market that could address a number of the needs for meeting the four pillars of PHM described earlier. The 2.0 iteration added a provider focus with multiple data sources, predictive analytics, and visualization and drill-down tools, while improving delivery of insights in the clinical workflow and adding limited care management and modest engagement functionality.
• By early 2020, PHM 3.0 has evolved beyond payers and providers to a market-agnostic focus in which PHM is a true open API/ecosystem that sits atop a robustenterprise data warehouse(EDW) and analytics engine that engages the full-care continuum. The bottom of 3.0 (Figure 2) includes systems of record (including home monitors, mobile devices, etc.) that feed up into the EDW, where the data aggregation and normalization occur via FHIR and other open APIs. FHIR and APIs then deliver analytics insights and visualizations into a range of applications designed for particular needs (e.g., chronic disease management, utilization management, community engagement, and patient engagement).

What PHM Challenges Remain?

Even with the PHM evolution to 3.0, key challenges remain in carrying out a population-focused strategy:

• 建立临床整合的网络整合对于从门诊方面了解工作流程至关重要。
• 获得终端用户的信任——有效地将针对特定患者或人群的最佳方法传达给终端用户(例如，临床医生)需要分析的透明性。
• Resolving data quality and latency—a lot of the tools aren’t mature enough to successfully aggregate data, cleanse, and normalize data.

The Slow Migration to Risk

While PHM has matured from 1.0 to 3.0., the industry migration to risk has moved slowly since the passage of the ACA in 2010, with fee-for-service (FFS) payments still comprising a majority. Figure 3 shows the percent of risk-based payments in 2017 with four payment categories, listing those with any downside risk in category 4. As the graph below illustrates, as of 2017, a lot of payments don’t include some form of downside risk. Most payments have been category 1 through 3 (standard fee-for-service or a fee-for-service chassis with some quality metrics and some cost targets, as in category 3).

Organizations continue to struggle with their ability to take on risk, especially downside risk in value-based payment models. In a 2016survey关于人口健康状况，各组织大多预测，到2018年，他们将准备好承担风险。Between 2016 and 2018, however, respondents’ actual readiness to assume risk fell from a 61 percent confidence rate to25 percent.

With market uncertainty, FFS remains the primary source of healthcare revenue in 2019, as organizations decide whether to invest in VBC or wait for more direction from the federal government. A bigger shift towards VBC requires restructuring, resources, and executive commitment, as leadership must drive cultural realignment from volume to value.

Who Are the Major Adopters of PHM?

During the slow migration to risk, three majorPHM adopter profilesare emerging:

#1: Innovators

大约5%的PHM采用者是真正的创新者。他们从战略上关注人群健康，并将能力视为一种基于价值的核心能力。创新者非常关注成本，因为他们已经认为质量是一种能力，现在转向构建他们的成本配置。

#2: Early-Mid Adopters

At 38 percent, the early-mid adopters are process focused, with an eye to workflow. They’re looking at how to get insights into the point of care and enable the physicians, clinicians, and community to make informed decisions. Early-mid adopters are implementing benchmarks of baseline agnostic measures with strict, but reasonable, quality measures. If a payer comes to them with measures that exceed those benchmarks, they will walk away from the contract. Early-mid adopters focus less on cost and more on quality.

#3: Late Adopters

The late PHM adopters, making up 57 percent, are tactically focused. They’re taking a contract-by-contract approach to population health and VBC, typically starting with their own employee base.

这三个关键驱动因素正在推动行业走向风险

In spite of VBC slow progress, notable trends are driving providers to take on more risk:

The Activist Push for Providers to Take on Risk

当前的CMS和HHS管理部门正在积极推动医疗服务提供商承担风险。The most recent rules for theMedicare Shared Savings Plan(MSSP) position ACOs as the pathway to success, giving providers only one year of basically no risk (just upside) on these contracts; after the first year, providers have to assume downside risk as well.

虽然CMS收紧了组织承担风险的窗口，但它也提出了更灵活的豁免，允许组织在如何满足指南方面有更多的选择。Other flexibility initiatives include talk about relaxing theStark Law(the physician self-referral law) and some states moving to acapitatedmodel for Medicaid.

Growth in Medicare Advantage

Medicare Advantage is currently an active market, as over 50 percent of new beneficiaries are choosing it, which is accelerating partnerships between providers and payers. Payers are actively looking for providers they can partner with on Medicare Advantage to improveHealthcare Effectiveness Data and Information Set(HEDIS) scores, as by improving those scores, organizations can maximize incentives.

Employer-Driven Growth in Value-Based Care

Commercial (employer-supported) ACOs are relative newcomers to the payer scene, but employers are looking to support ACOs, basically doubling current contracts by nearly50 percent. Employers are also increasing direct contracting with providers, particularly providers with high-performance networks (networks that can deliver value).

Measuring Population Health Management ROI

Even with the above drivers pushing healthcare towards risk, getting value out of PHM differs among regions in the nation. The local and regional stakeholders (employers, payers, etc.) will define the value equation by their region, leaving an inconsistent understanding of ROI across the country.

In a 2019Chilmark Researchsurvey, over 22 percent of respondents said they were getting positive ROI from their PHM/VBC investments, two-thirds said they expected positive ROI over the next one to three years, and only 11 percent said they had no plans to measure ROI. However, when the researchers drilled down and asked organizations how they defined ROI, they learned that organizations were omitting some costs in ROI calculations, such as all the PHM investments they’ve made to date.

由于价值和ROI的定义各不相同，衡量PHM是否交付了价值——如果它为自己买单的话——是困难的。也许当组织完全致力于VBC时，ROI会变得更容易实现。

Following a Value-Chain Model and Best Practices

For now, value is a moving target, with definitions and goals shifting by the year. Even CMS can’t promise consistency, making it difficult to create a roadmap and a repeatable way to track cost and revenue to understand ROI. Health systems overall, however, seem motivated to continue with value, as VBC activity research shows. To move forward amid the uncertainty, organizations can use a value-chain model and best practices to ensure a successful path to value. The Chilmark value chain model (Figure 4), for example, can help organizations begin mapping how they would approach population health and, ultimately, VBC, with the goal of improved outcomes and margins and lower cost structure.

Organizations that have launched PHM tend to agree on a set of best practices:

• 从医疗保险优势开始:这是一个很好的增长机会，进入门槛最低，卫生系统通常可以找到一个支付伙伴来帮助识别风险和解决医疗保健方面的差距，以实现医疗保险优势计划内的目标。
• 关注门诊护理，而非急诊护理:门诊护理不如急诊护理自成体系，因此会增加PHM的难度，但能带来更多的价值。
• Leverage registries not based on diseases, but on utilization: Focus on the last 3 to 10 percent of utilizers. The first 1 to 3 percent are hard to impact because they have a serious chronic condition; but beyond that level are the high utilizers with more candidates for self-management.
• Simplify the physician burden: Only accept reasonable measures—those the organization staff can support. Look for opportunities to drive operational efficiencies across the organization, network, and community.

Navigating Uncertainty: The Path to Value in Population Health Management Investment

虽然医疗保健向价值的转变是缓慢的，但随着关键驱动因素将提供商推向风险和采用者的出现，这一点越来越明显。卫生系统需要PHM战略才能在VBC下取得成功，但在不确定的监管环境中，各组织在评估PHM倡议的道路上举步维艰。组织可以通过遵循PHM战略的价值链模型和最佳实践来应对不确定性。

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

1. Achieving Stakeholder Engagement: A Population Health Management Imperative
2. Introducing the Health Catalyst Population Health Foundations Solution: A Data- and Analytics-first Approach to PHM
3. From Volume to Value: 10 Essential Strategies for Navigating the Healthcare Shift
4. The Future of Employer Health Insurance