Approximately 750 accountable care organizations are in operation today, covering some 23.5 million lives under Medicare, Medicaid and private insurers. Although still in the learning stages, many ACOs have had notable success in improving quality while reducing cost. As promising results continue to emerge, more of these organizations — whose existence was once thought to be more fantasy than reality — are expected. In fact, Leavitt Partners predicts that 105 million people will be covered by ACOs by 2020.

Similarly, while the industry’s move to value-based payment is also in its early stages, value-based contracts are expected to increase substantially in the next decade. For example, the Centers for Medicare & Medicaid Services has a goal of 50 percent of Medicare payments being tied to alternative payment models by the end of 2018. In addition, Aetna expects that 70 percent of its contracts will be value-based by 2020.

Moreover, the projected impact of the Medicare Access and CHIP Reauthorization Act of 2015 on adopting value-based payment models is expected to rival the impact of meaningful use on adoption of electronic health records. Since providers will need to implement alternative payment models to obtain a higher reimbursement rate, they might as well do so during the time frame in which they’ll receive a bonus payment to help offset the risk.

These trends will accelerate the demand for services and technology that enable health systems and other organizations (health plans, Medicaid, community-based organizations, employers and so forth) to jointly manage the health and care of populations — either as an ACO or in an ACO-like fashion. While diverse, these organizations will have a common need to optimize operational efficiency, improve financial management and effectively engage consumers in managing their health and care.

Defining an idea

Population health as a concept made an early appearance in 2003 when David Kindig and Greg Stoddart defined it as “the health outcome of a group of individuals, including the distribution of such outcomes within the group.”

“Improving the health of populations” was later identified as one element in the Institute for Healthcare Improvement’s Triple Aim for improving the U.S. health care system, along with improving the individual experience of care and reducing the per capita cost of care. As we know, there is now widespread belief and a growing body of evidence that suggests that at-risk models can help to deliver on the Triple Aim.

Once primarily used in policy discussions, today the term population health management has become nearly ubiquitous. It encompasses the proactive application of strategies and interventions to defined groups of individuals (e.g., people with diabetes, cancer patients with tumor regrowth, the elderly with multiple comorbidities and so forth) to improve the health of individuals within the group at the lowest cost.

While population health can also mean the health of the entire population in a geographic area, the population health efforts most health systems and ACOs are undertaking are aimed at providing better preventive and medical care for the population of patients attributed to their organizations by Medicare, Medicaid or private insurers.

Whether participating in an ACO or not, all organizations should consider building a population health management strategy and addressing related gaps in their information technology capabilities. Minimally, this would include acquiring the capabilities and tools to:

  • Know, characterize and predict the health trajectory that will happen within a population.
  • Engage members, families and care providers to take action. 
  • Manage outcomes to improve health and care.

Essential elements

As more providers and health systems evolve into ACOs, they are becoming increasingly aware of what it takes to manage care from a population health perspective. This includes establishing new partner networks, targeting populations, aligning providers and contracts, and developing cross-continuum protocols for care and for maintaining health while enabling efficient data sharing.

Furthermore, data from multiple, disparate sources must be aggregated into a single, comprehensive view of the patient to drive new insights in care planning, risk stratification, total cost of care and utilization patterns, for example.

While a certified EHR certainly provides the necessary foundation to support the shift toward increased accountability, transparency and value, population health requires a range of IT applications and analytical capabilities. For example, expertise in claims data interpretation and risk modeling are core requirements for successfully participating in the value-based transformation.

In fact, early adopters of population health management solutions are already seeing the need for next-generation capabilities to support the following transitions:

  • From management of the sickest patients to management of all patients.
  • From static risk categorization to risk categorization that follows a patient’s evolving risk.
  • From a focus on a single disease or condition based on simple data values and events to a focus on multiple diseases or conditions using evidence-based care plans.
  • From "list" generation with significant manual work for care managers to significant process automation.
  • From loosely connected care “actors” to a care team that includes the patient and family.
  • From retrospective analysis to concurrent analysis.

As organizations look to enhance their population health management strategies, they should make investments that enable the IT platform to:

  • Collect data from multiple, disparate sources in near–real time, including any EHR, devices used in the home and at work, and other data sources, such as pharmacy benefit managers or insurance claims.
  • Support organizations in not only aggregating, but transforming and reconciling data to establish a longitudinal record for each individual within a population.
  • Identify and stratify populations to pinpoint gaps in care, enabling providers to act on information and match the right care programs to the right individuals.

This platform sits “above” the EHR and other sources of data and must be EHR-agnostic. The IT platform is much more than an EHR module.

With access to an individual’s demographic, clinical and sociological information, a provider would know in real time that a person with type 2 diabetes in an attributed population is struggling to appropriately manage his or her glucose values. With the right tools in place, the IT system would alert the care team to help the patient better manage the situation before it results in an unnecessary physician or emergency department visit.

Several key components of population health management are essential in aligning care team members and other stakeholders as well as engaging patients in their own care. Consider the following:

Registries and scorecards: By integrating clinical, financial and operational data from disparate sources into a single chronic-condition and wellness-registry solution, organizations can normalize data and turn them into meaningful information. Registries and scorecards enable providers to identify, score and predict risks to individuals or populations to allow targeted interventions.

Data warehouses and analytics: An enterprise data warehouse can fuel a wide range of analytic needs and provide intelligence to enable continual care process-improvement initiatives. For example, an organization can compare patients' total cost of care relative to the health system's peers and, perhaps even more important, predict if those costs will significantly increase.

Care management: These systems enable proactive surveillance, coordination and facilitation of services along the care continuum. Specific capabilities might include helping to facilitate transitions of care more efficiently, using automated campaigns (email, text) to better manage high-risk patients and employing evidence-based interventions to reduce high-cost utilization.

Longitudinal record: Even if a provider is diligently capturing patient information in an EHR, the data are valuable for collaborative, accountable care only if they can be integrated with patient data from other sources and harmonized to produce a single, consolidated record at the member level. The longitudinal record presents a complete picture of the patient’s medical history in an organized, coherent view.

Longitudinal care plan: Serving as the sister solution to the longitudinal record, a longitudinal care plan provides a consolidated, normalized view of indicators to be monitored, events due to happen and actions to be taken to ensure that a patient maintains and improves his or her health.

Patient engagement tools: Health care interventions that occur solely through office-based patient or provider interactions will no longer provide the level of monitoring and scrutiny we need to manage the health of individuals and populations. Thus, we must continue to harness the power of technology to engage patients in their care via tools such as patient portals and personal health records, as well as the use of social media, texting and email. Additionally, the growing use of telehealth can make patient interactions more convenient; expand geographic horizons, particularly where needed medical specialists are few in number; and make care more accessible to those with mobility issues.

From records to health

As the industry continues its transition from a fragmented, volume-based system toward one that embraces the notion of patient-centered, accountable care driven by value-based payment models, now is the time for organizations to consider what new relationships, IT assets and skills will be required to succeed — particularly when it comes to managing the health and care of attributed populations.

Organizations looking to enhance their population health management strategies should consider several key solution components. Population health management technologies can help providers to stratify and select target populations, identify gaps in care, predict outcomes and apply early interventions to improve health and care. Moreover, they can enable an organization to understand its aggregate performance in undertaking disease-specific plans for multiple patients and better manage contracts and financial performance.

Additionally, since payment is based on conformance to chronic disease protocols, the organization must have near real-time, complete and accurate data illustrating how well it conforms to those protocols.

Population health management solutions are intended to complement — not replace — the traditional EHR. They represent a shift from applications focused on documenting the patient’s record of care to applications focused on developing the patient’s plan for health.

Ultimately, this shift in technology adoption will move the industry beyond incremental change and experimentation with value-based payment toward a committed path where all roads lead to population health management.

John Glaser, Ph.D., is senior vice president of population health with Cerner in Kansas City, Mo. He is a regular contributor to H&HN Daily.