News & Commentary

Teams Make Value-Based Population Health Management Possible

March 19, 2018

As a cardiovascular and thoracic surgeon I was trained to understand the impact that a team of high performing individuals can have on outcomes in care delivery. Each member of the team brought subject matter expertise and personal commitment that drove superior results. The same is true in the case of value-based population health.

Population health care providers should also adopt this type of team approach when implementing value-based population health management. Team members focusing on specific functions helps clinical practices and hospitals effectively manage the identification and documentation of the burden of illness of a given patient population. This is arguably the most critical piece in value-based population health management, especially when caring for the Medicare population since 7 out of 10 Medicare beneficiaries have multiple chronic conditions which can result in avoidable episodes of treatment if under-documented or not well managed.  

To really know a population’s burden of illness, the team must have 1) clearly defined structure and functions, 2) well-delineated processes and outcomes, 3) monitoring and managing of compliance to protocols, and 4) accurate, actionable, and timely data sharing.

Clearly defined structures and functions. Clinical practices and hospitals must have individuals with skills to establish the operational framework needed to excel in delivering value-based population health management. Team members must understand their roles in activities such as validating which patients can be attributed to a specific clinician, implementing patient-specific outreach strategies, collecting and reconciling patient health data from external sources (patient-generated data, diagnostic data, data from inpatient settings, etc.).

Teams also need people who can establish structures that automate certain member encounters (check-in, payment, etc.). This will give older adults more face time with their clinicians. Time they value and something that will improve their relationship with the clinician. Having better relationships will also make it easier when health care providers need to address gaps in care for that older patient – be it why they’re not taking their medication or what’s led them to not schedule their next appointment.

Lastly, there needs to be clear lines of responsibility and accountability for sharing information about burden of illness for every episode of care, since older adults often receive care in multiple settings – be it inpatient vs. outpatient, acute vs. chronic, or medical vs. non-medical.

Well-delineated processes and outcomes. Successfully implementing value-based population health management requires teams with leadership that is able to provide vision that balances automation and people power. Older adults may be adopting technology more than before but there are still many who would rather interact directly with staff. In finding this balance, teams need to address items such as:

  • How to effectively and efficiently obtain and validate patient attribution and assigning patients to specific providers.
  • How to collect and aggregate health information on new patients prior to the initial health assessment.
  • How to reconcile discrepancies in health information.
  • How to identify and target members who have the greatest burden of illness.
  • How to train staff on best practices for patient engagement.

Once the team codifies these processes, they need to establish performance benchmarks that ensure these activities are achieving the goal of improved patient health outcomes.

Monitoring and managing of compliance to protocols. It is impossible to control every variable that determines the success of value-based population health management. That said, teams must have individuals who are tasked with monitoring and managing compliance with established protocols. They must also have the skills necessary to identify the outliers and make the needed course corrections.

Accurate, actionable, and timely data. More providers are moving toward alternative payment models that are based on risk-adjusted compensation, which determines payments to clinicians based on a patient’s demographic information and documented burden of illness. These teams must have a leader responsible for the analytics as well as other team members who understand the data and can take action. This approach will strengthen businesses, lower costs, and increase resources available to effectively improve patient care. This is especially true with providers who care for older or disabled adults, since these individuals are more likely to be sicker and therefore acquire more data about their health.

In the course of caring for a patient, a clinician goes through five steps involving data: collecting health data, storing that data in an accessible manner, analyzing it, reporting it to those who need access to it, and then utilizing the data to deliver superior care.

If only 50 percent of the data made it through each step, you’d only have 3.125 percent of the data to utilize in patient care (see chart below). Now let’s image a higher-performing data team puts in place practices that result in 75 percent of data making it through each step. The end result is 23.73 percent of data being utilized for patient care. That’s a 659 percent improvement by just having a 25 percentage point increase in data captured at each step.

Data Collection Storage Analysis Reporting Utilization Improvement
100% 50% 25% 12.5% 6.28% 3.13% N/A
100% 75% 56.25 42.19% 32.64 23.73# 659%

This type of function-focused team approach can help providers excel in more than just identifying the burden of illness. It can also help close care gaps and allocate resources to reduce avoidable treatments and lower costs – two additional areas of value-based population health management. It is only after these processes and measures are in place that health care professionals can effectively apply value-based population health management to their attributed patients in risk-sharing care delivery models.

Michael Vincent Smith, MD, FACC, FACS, FCCP is the Regional Vice President and Medical Director of Central Region Medicare at Anthem, Inc. Dr. Smith currently oversees Medical Management, Quality Management and Population Health Management for Anthem’s Medicare Advantage, Medicare Supplement and Medicare Part D Plan membership in Indiana, Ohio, Wisconsin, Kentucky, Missouri, Tennessee and Georgia. Dr. Smith is a board-certified cardiovascular and thoracic surgeon and former Chief of Cardiovascular Surgery and Vice-Chairman of Surgery of an academic medical center in Atlanta where he founded the first bloodless cardiac surgery program in Georgia. As the Director of a Cancer Center he also started the first lung cancer early detection program in the same state.

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