The goal of population health management (PHM) is to keep a population as healthy as possible. It is well known that about 5 percent of patients’ use 50 percent of healthcare resources and 10 percent use 70 percent of those resources. So, while PHM’s goal is to take good care of every person, organizations must pay special attention to these high-risk patients in order to lower population health costs to the maximum extent possible. Many organizations that are beginning to manage population health are focusing on the top 5-10% as a beginning strategy.

But keep in mind that this is the “tip of the iceberg”. As was learned by the disease management industry and emphasized in a recent publication by Ian Duncan, this could be a mistake. Below the waterline, so to speak are other cohorts of individuals with varying degrees of health risk and cost that will be the next individuals in the top 5-10%.

Beyond High-Risk Patients

So while PHM focuses partly on the high-risk patients who generate the majority of health costs, it has to systematically address the preventive and chronic care needs of every patient. Because the distribution of health risks changes over time, the objective is to modify the factors that make people sick or exacerbate their illnesses.

According to the Healthcare Risk Adjustment and Predictive Modeling by Ian Duncan, the implication of the analysis for predictive modeling may be seen in the transition of members between cost groups.

The first point to note is that the overall cost distribution remains relatively stable. Healthy members count for 69.5 percent of all members in the baseline year and almost 67.6 percent in the subsequent year. Within the Low cost category (67.6 percent), however, 85 percent of members (57.4 percent of the total 67.6 percent) were previously healthy, and 15 percent regressed from Chronic or Catastrophic categories to Healthy. Conversely, Catastrophic cost members were 1.8 percent of the population in the baseline year and 2.2 percent in the subsequent year. Fewer than one-third of these members (0.6percent of the total 2.2 percent) were previously catastrophic.

Importance of Intervention for All Risk Levels

This and other research has demonstrated that there is considerable movement between cohorts. Understanding that and being able to effectively and efficiently intervene is crucial. Or said another way, managing, outreaching and providing care and education to what is beneath the waterline is critical to success.

Leveraging Technology and Automation

Such an approach requires the use of automation. Not only are there not enough providers and care managers to manage every patient continuously, but PHM also involves a large number of routine tasks that do not have to be performed by human beings. Bringing modern information technology to bear on these tasks saves time and money and makes PHM economically feasible. Automation also allows organizations to better assess population needs and stratify populations based on geography, health status and utilization, and demographics.

So in the end:

• You have to accept that there is a roll for managing the complex patients with the highest costs at the top but if you don’t manage the patients across the population, you will fail in managing cost across the whole population.
• Being able to stratify the population by health risk and clinical care gaps is critical to be able to mange with limited resources.
• You need both a high-performance team as well as technology automated wherever possible to achieve the goals of population health management.

Download Phytel’s white paper on Population Health Management.

As a veteran of the disease management industry, and most recently, spending several years assisting provider organizations to manage their patient populations, I fully appreciate the problems inherent in traditional employer-based and health plan-sponsored disease management programs.

However, like Al Lewis, I also disagree with the statement that disease management is dead. Although some models have failed in the past, disease management models continue to evolve and are being transformed and incorporated into new physician-led population health models such as the Patient-Centered Medical Home.

Further, as health systems assume more financial risk and move towards Accountable Care Organizations, they will take on responsibility for managing entire populations and will be using population health tools and services that evolved from the original disease management principles and fundamentals.

I would like to emphasize several points that strongly indicate that disease management is alive and well.

Provider-Led Population Health

Today, there are a number of marketplace drivers such as Meaningful Use, Pay-for-Performance, PCMH and ACO and, not coincidentally, that share an underlying objective of provider-led population health. Population health means responsibility for everyone in the population: both those who are active health seekers and those who are not.

Achieving the IHI Triple Aim will require providers to provide patient-centered, personal, coordinated care across their populations. Provider-led population health will demand new tools and automation to be successful and will resemble those introduced and pioneered in employer and health plan-sponsored disease management programs (e.g., define population, identify care opportunities, stratify by risk, engage patients in care, proactively manage care, and continuously measure and monitor outcomes).

NCQA and Disease Management

I see no evidence that NCQA was in any way responsible for the demise of disease management. NCQA should be praised for their pioneering work on population health, quality reporting, disease management programs and HEDIS measures. They are now on the leading edge in the development of Patient-Centered Medical Home (PCMH) and the Accountable Care Organization (ACO) standards. Again, disease management principles and population health management are embraced in the new standards that NCQA has developed. The PCMH is widely endorsed and adopted. There are now 3302 NCQA-endorsed practices across the country and the number continues to grow.

Demonstration Projects

The demonstration projects from 2006 showing equivocal outcomes and financial results for disease management programs are dated and not a part of the newer provider-led delivery models. More recent demonstrations around PCMH, multi-payer pilots, and ACOs have shown successful health outcomes. Key components from the disease management industry and programs were incorporated into these new demonstrations.

• PCMH Demonstrations showed positive results which were attributed to dedicated care managers and data-driven analytics, principles used in disease management programs. (Fields, Leshen, and Patel) (Takach).
• Payers publishing positive results around ACOs are using all of the principles established in the disease management programs but in a new environment, featuring collaboration between payer and physician. (Higgins et all).

Implementation

One of the biggest issues in the early disease management programs was that the physicians and care teams were not involved in their implementation. Many of these programs were designed very well but were focused predominantly on patient education and behavior change. Doctors became very disappointed and distrustful and cited many reasons to not accept these programs as valid.

• Patients were getting enrolled into programs without their provider’s permission. Patients were getting information or education that was coming from the employer or health plan, rather than their physician.
• Results were coming back to physicians based on paid claims and were not timely or comprehensive, raising questions of accuracy. These reports used data that was old and not as rich as could be found in their offices, such as lab results and other biometric indicators.
• Doctors were frustrated by the multitude of payers offering DM programs to segments of their patient population and expecting doctors to follow different rules or incentives for different patients.

Doctor Involvement

Doctor involvement, not disease management, was one of the principle issues that needed to be changed. New legislation, payment reform/quality incentives, movement toward value-based accountability emphasizing the other marketplace drivers mentioned above will continue to embrace providers around improving quality and value. Provider organizations are being given the responsibility to manage their entire patient panel. To do so, providers will use the tools built and pioneered by the principles within disease management programs:

• Patients will be engaged proactively by their physicians and care teams, providing them with self-management tools and behavior change support to prevent disease and complications, and coordinating their care when other services are needed.
• Reports will use data from EMR systems, which are more timely and accurate. More importantly, physicians recognize that data in these reports are related to them and their patients, and they accept the information as opportunities to improve.
• Physicians and physician leaders are now beginning to think in terms of “my population”, which may include multiple payers, but one set of evidence-based standards and financial goals.

Conclusion

So, in the end, disease management is becoming transformed and deployed into new models, refining some aspects and putting the provider in the leadership role to achieve new thresholds of success.

References

• Fields, D., E. Leshen, K. Patel. 2010. Driving Quality Gains and Cost Savings Through Adoption of Medical Homes. Health Affairs. 29(5):819–26.
• Health Affairs, 30, no.7 (2011):1325-1334; Medical Homes Show Promising Results Reinventing Medicaid: State Innovations To Qualify And Pay For Patient-Centered Mary Takach
• Health Affairs, 30, no.9 (2011):1718-1727; Between Health Plans And Providers: Early Lessons From Accountable Care Models In The Private Sector: Partnerships; Aparna Higgins, Kristin Stewart, Kirstin Dawson and Carmella Bocchino

A growing number of primary group practices are taking a proactive approach to care management because they know coordinated care will be a linchpin driving impending changes in the care delivery system. Larger organizations especially are building the infrastructure they will need under new delivery and payment systems that are emerging for Medicare, Medicaid and commercial programs.

Medicare’s PGP Demonstration

Let’s look at the Medicare PGP program for example. The experiences of the 10 groups that participated in Medicare’s five-year physician group practice (PGP) demonstration show exciting examples of how these healthcare leaders took on the challenge of care coordination inside their practices and between sites of care to meet their goals.

Incentives for Innovation

The PGP pilot turned out to be a dry run for Medicare’s shared savings program for accountable care organizations (ACOs). Similar to what’s been proposed for the Medicare ACO program, the PGPs were eligible to split savings with Medicare if they met certain quality benchmarks and the savings exceeded 2 percent of expected costs.

In the demonstration project, participants could keep up to 80 percent of the savings they generated, depending on how well they did in meeting 32 quality goals, which is a powerful incentive for finding innovative and effective ways to better manage patient care.

Quality Improvements

According to the Centers for Medicare and Medicaid Services (CMS) report released in July 2011, in the fifth year of the five-year demonstration:

• All 10 groups achieved benchmark performance on at least 30 of the 32 measures.
• 7 groups achieved benchmark performance on all 32 performance measures.
• All 10 groups achieved benchmark performance on the 10 heart failure, 7 coronary artery disease measures and 2 preventive care measures.

Also for Year 5, four of the PGPs earned incentive payments based on the estimated savings in Medicare expenditures for the patient population they serve. The groups received performance payments totaling $29.4 million as their share of the $36.2 million of savings generated for the Medicare Trust Funds in performance Year 5.

Reasons for the Savings

The PGPs attributed their savings to a number of factors:

• Organizational structure
• Investments in care management and care redesign
• More intensive diagnostic coding
• Changes in market conditions

Each PGP that achieved savings used different care management strategies that may spark ideas for other primary care groups moving towards ACO models and similar population health models.

• The Dartmouth-Hitchcock Clinic in Lebanon, NH, focused on evidence-based care initiatives, including better use of care alerts, changing workflow for support staff, and using nurse case managers to work with high-risk patients.
• St. John’s Clinic in Springfield, MO, used a comprehensive patient registry, care alerts at the point of care, a case manager in the emergency department to plan transitions of care, and a care team dedicated to patients with congestive heart failure.

Conclusions

RTI International, the company that analyzed the PGP pilot for the CMS, drew these lessons from the test, many tied to the use of technology-based solutions:

• Medicare patients often have several comorbidities that need to be treated simultaneously. Therefore, group practices must address the need for complex care management that goes beyond traditional disease management for single conditions.
• Complex care management could be enhanced by combining disease-specific patient registries, or by using registries that encompass all patients.
• Planned visits can be facilitated through the use of data systems (e.g., registries and electronic health records) that analyze data and provide physicians and other clinicians with pertinent information about the patient prior to a visit. A visit planner report may, for example, provide a list of overdue tests for a patient that could be performed prior to a visit.
• Key change opportunities include increasing patient engagement, expanding care management, improving care transitions, and expanding the role of nonphysician providers.

The groups that were part of the PDP pilot demonstrated that technology, such as patient registries, plays a major role when adopting a proactive approach to care management.

What’s Next

In future blog posts, we will build on these takeaways, and talk about how the combination of technology and automation can foster even greater strides in population health.

In 2005, the Centers for Medicare & Medicaid Services (CMS) launched a physician group practice (PGP) demonstration designed to:

• Create incentives for physician groups to coordinate the overall care delivered to Medicare patient
• Reward them for improving the quality and cost efficiency of health care services
• Create a framework to collaborate with providers to the advantage of Medicare beneficiaries.

The successes of two PGPs that participated in the demonstration — the Marshfield Clinic and the Geisinger Clinic —depended largely on their well-executed coordinated care approaches and their effective use of technology.

Marshfield Clinic

The Marshfield Clinic, a 730-doctor clinic in Marshfield, WI, generated about half of the total savings in the demonstration that included 10 PGPs. The group has been using an electronic health record since 1985 and has long-running quality improvement programs.

For the demonstration project Marshfield:

• Focused on reducing hospital admissions, partly by expanding its telephonic case management program for patients who had heart failure and hypertension complications
• Expanded its anticoagulation drug therapy management program, designed to reduce costly complications of warfarin therapy
• Introduced partial open access scheduling and redesigned care processes for chronic disease patients to ensure they received all recommended care

Electronic tools are essential to population health management at Marshfield. The clinic’s EHR automatically generates an intervention list for each physician that identifies high-risk patients with multiple chronic conditions. Marshfield also uses electronic prescribing, a data warehouse for analytics, patient registries and care management software.

During its first year of participating in the demonstration, Marshfield reduced hospitalizations of patient in the anticoagulation management program by 29 percent. Satisfaction among patients enrolled in care management programs exceeded 85 percent.

Geisinger Clinic

Geisinger Clinic based in Danville, PA, is part of a health system that includes the Geisinger Medical Center and two other hospitals. The Clinic employs about 640 physicians in 41 practice sites.

Geisinger had disease management programs in place when it joined the PGP demonstration. The group wanted to extend those programs to Medicare patients. Additionally, Geisinger introduced a case management program for high-risk, complex patients.

In the pilot, Geisinger sought to reduce hospital admissions and readmissions through disease and case management, enhanced use of its EHR and an advanced medical home model. Geisinger emphasized patient-centered, team-based care across the continuum, transitions of care coordination, readmission risk screening and telephonic care management and/or device-based remote monitoring for CHF patients. It also redesigned its systems of care to reflect evidence-based guidelines.

Geisinger’s EHR can provides best practice alerts to providers at the point of care. Physicians can view a summary of the patient’s care, and they receive reminders about needed tests and other interventions. Equally important, they’re in close touch with the care managers who are handling their most difficult cases.

Coordinated Care Lessons Learned

Registries, care management software, and automated patient outreach—all used in conjunction with EHRs—are among the tools that these groups deployed successfully to manage their populations.

Many patients won’t take advice … unless it comes from their physician. We trust our physicians.

A recent Gallup survey showed that more than 85% of adults over 65 years old express confidence in their doctor’s advice. But it’s not just seniors that feel this way. Despite online access to a wealth of medical information and widespread questioning of common medical practices in the media, trust in our providers is high across the country. For example, more than 70% of Americans do not seek a second opinion because they are confident in the accuracy of their doctor’s advice.

So there’s a lot of trust – and for the aging, a lot of visits. The average Medicare beneficiary makes 6 physician visits each year and 90% see a physician at least once a year.

Recommended Care Visits Lacking

Yet, a recent CDC report finds they don’t get what they should:

• In some states, 28% of women over 65 have not received a mammogram in the previous 2 years even though almost 50% of all new breast cancers occur in this age group.
• More than 65% of new colon cancers occur in patients over 65 but more than 30% have not received a colorectal cancer screening.
• Less “invasive” prevention measures don’t fare much better. More than 30% of older adults do not receive an influenza vaccine, have never had a pneumococcal vaccine or have not been screened for diabetes (if they don’t already have the condition).

Keeping Patients Healthy

New models of care such as the Patient Centered Medical Home are at the forefront of prevention over treatment, bringing clinics a population health framework and a focus on keeping patients healthy. Medicare is also removing some financial barriers by providing preventive services at no cost to patients.

Medicare’s Annual Wellness Visits

But that’s not enough. Eliminating cost alone is unlikely to result in widespread use of these services. Providers can initiate discussions with their patients about prevention. Older adults, especially, rely on their physicians’ advice. Medicare’s new Annual Wellness Visit and the development of a personalized prevention plan are a perfect opportunity.

Many patients are just waiting to hear about it from their doctors.

What if you were asked to take on the role of a primary care physician? Your objective would be to ensure that ALL of the patients you are responsible for receive the quality care they need at the right time and in a cost-effective manner. After all, isn’t that what you and I want as a patient? Let’s just walk through what that would be like. You would:

1. Identify who your patients are (the average primary care physician has about 2,500).
2. Research each patient and evaluate them against all the guidelines for their applicable conditions and risk factors.
3. Ensure they receive the recommended care needed during each visit, and if they are not active in their care, reach out and engage each patient.
4. Track and measure the quality of care you provide ensuring every patient gets consistent and high quality care, and since you are probably participating in multiple different quality initiatives (P4P, Meaningful Use, PQRS, etc,) capture the information to meet all the requirements of each initiative.

As reported by David Margolius and Thomas Bodenheimer in a 2010 Health Affairs article, “Transforming Primary Care: From Past Practice To The Practice Of The Future,” providers and care teams are increasingly challenged to keep up with all the activities surrounding patient care.

Many physician organizations have begun to solve the problem through a significant increase in the use of midlevel practitioners, care managers, care coordinators and health educators. Recently, I attended a conference at which a large medical group presented on how they were going to hire 50 data coordinators to help their care teams deliver higher quality of care.

Unfortunately, hiring your way to a patient centered medical home isn’t realistic. Most of these organizations see the future and are preparing to become an Accountable Care Organization (ACO). In an ACO, the cost of delivering care will be controlled and hiring large numbers of resources to manage the patient demand won’t be an option.

The Care Management Role

I am a firm believer in the critical role that a care manager will play in this new world of healthcare that is upon us. The care manager is responsible for making sure patients are having effective visits, providing one-on-one care for the highest risk patients and making sure at-risk patients stay healthy when they aren’t in the office.

In my experience, one thing is clear, the care management processes being implemented today tend to be very manual and touch only segments of the patient population, and often only those patients that have an office appointment.

How many patients can an individual care manager attend to using only manual processes?

Data suggests that the average physician has about 900 adults with chronic conditions.  Thirty percent of those, or 270 patients, are high-risk or complex and should be assigned to a care manager.

By extrapolation using this simple scenario, every physician with this size panel would require 1.35 care managers; 10 physicians would require 13.5 care managers and 100 physicians would require 135 care managers.

And still, only the highest risk patients would receive support from the care management team.

The Importance of Technology

Technology has become a ubiquitous part of almost every aspect of our lives:  online shopping with suggestions about what I would like to read, a text message telling me my flight changed gates, emails reminding me my car is due for a 60,000 mile checkup. Unfortunately in many areas, healthcare delivery can appear behind the curve.

The only way care management fulfills the design of its creation is leveraging the power, repeatability and scalability of technology.

What would the world look like if you combined the power of modern technology with the power of a care manager?

• ALL patients would receive personalized, systematic, and just-in-time reminders about an overdue test, a reminder for a cancer screening or the need for an office visit. The reminder would be in the patient’s preferred mode of communication.
• The care manager would receive a stratified and prioritized list of high-risk patients that will always need the personal touch of a care manager.

By applying technology to population health strategies that continually identify, assess and stratify provider panels, physician groups can use automation to augment the role of care teams, manage the patient population more effectively and efficiently, drive better outcomes and decrease overall cost as demanded by new delivery model payment incentives.

As group practices grapple with the paradigm shift to population health and ACOs, they would do well to heed the lessons learned by large employers that have been practicing a form of population health management for years. For a self-insured corporation with thousands of employees, the patient population consists of all those employees and their dependents. To the extent that companies can prevent these people from getting sick or help them control their conditions, they can lower their healthcare spending and improve their workers’ productivity.

Interestingly, ACOs have the same motivations to embrace population health as employers do:

1. Financial Accountability. Employers, as self-insured plans are responsible for the healthcare costs of their employees and dependents; ACOs will be financially accountable for their patients through contractual arrangements with payers.
2. Risk Management. Employers and ACOs both understand that today’s unmanaged health risks can become the high cost cases of tomorrow without effective health programs in place today.
3. Member Engagement. Employers invest heavily in engagement strategies to increase employee loyalty and retention, making participation in health management programs more successful.  ACOs will adopt similar tactics to build “stickiness” with all of their assigned patients.

Many employers started down the path to total population health management with programs targeted towards employees who are already sick.  Employers have implemented these “disease management” programs over the past decade to minimize costs and improve compliance with evidence-based care standards among individuals already diagnosed with common chronic conditions such as diabetes, heart failure and asthma.  According to the National Business Group on Health (NBGH), 72 percent of big employers are investing in this $2.5 billion-a-year industry, up from 67 percent in 2008. Although the programs have been broadened to include a wider range of conditions, disease management programs still touch only those who have been diagnosed, and the most intense interventions are focused on the “sickest of the sick.” Employers have recognized that disease management programs alone do not equate to a population health approach, because these programs do nothing to prevent or mitigate the causes of chronic conditions in the first place.

Now, in addition to disease management, many companies are increasingly emphasizing wellness and health promotion, which promise to deal with what they see as the number one driver of health spending: poor health behavior by their employees and dependents. Once a relative rarity, wellness programs are now embraced by most large employers and round out total population health strategies that address health needs across the continuum of care. Nearly half of employers purchase specialty programs to alter lifestyles and health behavior, and the majority of companies offer smoking cessation and weight management programs, according to a 2010 survey by the NBGH. Thirty-nine percent of employers consider wellness programs to be their first or second most effective strategy for controlling health costs.

Companies with effective and comprehensive population management strategies have demonstrated lower health costs, higher productivity, and higher profitability.  Companies that achieve the best results use a combination of tactics to drive participation in health management programs, including financial incentives, creative marketing and automated communications, onsite health clinics and coaches, as well as online education and self-management tools.  ACOs preparing to achieve their twin goals of cost savings and high quality outcomes will be able to apply many employer strategies to their delivery model.

One advantage that ACOs may have, however, over employers is the ability to leverage the patient-physician relationship to encourage participation and positive behavior change.   Despite employers’ longstanding experience with population health, they have failed to integrate effectively with the patient’s most trusted health advisor, his or her personal physician.  In fact, progressive employers are looking to ACOs to take population health to the next level by bringing the physician to the center of the equation.

Karen Handmaker is the Director of Population Health Management at Phytel.