Online health risk assessments (HRAs) can be used to help make patients aware of their health problems and to help care managers stratify their patient populations by health risk. This approach complements the primary risk stratification strategy, which relies on registry reports to classify patients based on clinical data.

Using Automation to Reach Patients

Provider organizations can use an automated process to generate health risk assessment data. Patients receive an e-mail inviting them to complete an HRA. When they click on a link, it takes them to the HRA on a website. After they answer the questions, the application automatically calculates scores for their risk factors and their willingness to change their health behavior.

Care managers can use this data in a variety of ways. For example, they can identify all patients with high-risk scores. They can also stratify the population as high, medium or low risk, with the assistance of registry reports, and use that classification as the basis for appropriate interventions.

Engaging Patients to Change Behavior

Care managers may also factor in each patient’s willingness to change. For example, if a patient has high blood pressure, is overweight and is an active smoker, but is not ready to change, the care manager might consider that patient for an online education program or might send a message inviting him or her to attend a motivational program offered by the healthcare system.

Learn More

Listen to a webinar about engaging patients using care automation within an ACO environment.

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.

We are hearing more and more these days about population health management and how provider organizations are increasing their focus on it. Provider organizations understand well how to manage individual patients when they come into the office. Physicians and other care team members strive to use each visit as an opportunity to communicate with their patients about their health, preventive care and follow-up treatment, taking into account each patient’s  needs and preferences. Patients respect their provider’s knowledge of research and standards of care and trust their judgment to recommend the right care plan for them. Why the surging interest in population health?

The current visit-centric model works when providers only have to keep track of and manage the patients who schedule a visit; however, when new payment models, such as pay-for-performance and capitation require providers to keep track of and manage every patient in their panel — their patient population — provider organizations need new sources of expertise and ways to scale their services beyond the visit encounter. Many provider organizations are rightly looking for population health expertise from prestigious and successful health maintenance organizations such as Kaiser and Geisinger. Other sources for population health expertise that provider groups may not have thought of right away are self-insured employers.

As I described in the first blog in this series, self-insured employers and provider groups that seek to be accountable care organizations (ACOs) share the goals of population management — and employers have been at this for about 20 years and have figured out the best practices that the most successful employers consistently apply.

The lessons learned from employers that have implemented successful population health programs are readily applicable to physician organizations preparing to transform themselves into patient-centered medical home (PCMH) models on the road to becoming effective ACOs.  The following table maps the employer best practices to the practice-based population health (PBPH) environment to illustrate the important parallels and common strategies.

Each of these “Employer Best Practices” deserves a dedicated discussion and blog entry to explain further how leading employers have created the infrastructure they need to identify, manage and engage employees to improve their health. In fact, if your organization has already become a certified PCMH or is in the process of doing so, these employer best practices may look familiar — and that’s because the PCMH (and the ACO, by extension) is based on population health principles.

In a population management culture, providers will let their patients know they will be identifying opportunities and resources to help them to be healthier all year long, not just when they come into the office or have an acute event. And, providers will create efficient and proactive care teams to support greater numbers of patients than they can today with manual processes, disparate sources of data, and limited staff.

Now, progressive employers are increasingly looking to partner with providers who adopt the same best practices and leverage the physician-patient relationship to achieve even better results than employers could on their own.  So, provider organizations with their eyes on ACOs, should take a closer look at what employers have demonstrated thus far.

Karen Handmaker is Director of Population Health Management at Phytel.

It’s an enticing notion: focus resources on the sickest patients if you want to drive savings in health care, the 20% of the patients that drive 80% of the costs (or the 5% that drive 43% of Medicare‘s costs).

As I write, smart people are getting caught in the appeal of the notion. We can solve a big chunk of our health care crisis if we just take advantage of the 80-20 rule! There are health system administrators busy instructing data analysts to mine their data for high-cost patients. Those same analysts will be instructed to pass the information along to case managers who will then be told to bring order to the spiraling costs. When the administrators review their efforts, it may even look like they worked: the patients who were “case managed” showed lower costs in the period after they started getting managed. The problem is that there really wasn’t any other outcome possible.

I’ve been involved in health care analytics in one form or another for the past 15 years. The most common analytic error by far involves concluding that the inevitable was instead caused by intervention. One example is showing savings on a disease management program for heart failure patients in which the patients were enrolled right after they’ve had a hospital stay for a heart attack. The statistical problem with such an analysis is called “regression to the mean.” In practical terms, it means that most patients don’t stay acutely ill all the time. If you measure future outcomes versus the time a population was sickest, odds are that at least some of the population will improve and the outcomes will look better.

Back when I ran the analytics department at a disease management company, we did research in which we found that even for the rare diseases we worked with (diseases such as multiple sclerosis, cystic fibrosis and systemic lupus) the highest cost patients in one year were not always the highest cost patients the next. Generally, there was more than a 50% turnover of the top 10% of patients from year to year. That means that if you took the 1,000 highest costs patients in 2009, 500 or less would still be high cost patients in 2010. Usually, it was because they had some kind of an acute crisis from which they recovered. Whether we did nothing or provided intensive case management to the costliest patients, about 50% were going to get better and their costs were going down (which is why we didn’t just focus on the sickest of the sick).

One of the standard quality metrics followed by groups that track health care quality is the percentage of diabetic patients with an HbA1c value of greater than 9%. (The Wisconsin Collaborative for Health Care Quality does a good job of creating visibility around this metric.) Programs are currently being designed to target the 9%ers, to bring their scores back in line. The challenge with focusing only on the 9%ers is the same as with the high cost patients. Here at Phytel, we’ve done research on the turnover rate of the 9% patients. We’re finding that like any other outlier, they change from year to year – at a rate of over 60%. That is, for every 1,000 patients with an HbA1c score of 9% or more in 2008, only 400 of them continued to have a score of over 9% in 2009. Despite the turnover of the 9%ers, the overall percentage of patients with 9%+ HbA1c scores has remained relatively stable from year to year (at least in the data we’ve analyzed). In other words, as soon as one 9%er drops to a lower level, another is waiting to take his or her place.

I grew up in the North East where we had frozen ponds most of the winter. That meant a lot of pond hockey. The best players were always the ones that skated to where the puck was going to be rather than to where it was at any point in time. The same approach is critical when it comes to affecting the small pool of patients that drive the bulk of health care costs. You need to find them early, before they’re a high cost patient.

Why is this issue important? I wrote in the second paragraph that some health system administrators are busy creating case management programs designed to target their sickest patients. One of the reasons is to prepare their organization to take on global payments, with the goal of becoming an accountable care organization. The reasoning is that if they can just remove unnecessary costs for the sickest patients, they’ll save enough money to make those global payments profitable. But their efforts are akin to Sisyphus rolling his rock up the hill only to have it fall once he gets to the top. No sooner will a high cost patient start improving in this scenario than another will be waiting to take his or her place. If the “manage sickest 5, 10 or 20%” approach is employed on a grand scale, we won’t move any closer to bending the health care cost trend curve.

The trick is finding sick patients before a crisis event, before they’re really sick. The availability of lab results data from electronic medical records is critical in that regard. And once you find them, affecting those patients requires a skill set that our health system (which includes more than only the providers themselves) is just beginning to develop – that of reaching out to patients and motivating them to actually modify their behavior. One just has to reference the massive efforts (both public and private) that have gone into reducing the number of smokers to understand how significant this challenge truly is.

Ted Courtemanche is the Vice President of Analytics and Outcomes at Phytel.

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.