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.

On April 12, 2012, Joslin Diabetes (the world’s largest diabetes research and clinical care organization) and Phytel announced a collaboration on a landmark research initiative to compare the accuracy and predictive value of current assessment methodologies in diabetes care.

Methods of Evaluating Educational Outcomes in Diabetes Care

The study will compare four methods of evaluating educational outcomes in diabetes care:

1. Physician self-reports
2. Competency assessments based on case studies
3. Examination of a sample of patient charts
4. Data drawn from Phytel clients’ electronic registries, which cover all of a practice’s patients with diabetes

“Phytel’s expertise in population health management and its comprehensive database will enable Joslin to make valid comparisons among different methods of assessing performance and patient level outcomes relative to educational and non-educational interventions.”

– Julie Brown, CCMEP, director, Joslin Diabetes Center

Quality Initiatives Focus on Physician-Led Population Health Improvement

This is just one of many Phytel quality initiatives that are focused on physician-led population health improvement.

Other recent 2012 announcements include:

• NCQA Approved Use of Phytel Solutions to Meet Medical Home Criteria. Physician practices can receive automatic credits toward NCQA recognition if they deploy Phytel’s patient outreach and care management services.
• Phytel was announced to be on the advisory committee of the AMGA’s Chronic Care Challenge around Hypertension. The American Medical Group Foundation (AMGF) is launching a national multiyear campaign to reduce the burden of hypertension and related chronic conditions.
• Dr. Richard Hodach, Phytel’s Chief Medical Officer authored a peer-review article within HMFA entitled Automation is Key to Managing a Population’s Health. The article discussed requirements for success with population health management include a high degree of clinical data integration across the healthcare organization’s care enterprise and automated tools for engaging patients in their own care.

Whether our clients are pursuing PCMH, ACO or P4P quality initiatives, our solution and services can leverage existing EMR data to help automate and engage patients for population health management across dozens of conditions and measures – all while demonstrating financial performance! In fact, hundreds of physician groups and healthcare systems that collectively care for more than 20 million patients use Phytel’s patient outreach, care management, patient engagement, transitions of care and analytics solutions in population health management.

And Phytel, because of our focus around quality and health outcomes – is invited to become engaged in more and more projects like Joslin Diabetes.

Read our white paper Improving Compliance to Diabetes and Hypertension Protocols Using Coordinated, Proactive Outreach.

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.

Recently, Physicians Practice published an article, “Top 4 ACO Considerations for Physicians.” It posed this question to readers: “Confused about how ‘accountable care’ will affect your practice? We’re here to help.”

Overall, this was a great article with comprehensive points detailing the challenges that physicians and practice administrators need to consider for an ACO model. However, I had some concerns over the prominence the article gave to using an EHR to mine population data. Specifically in point #2, the author briefly mentioned “Additional Responsibilities,” stating that staff needs to take on extra responsibilities for outreach to manage a population etc.

ACOs Will Benefit from Automation

While it’s true that EHR systems have the data, they are specifically designed to assist physicians to care for individual patients, not for managing a population or large patient panels, as ACOs will require. It is crucial that physicians and administrators understand the drastically different workflows and capabilities needed beyond the raw data, and that without proper automation, these “additional responsibilities” cannot be scaled to effectively impact the population and have the potential to break a practice’s back.

For ACOs to be effective, practices will need to closely track a patient’s care history to identify and meet their care needs. This includes monitoring a patient’s status between episodes of care so the practice can intervene proactively, give patients appropriate support, and engage them in their own care. More and more physician groups are using electronic registries and patient outreach programs to assist them in these efforts. By using the registry data from EHRs, these programs can send automated phone, e-mail or text messages to patients, telling them to make an appointment with their physician. Such tools enable physicians to practice at the top of their license and relieve their care teams from being overwhelmed with the responsibilities care management of large populations entail.

Engaging Patients, Managing Care

In effective ACOs, automation will be key to engaging the patient and managing their care, allowing practices to:

• Use registries to track the health status and care gaps of all patients
• Use proactive outreach to notify patients when they need care
• Manage more patients at different levels of risk
• Automate case management and transitions of care workflows
• Implement educational and operational improvement processes

The transition to ACOs and other emerging models of care is certainly top of mind for physicians right now so the more education and communication we can have on these issues, the quicker we’ll reap the rewards of better population health.

Automation tools for population health management will become more important than ever in 2012 as a growing number of healthcare providers begin to take responsibility for the cost and quality of care. Some organizations will further integrate their information systems and automate their care-coordination processes to prepare for the assumption of financial risk. And more and more providers will focus on the patient-centered medical home (PCMH), which can produce short-term financial and clinical benefits while paving the way for the formation of accountable care organizations (ACOs).

Patient-Centered Medical Home Improves Care Coordination

The PCMH is already generating tremendous enthusiasm among providers and payers. In 2012, it will join the mainstream of healthcare delivery as organizations recognize that it is the best vehicle for attaining the objectives of accountable care.

Without the ability to leverage digitized clinical data, it is impossible to achieve the medical home’s primary goal of improving care coordination in a scalable way. Fortunately, the federal government’s HITECH incentive program is driving the rapidly increasing adoption and meaningful use of EHRs. As structured electronic data becomes the norm, many more providers will be able to tap clinical databases for real-time identification of care gaps, automated outreach to patients who need preventive and chronic care, care coordination, predictive modeling and risk stratification of the population. These tools will help providers build successful medical homes and ACOs.

Automation Technology Supports Patient Engagement

Meanwhile, efforts to promote patients’ engagement in their own care will benefit from the accelerating use of automation technology to replace outmoded, inefficient manual processes. In addition to automated patient outreach methods, online educational tools and health-risk assessments will become commonplace. Mobile health applications will proliferate. Most important, physicians and care teams will have the tools they need to maintain continuous contact with patients between office visits or episodes of care.

Population Health Management and Automation

Finally, care management will benefit from the new automation approaches. Healthcare systems are placing care coordinators within physician practices, and those professionals are beginning to leverage digitized health data to help them manage patient populations. We will see much more of this kind of activity in 2012.

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.