Now is the opportune time for pop health management

Healthcare reform, emerging payment models that reward quality versus volume, and technology are driving providers toward a trend that payers have embraced for years: population health management (PHM), according to a recent KPMG survey.

In addition, provider organizations are realizing that effective PHM and cost reduction requires a holistic view of data, including claims, medical records and other information from throughout the healthcare ecosystem. Not only have payers invested in data analytics tools and in-person chart reviews to validate diagnoses and identify care gaps, they have also worked to ensure that the highest-risk patients are receiving the care necessary to avoid emergency department or hospitalization utilization.

ShultzHowever, unlike periodic chart reviews, provider organizations have access to technology that can automatically mine data and offer real-time notifications regarding high-risk patients based on their electronic health record (EHR) and payer claims data. This holistic approach to data management offers providers the opportunity to successfully manage population health, with continued support from payers, in ways that were never truly feasible before.

Electronic records open the door

When nearly all providers used paper charts, monitoring populations was an extremely time-consuming, labor-intensive process, requiring pulling charts, manual data entry, and manual analysis. Historically, payers attempted to assist providers with this endeavor by offering guidance based on claims data, but these efforts were often met with resistance.

Part of the resistance was that claims data was too old (45 to 120 days) to be useful for effective interventions. By the time the health insurer received the claims data and notified the provider about care gaps impacting their high-risk patients, many of those patients had already visited the emergency department, been treated by their doctor, or resumed adherence to their treatment plan.

With the arrival of the The Health Information Technology for Economic and Clinical Health (HITECH) Act, and associated incentives to adopt EHRs, providers began building patient registries to monitor high-risk patients with chronic conditions, recognizing their collective strain on healthcare costs, according to the Robert Wood Johnson Foundation’s report “Chronic Care: Making the Case for Ongoing Care.” These registries often were created to support participation in pay-for-performance programs that rewarded providers for managing patients with common high-cost chronic illnesses such as diabetes, asthma, and congestive heart failure. While these registries were based on more timely data than claims, they were usually built in Excel spreadsheets or Access databases, requiring manual updates.

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