Is your plan making full use of its population health management systems? To help you find out, we asked two experts to weigh in.
Risk optimization algorithms have traditionally been used by health plans to look for undercoding in Medicare, Medicaid and Affordable Care Act populations both on and off the health insurance exchanges. Undercoding can have a significant impact on health plan profits for these populations as the health plans’ premiums or ACA risk fund adjustment transfers are driven by the risk they take on.
Health plans can have additional success by repurposing risk optimization algorithms for population health purposes. Risk optimization looks at pharmaceutical patterns, procedures codes, diagnosis codes, and co-morbidities-both current and historical-to derive a probability that a member has a condition that is not accurately accounted for in claims data (e.g., there is a 90% probability that this person is diabetic).
Health plans should use this as an additional mechanism for opportunity identification and outreach in population health. This will help them identify new population health opportunities, and it may positively impact health plan profits by getting accurate coding in-house as the members engage with the programs and the healthcare system.
- Kevin Ruane, senior consulting scientist, Truven Health Analytics
Health plans should adopt population health management as a way to effectively identify opportunities to improve individual health and care. Insight gleaned from data collection and analysis allow plans to target and engage patients for improved outcomes and meet new care standards, such as NCQA HEDIS and Medicare STARS.
- Madhavi Vemireddy, MD, chief medical officer and head of product management at ActiveHealth
In addition to risk stratifying their population by utilizing claims data, lab results, and health risk assessment and biometric data, health plans should utilize sociodemographic and survey data to understand a population’s attitudes and behaviors toward healthcare.
Health plans have much greater success in member engagement and follow through when they tailor their outreach and messaging to “who” the consumer is. What makes the person tick? What barriers prevent them from seeking preventive care or refilling a prescription? How do they prefer to receive health information? What will incentivize them to take an active role in their healthcare?
Combining sociodemographic and survey data with traditional population health data sources allows health plans to bring the right message to the right patient at the right time. This improves compliance and outcomes and helps drive member satisfaction.
- Kevin Ruane
Health plans' employer clients and new prospects are beginning to demand more rigorous performance analysis and proof that initiatives, such as population health, are working to both impact the bottom line and improve employee health. That demand is only expected to increase, as healthcare costs and population health remain on the mind of just about every corporate executive in the nation.
In order to help employer groups understand the impact of their programs, health plans need an approach that is both practical and highly reliable and credible. One of the best approaches is an external validation of their population health outcomes using a matched cohort study that delivers an unbiased, evidence-based evaluation which further builds trust between health plans and employers. It is also an excellent way to attract new employer groups and to demonstrate continued value for program costs beyond just financial ROI, incorporating engagement and clinical outcomes metrics.
- Kevin Ruane
Employing a population health management approach in a value-driven world will drive success for health plans by enabling accurate and effective planning for healthcare organizations through better data analysis and population tracking.
- Madhavi Vemireddy, MD
With a population health management strategy in place, health plans can better manage and coordinate the care needs of high-risk patients to drive down unnecessary hospitalizations and ED visits in patient populations.
- Madhavi Vemireddy
Population health management empowers health plans to improve the consumer experience through a framework that emphasizes patient-centric care planning and coordination. This focus on holistic health management for each individual supports engagement by driving more personalized care and strengthening the physician-patient relationship.
- Madhavi Vemireddy