An Exciting Journey: Four Phases to Population Health Management Maturity

1. An Exciting Journey: Four Phases to Population Health Management Maturity

2. American healthcare system is undergoing change at an unprecedented pace. New care models are directed at preventive care, proactive chronic disease care, and utilization management and are being implemented in conjunction with payment models that incorporate financial risk-taking and incentive management.

3. Emerging provider-driven, practice-basedpopulation health management (PHM) programs open up exciting opportunities that build on the physician-patient relationship and demand accountability for outcomes.

4. PHM is not a new concept. Predominantly driven by payers, it has been practiced piece-meal over the last 20 years, with generally unsatisfactory results as measured by healthcare costs. In most cases, payer-driven PHM programs consciously avoid the physician role due to conflicting incentives—the more services clinicians provide, the higher their payment.

5. Four-Phase Model Despite their promise, provider-led PHM programs do not just form overnight. Medical Groups must transition from the traditional siloedpayer-driven PHM program to a provider-driven model that is patient-centric and payer-agnostic.

6. As organizations make this journey, they will travel through four phases of maturity (Figure 1): • The Pilot • Care Program Development • Physician-Driven Services • True Patient Engagement Increasing financial returns from shared savings, performance-based, or risk-based rewards follow each phase.

7. Figure 1: Physician-Led Population Health Maturity Cycle

8. Each phase has its own challenges across multiple dimensions—leadership, care management processes, information technology (IT)/data analytics, physician alignment, and patient engagement. These challenges change as groups progress through the four phases of PHM maturity.

9. Factors Impacting PHM Growth

10. Phase 1: The Pilot The pilot is when an organization will apply to become an accountable care organization (ACO) with the Centers for Medicaid & Medicare Services (CMS) or a patient-centered medical home (PCMH) with commercial payers and negotiate its first risk-based or pay-for-performance contract. In the pilot phase, the organization assesses its capabilities and the potential benefits of developing a PHM program. Based on the findings of the readiness assessment, an organization could start on the path to a PHM program as an ACO or PCMH with one payer for a small population of 10,000 to 15,000 members.

11. Leadership: Executive leadership (e.g., CEO, president) sets the priority by communicating a vision of the PHM program for the organization. Care Management Processes: In Phase 1, most of the PHM processes are driven by the payer. The payer will want to dictate quality performance reporting needs, patient care protocols, and provider incentives.

12. A typical PHM process in Phase 1 is illustrated in Figure 3: Figure: 3

13. IT/Data Analytics: During Phase 1, technology requirements for the new care processes are identified and a roadmap for future infrastructure and applications needs is developed. The priority at this stage is to get the pilot program rolling with minimal investment. Physician Alignment: On the clinical side, most of the challenges in the pilot will stem from attempting to garner physician alignment. Physicians are asked to focus more on preventive care and use clinic visits as opportunities for proactive chronic care management in order to identify and address any gaps-in-care. Initially, most of these processes will be ad hoc, episodic, and not systematically followed across the provider network.

14. Patient Engagement: Patient engagement in Phase 1 is very basic and also driven by payers. Most of the proactive patient involvement relates to educating patients about managing their chronic diseases.

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