As healthcare reform places an increasing focus on population health, HRMR asks how this will affect the risk profile of healthcare providers and what its implications will be for patients.
The focus on population health in US healthcare is not new, but it has gained impetus in recent years, not least because of changes in reimbursement brought about as part of recent healthcare reform. Now more than ever before, the focus is on keeping patients out of hospital, ensuring they stay healthy and keeping their health conditions in check instead of engaging with them only once they become seriously ill.
What are the risk implications of this shift in perspective? On one hand, by keeping high risk patients well, it could cut the chances of adverse outcomes in the hospital setting, but it also raises new questions, such as whether a healthcare organization would be culpable if a wellness program is seen to have failed a patient.
Brian Drozdowicz, vice president of Population Health at Caradigm, a population health company, says the new risks, while yet to be fully understood, will be outweighed by the benefits.
“No-one has a well proven model for this, but the alternative is that you could have somebody that is, for example, elderly and diabetic, who likely has some other co-morbidities, sitting at home and having a sentinel event without anyone even knowing.
“It will take time for providers to transition to these new, proactive models and we’ll need to build a baseline to understand what is and is not reasonable, but any proactive model of care is far superior to a reactive care model, which is incredibly high cost and not efficient in any manner. I would argue that even the very elementary steps of trying to look proactively at your population are far better than waiting for that patient to present at the emergency department.”
A positive change
Brian Lovdahl, CFO for Baldwin Area Medical Center, an integrated hospital and clinic in Baldwin, WI, agrees that population health initiatives can only be positive—although the financial impact is certainly an issue.
“Healthcare organizations have made a lot of money by keeping patients in the dark but times are changing and we need to find ways to be successful by keeping patients out of our facilities,” he says. “I believe that people genuinely want to be healthy but many do not know where to start. There are smartphone applications and devices that help you count calories while monitoring everything from exercise to sleep habits. As we are looked at less and less for routine services we need to offer services that have a real return on investment for the consumer.”
He adds, however, that the financial rewards for providers that achieve this shift have not yet been properly structured and put into action.
“Unfortunately, the evolution of payment for quality is slow, unclear, and inconsistent. There are no industry standards and this leaves providers trying to manage numerous contracts, reports, and reimbursement mechanisms. It is difficult to accurately budget for an upcoming year when so many of the insurance companies are developing new methods of reimbursement that haven’t been thoroughly vetted.”
Looking to the future, costs look set to remain an issue with the increased focus on population health and preventive care, but the benefits for the population are not in question.
“Population health should be our goal every day we come to work,” Lovdahl says. “As the CFO, it has made my job more difficult because the mechanisms to be reimbursed are few and far between. We have hired staff specifically to improve the health of the community by going to schools and businesses and offering health screenings.
“I can confidently say that this has been great for the community but, unfortunately, it has also been a direct hit to our revenue stream. Our organization operates on a relatively small budget in a rural area and we operate with very high fixed costs. If we incrementally improve population health and reduce patient volume, it will actually force us to charge more for the fewer services we do provide.”
The changing landscape
One of the key risk issues surrounding the shift to population health is the changing field in which healthcare providers will operate. With the increased provision of healthcare services outside of the traditional hospital setting, the risk management landscape will undoubtedly alter, says Drozdowicz.
“The shift will force the focus of risk managers more towards the outpatient side of care,” he says. “Traditionally health systems have done a really good job of taking care of individuals when they’re within the walls of their own facilities and they’ve maximized their reimbursement by maximizing those services while the individual is within the facility.
“In the future risk managers will need to focus on how they can work with outpatient care managers, which is really a new role for most health systems in managing patients once they have been discharged. We’ve seen a whole emergence of new roles that are starting to form, with different care coordinators, and health and wellness coaches; the risk manager will be forced to understand the risks relating to these roles.”
Caradigm has responded to this changing landscape by developing technology that allows risk managers and care managers to understand the population they are managing in order to best serve that population on an outpatient basis. Quality improvement is a major focus of their solutions, through the provision of analytics that include quality measure computation, performance benchmarking, quality gaps analysis, patient-centric quality management and quality improvement programs and campaigns tracking.
Gaps in care
Caradigm’s solution also spots gaps in care provision, to ensure seamless care delivery. This is a major issue in the world of population health management, where individual patients may have several different sources of care and monitoring for their various health issues.
“We’ve created a strong foundation in managing data from all the different healthcare entities within a community,” Drozdowicz says. “Most healthcare executives will tell you that even if they have just a few electronic medical record vendors installed at their facilities, they have silos of data and their electronic medical records systems aren’t good at forming a longitudinal patient record that looks across all the pockets of care that are administered within a community.”
Caradigm’s solution is to bring all that data together into one place, enabling a provider to look at a specific patient and see all the services that have been rendered through all the various different types of care that could be provided in a community
“The first step is really bringing that data together; the second step is analyzing the data and understanding where your risk lies. We have a series of predictive algorithms that look at a patient’s history through all the care that has been administered over several years and predicts a variety of different measures that allow healthcare providers to decide who to focus on, to put a plan together and then to actually manage the care of that patient a little bit differently.”
It seems likely that these types of solutions will gain increased importance as healthcare providers seek to deliver quality, safety and efficiency within a population health model.
A focus on population health clearly has the potential to increase quality of care while also saving money. Although the implications for risk managers are still emerging, and reimbursement looks set to pose challenges for CFOs, its potential to have a transformative effect on the health of whole communities is not in question.
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