Population health management (PHM) is one of the standout areas in healthcare and healthcare IT today. The term encompasses many things, but a reasonable working definition is:
A team-based approach that uses various management techniques to ensure that care is efficiently planned, coordinated, and delivered, both proactively and emergently, across all care settings and all care domains, in a manner that is optimized for a designated population of people.
This approach underlies many of the value-based care programs that have swept the country in the past half dozen years. The logic is easy to follow:
- Healthcare costs are out of control, and payment reform is needed to erect a sustainable model for care
- The prevailing wisdom is to leverage fee-for-value paradigms over fee-for-service to enable risk sharing among the providers and payers of healthcare
- Providers assuming risk and capitation should be able to improve outcomes by effectively managing patient populations to maximize revenue through efficient care delivery and improved quality of care
- PHM is a key enabler of value-based care
PHM is maximized when it is comprehensive and community-based, includes all services that impact a patient’s health (e.g., medical, behavioral, social), and extends beyond the walls of any single care establishment to encompass all relevant service providers contributing to patient wellness. PHM’s breadth of coverage in care delivery can engage many stakeholders, making it a valuable platform to leverage to ensure maximum inclusion and applicability for healthcare change. And significant value is available to these stakeholders who can implement a successful PHM strategy.
PHM for Patients
Patients who participate in a PHM program gain the most. PHM done well provides continual monitoring and risk assessment, so preemptive intervention of serious health risks is not only possible, but is the norm. Patients singled out for more intensive PHM regimens generally are those that are more costly to the healthcare system and those who may not already be getting the best quality care—and PHM can make a difference.
Community-based care not only accounts for a patient’s medical condition, but manages it within the comprehensive context of the patient’s life, accounting for behavioral health factors and social determinants that affect a patient’s health. This ensures that barriers to wellness are addressed as a deliberate component of care, and coordinated with medical treatment. Care delivered under PHM is evidence-based or empirically validated, so quality outcomes are more consistently achieved as care delivery is normalized across the population.
PHM for Providers
Care providers in the PHM context span a wide range of care in a patient’s life. Social workers, housing agencies, psychiatrists, primary care physicians, managed care organizations, long-term care facilities, ancillary medical services, hospitals, home care agencies, addiction/recovery services, medical specialists, and even patients themselves may all be enlisted into a care team to coordinate the activities that lead to achieving a patient’s optimal health outcomes. This wide-tent approach emphasizes teamwork and information sharing. Providing unified views of patients across the care continuum—powered by common tools that enable collaboration among the diverse and disparate care team members—and using analytics to develop insights on effective treatment and intervention are central to PHM success. The benefit to all providers is that through the team-based approach, each provider is able to account for activity beyond its individual span of control, allowing for more risk to be taken on and truly mitigated, which makes value-based care feasible.
PHM for Payers and Managed Care Organizations
Payers as insurance companies and managed care organizations (MCOs) traditionally assume much of the risk for care performance, and distribute that risk across their customer base through premiums. As the industry embraces payment reform and allocates more risk to providers, MCOs can still participate in these new-breed care teams to bring their knowledge of best practices, eligibility parameters, and other expertise honed as the experienced underwriter of care. This participation infuses informed population management perspectives into the care of individual patients. These entities can also influence care as it is being planned and executed, rather than retrospectively reviewing activities through a claims adjudication process alone.
PHM for Employers
Many employers, especially large employers, self-insure the medical claims of their employees. This underwriting is often done without a clear way to impact the care of their employees and reduce their risk for costly claims. PHM can help these employers, and to a lesser extent employers that don’t self-insure, in two primary ways. First, by caring for large portions of the regional population in geographic HEZs, PHM can align the interests of the represented employers of those HEZ populations to support a common care model for shared investment and influence to impact their insurance risk profiles. Second, the HEZs provide tangible programs that employers can endorse for employee participation, and by leveraging the HEZ as a third party, employers can provide a direct channel for enrollment and information harvesting while remaining arm’s length from intruding on employee privacy.
PHM for Digital Health Companies
The breadth of activities involved in PHM models offers opportunities for many kinds of digital health offerings. Patient engagement, electronic health records, remote monitoring, telehealth, wearable devices, care navigation, referral management, health information exchange, mobile health, analytics, business intelligence, care management systems, and a host of other technology areas may be harnessed to power expansive PHM programs. This means that virtually the entire ecosystem of local technology businesses in the healthcare space can participate in the HEZs as they evolve. A secondary benefit of the PHM model within the HEZ, particularly for young companies, is enabling engagement with the healthcare system in a way that validates their offerings. Digital health is a young field, and often the opportunity for the companies to have reference sites that are successful is just as important as having customers. Many technology incubators are eager to engage with efforts that give early traction to their stable of companies. The HEZs can leverage emerging digital health technology to remain cutting-edge and aggressive, using the best innovations to provide transformative care.
Benefits to the Region
All stakeholders discussed here have opportunities to be successful with PHM programs in Philadelphia, and to trumpet that success in their professional communities. This notoriety will give our region a leadership position that will attract investment, businesses, working professionals, students, and residents to the area. A continual flow of press, publications, case studies, and other collateral will be produced to extol the progress and characterize the results of the new care models.
PHM is a job generator. Typically, the need for care managers and coordinators within communities implementing PHM. And, for companies supporting PHM activities such as digital health vendors, resources will be needed that will further add to the local economy. Local schools can develop programs that will be feeders to these new roles to field a trained workforce. Through these and other means, the broad adoption of the PHM paradigm will have a positive impact on Philadelphia employment.