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Providers and Plans Must Unite to Achieve the Goals of Population Health Initiatives


Population health initiatives took another step forward in December 2018, when the National Committee for Quality Assurance (NCQA) launched 2 new programs: Population Health Program Accreditation to assess how an organization applies population health concepts to programs for a defined population, and Population Health Management Prevalidation, which reviews health IT solutions to determine their ability to support population health management functions.

These new programs promote increased standardization in population health management practices, yet plans and providers are sometimes at odds. One of the biggest challenges in population health is agreement between plans and providers on attributed patients, ie, a shared definition of what population, or patient base, is under a provider’s responsibility. Furthermore, providers and plans are not always aligned on key target populations, major health challenges, and how to address barriers to health such as social determinants of health. They must align on payment arrangements that support shared population goals. To achieve the goals of population health initiatives, it’s imperative that plans and providers work together for a common understanding around accreditation and the strategies to reach different populations.

Here are 5 ways they can do so:

Understand your population. Plans and providers should proactively work together to determine the right attribution process: prospective, retrospective, or some combination of the two. Retrospective attribution means a health provider is responsible for anyone who they’ve treated in the past. Conversely, prospective attribution gives providers a list of the patients they’re accountable for ahead of time. A recent study found the majority of payment systems rely on retrospective attribution of patients to providers, but there is no universally accepted way to do so. In the end, the method of attribution should be clearly communicated early and often so all parties are on the same page in terms of which patients make up the population in question.

Implement an effective outreach strategy. Agree on the outreach and primary care physician (PCP) selection process and timeline. Providers should make sure their patients get attributed to them and get the opportunity to build relationships with new patients from day one. The earlier providers are able to reach out to patients, the more opportunity to have to identify high-risk patients or notable gaps in care. Providers are often challenged with low levels of health literacy among their population and need proven strategies to ensure their patients understand the care plan options available to them.

A recent study called The Other 45 illustrated just how effective patient engagement can be in improving population health. It found that just 45 minutes of one-on-one time with patients who are newly diagnosed with chronic illnesses can significantly improve health outcomes by delivering useful self-management techniques.

Assess and appropriately segment your data. Analysis of clinical, financial, and operational data is necessary to identify the gaps in care within a given patient population. Plans and providers should focus on the conditions patients struggle with most, as well as on the high-cost conditions plans prioritize. Continuous patient engagement throughout the care journey is key here, because it helps providers encourage prevention and more easily manage chronic conditions.

Consider a range of interventions. Reach out to high-risk patients to bring them in for care, and then implement technology that can engage them on an ongoing basis. Regular communication allows providers to send patients health tips and allow them to ask questions, while collecting patient-reported outcomes. Text messages, for example, have proven to be highly effective. In 1 study among a population of diabetic patients, 66% responded to a text prompt to send their glucose readings to their providers, compared to just 12% of patients who were asked to do so during a visit.

Get patient feedback and track your data. A population health program should improve the patient experience, not hinder it. Collect feedback from target groups on how they perceive the new interventions, allowing you to address areas of concern and further improve what’s already working. In addition, providers can work with plans to gain access to claims data from patients to understand their utilization beyond the system in order to track major quality measures, set improvement goals, and monitor overall success.

If successfully executed, population health is an “everybody wins” proposition. The main goal, of course, is to get at-risk populations to care in order to prevent the development of serious or chronic conditions and close gaps in care. This benefits both health plans and providers as well, but only when they work together will they have the best chance of success.

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