Population Health Management (PHM)

Population Health Management (PHM)

With the most advanced and sophisticated healthcare system in the world, the USA might be the most expensive medical care destination. But their expenditure is healthcare is skyrocketing due to lack of access to healthcare for many and gaps in the care provided. Experts in healthcare economy express the need for an organized healthcare reform focusing on making health care more affordable, accessible and delivering high-quality care for all the citizens in the USA.

Healthcare reform- The need for PHM

The first step towards the reform was HITECH Act of 2009 which authorized $19 billion in federal subsidies to physician and hospitals for the Meaningful Use of electronic health records. The Patient Protection and Affordable Care Act of 2010 encouraged providers to responsibility for the cost and quality of care. The Centers for Medicare and Medicaid Services (CMS) were instructed to create a shared savings program for accountable care organizations (ACOs).  ACOs are groups of physicians and hospitals dedicated to reducing the heath care cost and to improve the quality of care. As per this program, which began on Jan. 1, 2012, federal government will penalize hospitals for avoidable readmissions and base a portion of their reimbursement on quality measures.

The entire objective of the reform is to move to pay-for-performance from fee-for-service, which is considered as a major reason for cost in U.S.Healthcare system.  With the initial success of Patient-Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs) models, the reimbursement system is likely to replace fee-for-service.  The current shift in healthcare systems will involve increased financial and clinical accountability.  Thus, the healthcare system in the US is opting for “population health management” – An approach to providing affordable, quality healthcare and reduce the healthcare cost.

The aim of population health management (PHM) is to keep the patient population healthy, minimizing their encounter with emergency department, hospitalizations, and procedures. It helps to redefine care delivery paradigm from a disease-specific approach to patient-centric approach. To meet its objective, PHM requires automation across the continuum of care to access population needs and stratifying risk  based on patient risk arrived by analyzing clinical and non-clinical data.

Benefits of PHM: Enhances patient experience and lowers the health care cost.Use of IT in PHM helps prophylaxis of a disease.PHM’s BI tool which gives direct access and attention to individual patient requirements helps in bridging the gap between the elements of the health care system.  

Successful Implementation of PHM Program

A PHM program, implemented successfully, can work wonders in cutting down the healthcare expenditure and improving your patient’s health outcomes. The following five steps will help providers in planning for successful implementation of PHM program.

DATA is the ‘IT’ thing

Data is the heart and soul of PHM. The healthcare system yields a huge volume of data, at every touch point, from a patient-physician visit to discharge, from medication to health message alerts, from billing to insurance department.  These data sets, generated at different levels of care, are just dots. The first step towards implementing PHM begins with connecting these dots by acquiring, aggregating, and leveraging clinical data across the care network.  The PHM system demands an efficient data collection, storage, and 360° automation. This implies that we think beyond EHR and its interoperability with other systems. Efforts to make the EHR more sophisticated for data capturing at all levels may be worth exploring.

Analyze the population data:

Data without actionable insight is a waste. Analytics helps in giving insights into the population health status which is the core of any successful PHM program. Algorithms, designed using risk scores using clinical data from electronic medical records and claims, may help to predict vulnerable population.

Supported by non-clinical scores such as compliance, access-to-care and socio-economic, these analytics may help to identify the patients who have a high risk of being hospitalized or likely to have an expensive intervention. The data analysis may facilitate complex tasks such as tracking of the health status of patients, reminding them about medications, and warning them about the risks associated.  These interventions may ultimately result in improved patient outcomes, contributing to treatment success.

Bridging the care gaps

There could be many differences or gaps in care, when utilization of health care is compared to the distribution of healthcare, when the treatments provided are compared to the treatment outcomes, when the treatment ordered is compared to the treatment instituted. Care gaps can occur at any level of healthcare, due to numerous reasons. These gaps in care may adversely affect the healthcare costs and the patient health outcomes.  

The patient clinical data and utilization pattern, captured through a PHM program, is used to determine whether the patient has a gap in care. Based on this analysis, the care manager designs personalized a care management program to engage at-risk patients in receiving necessary services, alerts, and reminders at the point of care.

Engage your patients for better health outcomes

Population health solution strives to engage patients at various touch point along with physicians and other clinicians. To optimize the patient engagement, the physicians and care coordinators must be in constant touch with their patients, even if they are out-of-the-hospital. Contact can be established and maintained by sending reminders to the patient’s mobile phones, delivering e-mails, or placing a call. However, new technologies like telehealth devices seem to be a great promise. Using these devices, the physician can analyze the telemonitoring data and prescribe preventive and curative measures.

Empower and support the primary care physicians

Primary care physicians (PCPs) are the first point of care for most patients. Therefore, it is important to empower the PCP to ensure that patients receive appropriate and timely care. However, due to shortage of PCPs, formation of a care team, consisting of physicians, nurse practitioners, medical assistants, dietitians, physical therapists, care managers, health coaches, or other professionals, may be needed. The objective is to manage more patients and address their needs timely and efficiently.

The health care system in U.S. is a one-to-one effort, that is, the patient consults the provider even for an insignificant query. But, in the near future, the workflow might change to include phone visits, e-mail consultations, group visits, and encounters with a variety of care team members. This would then reduce the number of hospital visits, thereby benefitting both the PCPs and the patients. 

Automate, automate and automate

To accomplish the objectives of PHM, automation of the healthcare system is crucial. The automation would results in better data capture and analysis. It would also help the health care team to customize care management. As a result, the health care team would be able to spend quality time with the patients rather than doing the routine tasks. This automation may, thus, help the organizations in effective utilization of their human resources without the financial burden.

Measuring the outcomes of PHM- The Litmus test

The effectiveness of any program is measured through its outcomes. An outcome measurement in the form of a dashboard view of risk stratification, prevalent health conditions by population area or the evaluating provider, and practice performance may point towards weak areas that need strengthening and ineffective programs that need further modification. These adaptations would require a trained clinical analyst on board to filter the results by payer, activity center, provider, health condition, and care gaps to measure the outcomes specific care management programs.

The consequences of the PHM program can be measured in 3 ways. They are as follows –

  • Financial outcomes: A successful PHM program attenuates the cost of the health care incurred by a patient. Edging off the cost burden of the patients can be achieved by focusing on prevention and reducing the risk of further complications, through measures as simple as promoting medication adherence.
  • Clinical outcomes: The measurement of clinical outcomes should include both process metrics and outcome metrics. An example of low-cost intervention is medication-reconciliation program.  
  • Engagement outcomes: As prevention of a disease or reduction of its likelihood depends on the selection of choices of the daily activities a patient performs, the participation of patients’ in various activities affects the results of PHM. Therefore, their engagement should also be monitored.

If the indicators reveal improved patient outcomes or reduced healthcare expenditure, it means that your PHM program is implemented successfully!

Learning from the Learnt: Leading Horses in the PHM Run

Humedica (www.humedica.com) –  Humedica, based in Boston, MA, is the clinical intelligence company that powers health care providers and life sciences organizations to make better-informed, more confident decisions by transforming unconnected data from multiple sources into real-world insights. Humedica is now acquired by Optum.


VitreosHealth (www.vitreoshealth.com) – VitreosHealth, based in Dallas, TX is a pioneer of Advanced Population Health analytics leveraging EHR, Claims, HRAs and Socioeconomic data for predictive risk and prescriptive care management. The tool is used by Providers, Payers, and IPA’s.

Explorys (www.explorys.com) –  Based in Cleveland, OH, Explorys provides a secure software platform that allows healthcare systems to aggregate, analyze, manage, and research their BIG DATA to provide better patient care in a rapidly changing healthcare market. Explorys is now part of IBM and known as “Explorys – an IBM Company”.

Health Catalyst (www.healthcatalyst.com) – Health Catalyst enables healthcare organizations to fundamentally improve care by building the most comprehensive and fully integrated suite of healthcare data warehousing and process improvement solutions available. They are headquartered in Salt Lake City, UT.

Lumeris (www.lumeris.com) – Missouri based Lumeris is a pioneer in population health management solutions. Through operations, technology and consulting services, Lumeris enable healthcare organizations to successfully make the journey from volume- to value-based care.

Optum (www.optum.com) – Optum™ is a health services and innovation company on a mission to help make the health system work better for everyone. Optum™ combines data and analytics with technology and expertise to power modern health care.

Active Health (www.activehealth.com) – Active Health Management is a national leader in population health management and passionate about helping every person achieve his or her best health. They deliver personalized guidance through our analytics and insights, care management, health, lifestyle and wellness programs to help providers improve quality of care, lower healthcare costs, and drive sustained member engagement and behavior change.

Phytel (www.phytel.com) – Dallas, TX based Phytel is the premier company empowering physician-led population health improvement. Phytel provides physicians with proven technology to deliver timely, coordinated care to their patients. Phytel uses evidence-based chronic and preventive care protocols to identify and notify patients due for service, while tracking compliance and measuring quality and financial results. Phytel is also part of IBM.

Conclusion PHM is about having an organized system in place to manage population proactively and delivering highest quality care while reducing the cost by engaging patients. Automation and usage of Business Intelligence (BI) tools help PHM program in aggregating data from the medical records and claims to provide a comprehensive clinical picture of each patient in the given population cohorts. PHM helps providers in tracking and monitoring the patient’s medical condition to provide proactive care management.

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