A Phased Approach to Population Health Management

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Population health management is not a one-click approach to managing health care. Many parts of an organization need to work together, in order to help employees improve their own health, and to reduce costs for themselves and the plan. While some health care organizations prefer to execute a full implementation right out of the gate, others take a phased approach, putting pieces in place one at a time.

Since 2009, Cammack LaRhette has been working with one community health care system on a phased method for achieving improvements in employees’ health. The program started with data integration and a customized model of disease management, referred to as Personal Health Management. In the first year, this organization achieved a positive return on investment (ROI) from these services and identified further opportunities for improving the health of its total employee population.

This client chose to implement the program in stages. The firm’s corporate cul¬ture was better suited to gradual changes. Capabilities were constrained by tight resources. Moreover, management wished to minimize disruptions, and to avoid additional administrative burdens for personnel who were already working at full throttle. In addition, leadership was not fully convinced that results would be forthcoming, and preferred to see evidence of progress before making additional program investments.

In this article we examine the first phase of the client’s implementation. We have currently reached a decisive inflexion point: we can now identify additional oppor¬tunities to improve population health, and create a marketable infrastructure for the client, which they can parlay into relationships with payers and local employ¬ers to improve the health of their community at large.

The client began by loading both employee and dependent ("member") medical and pharmaceutical data into an integrated data warehouse and care management technology platform. The centralized data allowed Cammack LaRhette to define and measure health risks for individual members and the total population. A proprietary risk stratification tool identified high risk members who would benefit from the personal health management program. Rather than selecting members with the highest historic costs, the predictive tool prioritized actionable inter¬ventions with potential for improving health outcomes and avoiding significant expense. Additionally, the stratification tool looked holistically at each individual, including a range of complicating factors and co-morbidities, rather than at single conditions. Changes in risk were tracked over time, both for participants and the population.

Cammack LaRhette assisted in the setup and implementation of the Personal Health Management program, which uses local personal health nurses to engage high risk members. The nurses work collaboratively with members and their physicians on improving patient motivation, and developing knowledge and skills fundamental to achieving compliance with efficient and effective treatment of chronic conditions. Members, who often have multiple chronic conditions, may need guidance in navigating the health care delivery system or securing resources available through their employer. The personal health nurse takes a holistic view based on the realities and requirements of the family and employer.

First year results of the personal health management and targeted communications programs delivered an ROI of 1.6. In addition, absenteeism has declined. While the programs have been successful, Cammack LaRhette has now worked with the client to identify opportunities for improvement from implementing additional phases of the popu¬lation health management protocol.

First, it was noted that member engagement in the program was suboptimal. One basic reason was the lack of current telephone numbers. In addition, members did not fully understand the program and its purpose. Since the program began as a phased implementation, no underlying governance structure was put in place. In addition, a cohesive communication and engagement strategy was never adopted.

Even though the client offered many health and wellness programs to the com¬munity, a centralized governance structure was needed either to redirect or initiate new programs for employees. This disjointed governance also related to incen¬tives. Despite multiple incentives applicable to particular offerings, consolidation and branding would have led to increased engagement and improved outcomes. An integrated governance structure would also have helped to build an even stron¬ger communication platform for recognition and participation.

Another opportunity for improvement lies in better timing for enrolling high risk patients in the personal health management program. Patients were identified for enrollment through claims, late in the disease cycle, which meant that members were already receiving substantial medical care, and taking medications related to their condition(s). Ideally, the program should seek to identify those at risk of de¬veloping a condition, before the full onset of the disease. Relying on claims exclu¬sively implies that members have already suffered an adverse health event. Adding data from a biometric screening campaign is one example of leveraging predictive modeling to identify high risk patients earlier in the disease cycle. This would al¬low for alignment with high performing providers, and utilize health resources at a more efficient point, before serious complications arose.

A final opportunity for improvement derived from optimizing domestic utili¬zation. The health plan design did not sufficiently differentiate domestic from non-domestic, out-of-pockets costs for members, nor did it "capture" them at the point of entry for beginning a course of treatment. By tying a pre-certification or pre-notification protocol to the personal health management program, the plan could begin health management earlier in the cycle – plus, keep members within the system. Retaining members within the health system’s facilities can make a critical difference. For example, the information flow housed in one sole system is far superior and leads to improved outcomes. Domestic utilization is also more efficient, helping to align affiliated physicians with the system, while at the same time reducing payments to competitors.

1. Year one results drove the client’s decision to move forward with the next stage of implementation. The opportunity analysis indicated that the client should focus on four key areas: cen¬tralized governance structure, early identification of disease, supportive plan design, and compelling communications. It was recommended establishing a supportive internal governance structure to enhance ex¬ecutive buy-in and create formal processes for developing new programs and integrating communications with overall strategy. Within the gov¬ernance structure, physician engagement is a top priority. Strategies for promoting engagement include directing more patients to physicians and increasing reimbursements for physicians willing to participate in the population health management approach to care, offering tools, such as a physician portal to access the data warehouse, increase physi¬cian efficiency, and performance.

2. Identifying members in an early stage of disease is another pillar of the population health management model. We recom¬mend a number of methods:

a. An onsite biometric screening process, whereby data is collected and sent to the data warehouse, helps identify previously unknown conditions. Incentives to drive engagement and consolidate the screening with an existing process, such as annual compliance test¬ing, will increase acceptance and program continuation.

b. Integrating the pre-certification or pre-notification protocol into the personal health management program will capture other members early in the process. The utilization management proto¬col within the personal health management program will use the screening results; referrals from pre-certification or pre-notification processes will help identify members with risks (but no claims) who are potential candidates for personal health management. Utilization management will also serve to direct care internally, in appropriate circumstances.

c. Acquiring and integrating additional data elements develops a more robust profile of each member, improving risk assessments.

3. Refining plan design to adopt stronger incentives to stay within the health system will also help to ensure care is delivered efficiently. Incentives to engage/participate typically constitute a first stage; we advise, however, that clients work toward incentives for outcomes. Although these can be awarded in a number of ways, we recommend premium differentials and/or reductions or eliminations of cost sharing for employees who are compliant.

4. A compelling, actionable communication strategy is essential, to cre¬ate awareness, attract attention and interest, demonstrate that change is possible, and motivate different behavior. Ultimately, you cannot change someone who fails to engage. We take great pains to establish methods and messaging particular to the intended audience, including physicians. The engagement of senior executives is also critical, to emphasize the im¬portance of health management as a business imperative throughout the organization.

We will work with our client to move to this next phase and to measure success and return on investment for key economic, clinical/quality, and member experi¬ence/satisfaction metrics. Future phases to consider include creating an absence management program to optimize return to work and discharge planning, and establishing a culture of health through environmental wellness (e.g., onsite pro¬grams, food, tobacco-free) that leads to sustainable health management and long term risk reduction.

Erin O’Connor, Esq. is the health care practice leader where she works with clients to analyze the HR needs of their organizations, and to identify and implement practical and innovative solutions. In addition, Erin works across Cammack LaRhette’s practices to integrate client plans and programs into the overall employ¬ment relationship. If you would like more information on this article or the Health Leaders Learning Series, please contact us by e-mail to CammackLaRhette@clcinc.com. You may also contact Erin O’Connor directly at (212) 227-7770, ext. 228, or eoconnor@clcinc.com.