With the rollout of the most significant phase of the Affordable Care Act on January 1st, there are hundreds of new health plans offered in the market, many of which involve healthcare providers taking on risk in various forms. Exchanges aside, providers are increasingly working with health insurance carriers to capture savings they can achieve in their patient populations through different degrees of risk-bearing contracts. A key component of providers’ financial upside in taking on risk will be their ability to implement effective population health management programs in order to manage their highest cost patients.
While select provider groups across the country have been managing risk for years as part of capitation programs, most providers do not have the technology infrastructure, processes, or organizations required to maximize the financial benefit of managing risk through proactive population management.
- Technology: the market for population health technologies is hot. A variety a software companies and system integrators are trying to stake their claim in this rapidly growing market. Providers are looking for varying capabilities and the leaders in the segment are yet to be determined. Software vendors who have traditionally enabled care management programs for health plans are trying to adapt their solutions to meet providers’ needs, with some notable initial successes. There are also companies that are building tools and dashboards to harness clinical data from EMRs in order to create intelligible information that providers can use to manage their patient population.
- Process: Provider organizations must develop internal practices around who should be actively managed, what they will do with these patients, and how will they do it. Health plans have traditionally stratified populations and then attempted to enroll segments of their members into programs tailored to help manage certain health conditions. Providers have an opportunity to be much more successful in these endeavors than plans, due to their relationships with their patients and the potential to manage the patient as a whole person instead of trying to address only a single health condition.
- Organization: While implementing software and defining processes are perhaps easy to conceptualize, the biggest unknown related to provider based population health management is who is going to do it. One thing is for certain: in the vast majority of cases, it will not be the physicians. Some provider organizations are building out large call centers where nurses and case managers will be interacting regularly with by phone. In smaller provider groups, it may be the nurses in the physicians’ office that are asked to schedule health coaching appointments with patients or analyze results from remote monitoring devices to determine when interventions may be needed. Once the processes are defined, providers will need a variety of capabilities that do not exist today within their walls. Some providers will build out these organizations internally, while others may outsource.
We are in the very early innings of this shift and providers’ population health efforts will likely go through several evolutions before best practices are established. In our view, the opportunities for technology and services vendors who can help providers design, implement and deliver their programs are limitless; let us know what you think.