Population health management models being refined

UnityPoint Health became an early adopter of population health management back in 2014 when the West Des Moines, Iowa-based regional hospital network began testing programs centered on concepts first developed in its individual hospitals.

UnityPoint needed to look at a number of models because it had hospitals in a variety of markets with a variety of social needs. “We’ve got some very rural markets where the social determinants are completely different than in our more urban markets like in Des Moines or in Peoria,” said Dr. Julia Jenkins, medical director for UnityPoint.

Back then, because there wasn’t a well-established set of standards or protocols, the health system developed some on its own, though Jenkins said it often proved to be a challenge to decide if a population health management concept works systemwide.

Since then, other providers, vendors and consultants have stepped in, offering models and assistance designed to make population health management easier. And though the market for providing pop health management assistance is still in its early stages, much progress has occurred in the last five years.

“We’re now about to enter into a second wave where we’re really going to start learning more about which solutions work and which don’t and which of these companies have legs and true sustainability,” said Josh Lee, principal at Deloitte Consulting, who leads the firm’s healthcare provider strategy practice. Deloitte began formally offering population health management solutions as a part of its consulting services about five years ago and has since invested heavily in that line as a result of the increased demand during the past few years.

Lee said population health management was still a marginal part of the dialogue with Deloitte’s clients just a couple of years ago but has become a more integral part of its consulting services over the past 12 months. He said more hospital leaders have recognized the importance of addressing social determinants as a key part of their business model rather than merely using it as a way to generate positive marketing or comply with their community benefit requirements.

“We are starting to see a fundamental shift to them saying health is their business, not healthcare and that they’re going to align their resources and assets to achieve health,” Lee said.

Such interest has led to the creation of a market that’s expected to see rapid growth in coming years. Projections indicate the population health management market should reach $45 billion by 2021, up from $13 billion in 2016, according to a July report by research firm Markets and Markets.

Most companies offering population health management solutions generally work in data analytics, care coordination and patient engagement.

Some of the larger consulting firms offer a comprehensive set of services that can include everything from providing billing and claims support to quality metrics reporting and utilization management.

But market growth has also attracted a number of smaller tech companies that offer digital tools designed to provide data aggregation and analysis, risk stratification and patient monitoring to aid hospitals in disease and condition prevention efforts, such as increasing medication adherence.

“I think population health management is among the top three strategies for around 90% of hospitals,” said Himachal Mukhopadhyay, senior vice president and healthcare business unit head of technology solutions at Infinite Computer Solutions, a healthcare IT firm that has been providing population health management support for three years.

“While many of these not-for-profit, community-based hospital systems don’t have the resources to really run it effectively, they try and do it by themselves,” he said.

Mukhopadhyay said many system executives believe they have solved their population health management issues simply by purchasing digital platforms that offer data analytics or disease management support. But he said many find themselves unable to make significant improvements because they lack the resources to effectively execute their strategies.

Hiring an outside firm was a way for those providers to have a team committed to running an effective population health management program without hiring additional staff or adding responsibilities on to their existing workforce, Mukhopadhyay said. But many providers are still reluctant to make the kind of changes needed to work in a digital age when it comes to patient management.

“The industry has a long way to go,” he said.

Much of the demand for population health management solutions is being driven by anticipated changes to reimbursement structured on value-based payment. While the CMS has not traditionally directly reimbursed hospitals for their population health interventions, a number of state models and federal initiatives have been launched to address social determinants through Section 1115 Medicaid waivers and managed care contracts.

An April issue brief authored by Manatt Health and funded by the Robert Wood Johnson Foundation found that while 35 out of the 39 states that operate Medicaid managed-care organizations now require or encourage those programs to screen enrollees for social needs and provide referrals to community services, several states have begun requiring MCOs to track and report on the outcome of referrals.

“The level of activity around social determinants is very strongly linked to the growth in provider contracting that links provider payments to the cost of care,” said Michael Abrams, managing partner at healthcare consulting firm Numerof and Associates.

“Readmissions penalties and CMS pilot programs have also been a stimulus for delivery organizations to begin thinking about social determinants, but ultimately it is population health and the underlying contracting that makes providers accountable for cost and outcomes that will drive activity around social determinants,” he added.

But while Abrams contended interest in population health has been around for at least the past five years, the level of implementation has remained slow to take off because of disincentives within reimbursement.

In a March survey of 500 healthcare executives by Numerof, it found a lack of progress toward implementing population health within healthcare delivery. The survey found the majority of organizations receive only about 10% of their revenue through contracts that link reimbursement to the cost and quality of care.

But 94% of survey respondents felt fee-for-service was becoming obsolete and that accountability for cost and quality was the future of payment models. Eighty-two percent said population health was a critical tool toward success in that new reimbursement landscape.

Based on those findings, Abrams said he expected more population health management companies to enter the market in the coming years. But he said the pace of that growth will depend largely on how quickly healthcare providers transition away from fee-for-service reimbursement.

“They’re only moving on this as quickly as they absolutely have to because fee-for-service is what keeps them comfortable, and even if it’s a declining business model, they’re going to hang on to it as long as they can,” Abrams said.

For providers like Cleveland-based MetroHealth, developing strategies to address social determinants was a necessity as a part of their business model well before the current trend. In 2009, the system launched its patient-centered medical home for all of its primary-care services with a goal of mitigating social needs to improve the outcomes of its medically and economically vulnerable patient population.

MetroHealth CEO Dr. Akram Boutros said in the past couple of years he’s been approached with several proposals from vendors offering population health solutions. But he discovered the system’s own initiatives were more advanced in such initiatives—as its utilization of electronic health records to identify those with social needs, the development of risk stratification programs, and the assessment of social needs to help in the creation of its assistance programs.

In June, the system announced plans to invest $60 million toward providing housing, job training and other social services to the community and provide up to 250 new apartments to residents as part of its effort to address social needs.

Boutros said the health system has experimented with a number of initiatives with varying degrees of success over the years. But he said that approach has been beneficial to identifying what has been effective.

“We call it failing effectively,” Boutros said. “We fail small, we fail fast, and we fail forward so that we’re constantly putting programs in place, seeing if they are making a difference, fine-tuning them, and constantly learning from them.”

Similarly, Drew Crenshaw, chief population health officer at Oak Street Health, a community-based primary-care provider for Medicare patients headquartered in Chicago, said conducting robust pilot projects was an important step in working out problems and finding effective solutions.

Oak Street has developed such tools as a decision-support system called Canopy that has been used to obtain more detailed information on each patient and to track their care from hospital discharge to home. The system helped to reduce 30-day patient readmissions by 15% in 2017, but Crenshaw acknowledged that identifying population health strategies that work and can be scalable throughout its growing network has become a challenge.

“As you grow, you don’t have the luxury of shooting from the hip,” Crenshaw said. “You need to incubate things smartly before you go full scale.”