Three Barriers to Population Health

“Population health” is a common catchphrase in today’s healthcare delivery system.

Though many providers and systems apply the phrase differently, it most broadly refers managing a patient’s care holistically across the entire care continuum, both inside and outside of medical facilities.

This healthcare model helps merge the care experience and clinical intelligence gathering across facilities and providers, while also accounting for other care-impacting factors, such as social determinants, predictive and preventive care, demographics, and patient personas.

Although population health management is extremely beneficial to both hospital organizations and their patients, there are key barriers health systems must address in order to truly reap the benefits. Even the most established health organizations can struggle with shifting from fee-for-service to value-based care if they aren’t properly prepared to tackle these three key challenges:

1. Data Quality and Access

Culling data from multiple providers and presenting it in a way that’s clear and actionable is a seemingly constant struggle for health systems. Recent data shows that an abundance of health systems continue to have a self-governing, siloed and incommunicative business model that is proving detrimental to patients and hospital alike.

A recent report from former Centers for Medicare and Medicaid Services Administrator, Dr. Don Berwick, estimated that in 2011, $25 to $45 billion U.S. dollars were wasted due to a lack of care coordination within the country’s healthcare system. According to that report, lack of coordination resulted in increased complications, hospital readmissions, declines in functional status and increased care dependency.

Streamlined IT capabilities are crucial to enabling all providers involved in a patient’s care to make the soundest, most informed care and treatment determinations. An advanced IT framework, including an extensive electronic health records system, data exchange capabilities, case management software and analytics programs, is critical to upholding patient care quality as well as laying the foundations for a population health management model.

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2. Fragmented Ownership

Lack of total care system ownership and integration can lead to problems within a system’s IT and financial infrastructure and ultimately impact the quality of patient care. For example, a health system may purchase a primary care practice network and acquire elderly patients.

However, if they do not own a home health/hospice agency, rehabilitation facilities or specialty care resources, the health system must outsource and send patients elsewhere for that care. In some cases, the various facilities involved may not have a financial arrangement or similar electronic infrastructures, which can cause important details about a patient’s history and care plan to get lost in translation in between providers, physicians, caretakers, and medical facilities.

Mapping the entire continuum of care is a key first step toward averting care ownership and miscommunication challenges. By doing so, hospital executives gain a full understanding of all patient touch points and interactions and begin designing plans to close information gaps and foster patient relationships throughout the process.

Once systems understand the entire care continuum, and their role in each, then they can move toward a coordinated care model to foster communication across departments, specialties, and practices.

3. Current Payment Models

The healthcare industry is set up as a fee-for-service delivery system – a system whereby the more patients you see or procedures you do, the more money you will make. Shifting to a value-based payment model works hand-in-hand with better population health management. In value-based care, providers may be paid based upon outcomes of care they deliver rather than the number of visits or tests they order. In theory, this shift encourages collaboration, outcome-based payments and a new benefit design to align providers, members, employers and payers.

Focusing on improving value and outcomes is the key to delivering the best care for all demographics of patients. Tracking patient complications, HAIs, hospital readmissions (specifically 30-day readmissions) and employee and patient satisfaction provides hospitals the necessary insights they need to most effectively evolve and improve to best serve patients.

While still in it’s early stages, the healthcare system-wide migration from a fee-for-service to a value-based payment model is one that won’t be ending soon. In fact, the Centers for Medicare & Medicaid Services (CMS) recently added new components to the Affordable Care Act (ACA) effectively forcing hospital organizations to move toward value-based care.

Horizontal Shift

For true population health success to occur, the ‘business’ of care delivery must make a shift “horizontally” across the continuum, rather than vertically in siloes. IT capabilities must improve to pull data in a timely manner and payment reform must occur – and finally the health system payment model must move from a fee-for-service model to a more value-based model that hinges on quality outcomes and patient satisfaction.

John Gallagher is Senior Innovation Consultant, Simpler Healthcare.

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