Population Health Management: Who leads the game-Payers or Providers?

What is it?

There are many There are many interpretations of Population Health Management. However, we can simply say that Population Health Management is the analysis of patient data by aggregating data from different sources and creating actionable insights which can assist in improving clinical and financial outcomes.

Why Population Health Management?

In the United States, most health care costs are attributed to chronic diseases or conditions and patients with health risks.

For example, 86% of all healthcare spending in 2010 was for people with one or more chronic medical conditions.

In the USA, 7 out of 10 deaths are due to chronic diseases.

Approximately. $315.4 billion was the medical cost of heart disease and stroke in 2010. (Source: www.cdc.gov)

It is estimated that 78 million Americans age 18 or older would have doctor-diagnosed arthritis, by 2040.

How does it make a difference?

Implementing Population Health Management (PHM) assists in achieving the triple aim of better health, better patient care and lower costs.

Benefits of PHM, include identifying appropriate patient groups or populations, stratifying risks, addressing gaps in care, preventing diseases, enhancing the continuum of care, improving patient satisfaction, a reduction in overall cost, etc.

This also assists in gaining better visibility into effective care delivery to payers and providers.

Who leads the game – Payers or Providers?

Payers have the access to claims data. These data are structured, of a consistent format, and are readily available. The data span the continuum of patient care and include every record of each encounter and prescription. For these reasons, it is easy to use with other systems. Using these data, analysts can provide insights about the utilization pattern of the selected population, different types of diagnoses and procedures, costs associated with the patient population, access to health services, etc.

However, there are some limitations of using it as a sole source of data for PHM. These limitations include:

• A lack of detail clinical information like co-morbidities. These data are designed only to capture information required to determine payment.
• The retrospective nature of claims data, which are often a few months old
• The inability to provide an insight into the actual process of care

Providers have access to the detailed clinical data of the patient population with insights into the processes used in delivering care to patient, including but not limited to patient demographics, medical history, immunizations, diagnosis, allergies, lab results, etc. The data available with providers are real time and collected at every encounter. This allows for modifications in care delivery as the need may arise.

Limitations of clinical data

• Data collected is limited to a specific encounter and does not span the continuum of care
• Data is handled in siloes. , since different providers use different EMR/EHR and there is limited or no exchange of data among providers
• Data is unstructured, raising difficulties in extraction and normalization

Role of IT:

Healthcare IT organizations are leveraging technology to develop applications that aid in population health management. They do this by aggregating patient data by population and sub-population using data integration and data analytics against defined indicators. These products integrate with provider EMR/EHR for the data feed and provide a deeper insight into individual patient medical history, health status and the patient’s contribution towards their own health. Most products do offer data exchange using HIE, thus maintaining confidentiality and privacy while complying with regulatory standards.

Summary:

Neither clinical nor claims data provide enough information on their own. Therefore, we may not be able to achieve efficient population health management using a single data source. However, combining data from both of the sources can be beneficial. We can achieve this by using Structured Data Capture, a standards-based data architecture so that a structured set of data can be accessed from EHRs and be stored for a merger with comparable data.

With up-to-date clinical details along with a view of a patient’s continuum of care through claims, utilizing data from both of these sources will surely assist healthcare providers and payers to manage their populations more effectively and realize the Triple Aim of higher quality, lower costs, and a better patient experience.

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