So you think your health plan is managing members’ care?

Innumerable articles and blog posts have been written about the rise of value-based care (VBC), population health management (PHM) and care management. Yet definitions of these terms vary widely and progress toward achieving better value and better management of populations’ health and care has been slower than expected.

The Fourth Annual Numerof Survey Report (2019) on the state of population health found that while 40% of respondents consider PHM critically important for future success, only one quarter feel very prepared to take on risk. This reality contrasts with the blithe predictions of the 61% of respondents in 2016 who predicted that they would be very prepared to take on risk by 2018.

The bottom line: managing the care and health of populations is harder than anyone expected in the heady early days of PHM and VBC. No wonder that the same survey found that only about 10% of revenue is still being generated from risk-based contracts as of 2019 and progress towards pop health appears to have stalled.

Limited data sharing and risk stratification are barriers to care management 

A 2019 survey found that limited collaboration between providers and payers is one barrier. Over half of respondents to this survey said they lack the ability to share PHM solutions with their payer or provider partners. And while nearly all (94%) said collaboration was important or very important, many aren’t getting clinical data from their provider panels:

  • 20% of payers weren’t getting any real-time clinical data from providers
  • About three-quarters were getting such data from less than half of their providers

Further, 47% of payers and 81% of providers don’t have shared PHM tools in place for collaborating on quality and care management.  Both payers and providers considered technology among their top four opportunities and among their top challenges to better collaboration.

The National Committee for Quality Assurance (NCQA) is encouraging healthcare payers to incorporate clinical and financial data in their quality reporting. NCQA has also launched a new Population Health accreditation program that is seeking to help organizations move toward industry best practices for population health. This program aims to help healthcare organizations standardize care, become more efficient and better manage complex care by evaluating:

  • Data integration
  • Population assessment and segmentation
  • Targeted interventions
  • Support for practitioners
  • Metrics and quality improvement

Notice that the first area this NCQA program is targeting is data integration. Even over a decade after EHRs became widespread, the healthcare industry is saddled with an overload of data that is too often outdated, poor quality, not integrated, and not shared.  

Going beyond analytics to true care management

Too many PHM programs (and/or their technology platforms) have stopped at the point of analytics – of stratifying risk. Yet even in risk stratification, efforts are limited. We approached the development of our AI-enhanced VBC platform recognizing that we couldn’t build it to meet a single VBC program or risk model. So we incorporated not one but four of the most advanced risk models available today as well as Health Risk Assessments. And we enable users to integrate data from all sources across the entire continuum of care. Your providers don’t have to keep track of which VBC program a member/patient participates in or what the rules are for each program – we do that work for them. That means that they can deliver care that helps you meet your HEDIS scores and STAR ratings without undue burden.

The platform also enables health plans to:

  • Collect data from all sources (claims, EHRs, devices, patient reported, and socioeconomic)
  • Create interoperability across the entire network
  • Perform AI-enhanced risk stratification
  • Optimize network performance
  • Track and care for patients across all care settings
  • Create on-demand cohorts
  • Generate and deliver real-time HEDIS, HCC coding and care gaps alerts to providers
  • Implement workflows that make all this data actionable in caring for patients

There are many barriers to managing your members’ health and care. Those barriers are impacting your scores/ratings as well as your bottom line. If you and your providers can’t collect data across the continuum, meaningfully stratify risk, or use that data to take actions such as filling care gaps, are you really managing care? 

Having the right technology platform that can take you from data integration all the way through impacting care management and delivery can help you achieve this and improve your collaboration and relationships with providers. You can’t provide care, but the more you can make it easier for them to provide care, the better for both of you — and for your members.