From the Hayes Healthcare Leaders Blog Series (@HayesManagement)
By Don Livsey, former Vice President and CIO, UCSF Benioff Children’s Oakland, Founder DZL Solutions
Big data, informatics, business intelligence, and data mining have all been floated as “silver bullets” to solve the riddle of healthcare reform. One that will likely have the biggest impact, however, is population health. HealthcareIT News recently reported that population health and data analytics are the top two topics of interest for 2016. Everyone wants it, but few can clearly define what it is, and we don’t know what it will cost.
David Kindig of the Department of Population Health Sciences at the University of Wisconsin and Greg Stoddart from the Department of Clinical Epidemiology and Biostatistics at McMaster University in Ontario, are credited with this first attempt at a definition of population health in 2003:
“The health outcomes of a group of individuals, including the distribution of such outcomes within the group. These groups are often geographic populations such as nations or communities, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group.”¹
A 2015 survey of 100 healthcare leaders conducted by Milken Institute School of Public Health noted that the definition was accurate but focused strictly on measurement and didn’t explain or acknowledge the “role that healthcare providers must take to impact those outcomes.”²
What isn’t in dispute is the fact that population health will be a significant focus of the healthcare industry going forward. A recent industry 2015 report identified three key trends involving population health:
- A significant increase in population health investments on which healthcare executives expect a return in three to four years.
- More assumption of risk in the provider market as alternative payment models (APM) take hold.
- Better IT infrastructure to create and capture new data sources to manage the health of populations.³
The Changing Healthcare Landscape
The next step in healthcare reform is changing the reimbursement mechanisms from paying for sickness and fee-for-service, to reimbursing providers for higher quality, more effective utilization, and better outcomes. The common vehicle for this change is a diverse number of APM’s all based on some form of financial risk for providing care. To have a financially viable organization in this new environment, you need to better understand the population for which you are taking that risk.
This shift is driving hospitals and physicians into the world of risk-based, prepaid insurance. The most visible example is the Accountable Care Organization (ACO). The growth of the ACO has uncovered the obvious lack of infrastructure required to assume the financial risk of care. Organizations lack the technology, the human resource infrastructure, and workflow processes to essentially take on the role of quasi-insurance company.
To overcome these obstacles, you need to embrace the change in the way this country pays for healthcare and develop a plan that combines strategic goals with technical and tactical processes. Will your strategy be to partner with the traditional insurance mechanisms or compete against them? Some progressive ACO’s like Sutter in California have formed their own insurance companies. Others have chosen to partner with Medicare, Medicaid, and private insurance companies. Whichever path you choose, you must rethink everything about your organization – from people to process to technology.
People – putting together the right team
The leader of your business team should be experienced with health insurance products and have working knowledge of actuarial values, adverse selection, comparative effectiveness, guaranteed issue, medical underwriting, high risk pools, medical loss ratios, reinsurance, risk-based capital, and value-based insurance design. The entire team must be experienced in insurance products and be able to develop viable rate schedules.
I have often described a database as an answer looking for a question. Putting an actuary in charge of formulating these questions is the best way to get the most from your data. Hiring an actuary may appear to be expensive, but the expertise you’ll gain to minimize risk is well worth the cost.
You should also consider putting a data scientist on the team. Hiring clinicians to provide data for quality reports may look good at board meetings, but it is a recipe for failure as healthcare becomes an information-driven business. Clinicians are rarely trained in how to use a database and using a report writer from the IT department doesn’t work because they are too busy loading and maintaining the database.
Mt. Sinai in New York hired a data scientist from Facebook and saw a significant reduction in readmission rates. He had no medical training, but had the ability to recognize patterns in the data that led to better outcomes. Wall Street, Amazon, Facebook, Google, and Apple all employ data scientists to discover patterns that can be leveraged to provide the consumer with a better experience. Hiring data scientists to work with clinicians will better define questions that will lead to better outcomes and financial viability in the healthcare industry as well.
A database manager is another key function you should consider. Electronic medical record (EMR) systems produce the information that resides in vendor data repositories. All vendors have basic reporting tools but to obtain accurate, timely, and actionable information you must extract the data from the live database and place it in an off-line Microsoft or Oracle database. An off-line solution is your best choice since it eliminates performance drag to your EMR used to deliver patient care. A database manager is best suited to handle this data prep and analysis. You may have this resource already in your organization, but he or she may be busy writing reports. You should consider freeing them up and refocusing them on database management.
Update your processes
With the right people in place, you can now get the information about the group of patients to whom you provided services. In a fee-for-service model, this probably would be good enough. In a risk model, however, you need to consider the entire population for which you’re responsible – even those you haven’t interacted with yet. Unless these patients seek care, you don’t know anything about them. Even if they have received care, you are likely not verifying that they are following clinician instructions. This can cause unexpected issues that can severely impact your organization.
Institute or adapt your processes to ensure that your database includes more detailed information about your population. The good news is that you probably already have some of the tools to make that happen. For example, many EMRs have web portals that allow patients to interact with their physicians to schedule appointments, order medications, and review tests. Make sure the medical staff is on board and using your EMR to the fullest.
Establish a process for getting patients signed up and set up a contact plan to stay in touch with them to ensure they are doing the right things. This is the easiest and least expensive way to help manage your population.
Leverage your technology
According to the HealthIT.gov dashboard, EMR installations for hospitals are nearing completion. Office-based physicians are behind but with consolidations, the end is in sight for them as well. Now the question becomes, how do you manage all this data?
As the database grows you will need to adapt to increasingly detailed member information. You may need to acquire additional software solutions if your EMR can’t handle this growth. Care, even within your organization, will be provided in multiple different settings. Inevitably, care will be rendered out of network. Getting all that data into your database so you can manage your patient care plans becomes critical.
The technology currently exists for getting this disparate information into your growing database but you will need a tactical plan to make it happen. The first step is to identify the possible sources of the data – state and local public health databases, CDC, WHO, vaccination registries and others – and then establish the relationships and contracts needed to transmit the data. The final step is for your IT, clinical, and administrative teams to work together to establish proper data governance to ensure the accuracy and security of your data.
Moving to a new horizon
One thing is certain: we are headed for a more risk-based, patient-centered healthcare model. As the upheaval in the industry continues, it’s important that as healthcare leaders, we make the right choices, especially when it comes to population health. Developing an effective population health management model will require a change in mindset as well as significant investments in people and technology. Each organization must weigh this investment against the new reimbursement models and align it with their strategic direction. The organizations that do that most effectively will enjoy the greatest success.
¹What is Population Health? by David Kindig, MD, PhD and Greg Stoddart, PhD, American Journal of Public Health, March, 2003.
²What is Population Health? by MHA@GW Staff, George Washington University Public Health Website, April 27, 2015.
³The key trends behind the growth of population health management, by Leslie Small, FierceHealthcare, March 30, 2015.
This article was originally published on Hayes Management Consulting and is republished here with permission.