Deploying Value Based Care Contracts Under the Umbrella of Population Health Management: A Must for Success

 

August 14, 2019

Rose Maljanian, Chairman & CEO HealthCAWS

Chairman Population Health Alliance

 

The evolution of our nation’s healthcare system and ecosystem from fee for service to value based care has only just begun, and while the goal is to rapidly accelerate the membership under value based care payments, it will be a long journey to refine the model.  Legislation, market driven mergers and disruptive innovation from industry veterans inside and outside of healthcare focused on the consumer are contributing to what at times feels like a roller coaster ride.  At the center of all of this is the growing population of seniors who largely receive their health benefits from the government, either directly or indirectly, through managed Medicare, Medicaid or Dual-eligible programs.  Seniors as customers want and demand choice, convenience and value as consumers do in other markets and industries.  The focus on these three elements is fundamental to any business strategy. However, necessary but distracting details, including type of legal entity, payment rates, payment flow, shared savings methodology and disbursements can completely envelop the airtime in leadership meetings. Alternatively,  framing value-based care under the umbrella of population health management supports a focus on seniors’ needs and wants and the strategies that result in affordably achieving optimal health for these populations.

Understanding payment models as financial lever of alignment

Value-based care payment models have been aggressively advanced by CMS and commercial payers over the last several years.  CMS’s stated purpose is to transform the health care system through innovation by paying providers for quality versus quantity of services delivered. Whether the program is a CMS program such as Advanced Payment Models (APMs), Merit-based-Incentive Payment System (MIPS) or a value-based contract as part of a commercial payer network, the payment method is simply put, the financial lever to align the care provided with outcomes-quality, experience and cost of care savings.

Virtually all value-based care models promoted or reporting positive results deployed the key elements of the population health management model to achieve success. Under current CMS value-based payment models 1 and those proposed for 2020 and beyond2, quality improvement strategies and population health metrics such a readmission rates are prescribed with advancing flexibility to reduce burden and achieve desired value.

In terms of results, Humana reported significant improvements in numerous quality metrics and 23.4% fewer inpatient hospitalizations and 15.6% fewer emergency room visits under value-based care arrangements in Medicare Advantage members.  In their report 3, they attribute the improvements to population health management infrastructure and strategies such as proactive outreach and whole person management.  Aetna similarly cited tools, infrastructure and approaches common to population health management as important to the success of their accountable care organizations. With Banner Health for example their Aetna Whole HealthSM program achieved 24 percent decrease in avoidable surgery admissions, a 4 percent increase in generic prescribing, and a 11.5 percent overall reduction in medical costs.4

In order for the end result to be a value-based contract that produces a positive net income versus one that adversely effects the organization financially, a solid population health management strategy must be deployed, tightly managed and iterated as populations and market conditions evolve.  Furthermore, without a positive consumer experience and health outcomes, retention of patients/members in a practice or plan is likely to suffer, further eroding the chance of success.

Staying true to the principles of population health management (PHM)

There are three enduring components of the population health management model:1) defining and understanding the population for which the organization holds accountability; 2) a portfolio of evidence based solutions that can be tailored to individual need at any given point in time and 3) measurable outcome results. The Population Health Alliance outlined a value focused framework for Population Health Management more than ten years ago that included these elements with consumers at the center.5

Defining the population up front (assigned vs attributed) allows organizations to understand their populations, stratify risk and preference for engaging so that when crafting and triaging individuals to programs and tools, the programs and tools are those that consumers want and need.

Programs and tools must be available to address the full continuum of care whether to maintain health, address an acute event, support chronic care management or support comfort at end of life. Furthermore, solutions must include a multifaceted approach depending on where an individual is on the care continuum, their life goals and their preferred means of engaging. Studies by the PEW Research Center have demonstrated consistent increasing uptake in technology for seniors 6,7 including 53% owning a smart phone and 59% having broadband access.7 Addressing barriers such as trust, cost and tech support will likely fuel further adoption among all income and educational levels. In recognition of this trend, many organizations are deploying blended high touch and high tech strategies in their senior health programs.

Finally, a focus on the endgame of outcomes across populations will ensure success with multiple value based contracts. The population health management model has always had a focus on outcomes that include clinical, utilization, satisfaction and experience of care and cost metrics.  When staff deploy consistently high quality evidence based care that achieves consumer goals, the likelihood of missing mutually agreed-to standard metrics in a value based arrangement as a result of inconsistent care, lack of consumer engagement or gaps from confusion when doing different things for different populations is bound to decrease.

Executing well on solutions that solve needs and preferences

The need to execute well in a world of high visibility of alternatives for care, experience ratings and mounting pressure on cost transparency cannot be overemphasized.  Executing well no longer means getting ID cards and EOBs out on time and finding an opening for the consumer in the same week to be seen by a PCP or specialist.  It will command listening to what consumers desire to achieve, such as return to playing tennis, being able enough for air travel, controlling their diabetes versus diabetes consuming their life with too many appointments and tests, reducing days not feeling well enough to enjoy getting out and living life or just living long enough to see a marriage or birth. Furthermore, living life involves conserving seniors’ financial resources as well through optimized care, lower total cost of medications and value-added supplemental benefits such as concierge services and care management, home modifications, light housekeeping, transportation and nutrition support.  Scan Health Plan recently announced expanded benefits for seniors to age in place at home.  This followed a market survey confirming the trend in which 88% of their addressable market in Southern California expressed a desire to stay in their homes.8

As leaders, promoting common understanding of what it means to deliver value and how to get there

As leaders we need to guide the discussion on value amongst our colleagues, all payers and the public at large.  Value based care is not about the contract itself. The contract is a financial lever under the umbrella of population health management. it is about delivering value (quality and affordability) to each healthcare consumer, the payer customer, and keeping those that bear risk whole and flourishing as they serve at the front line of healthcare transformation.

 

 

References

  1. CMS Value based care programshttps://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/value-based-programs.html updated 5.17.2019.
  2. CMS QPP Resource Center https://qpp.cms.gov/about/resource-libraryupdated 7.29.19.
  3. The Intersection of Heath + Care: Value Based Care Report 2018. http://valuebasedcare.humana.com/wp-content/uploads/2019/04/2018-VBC-Report.pdf
  4. Accountable care organizations: Transforming care delivery to support members, increase cost savings https://news.aetna.com/2018/02/accountable-care-organizations-transforming-care-delivery-support-members-increase-cost-savings/February 12 2018
  5. Population Health Alliance Population Health Management  model https://populationhealthalliance.org/research/understanding-population-health/
  6. Anderson M and Perrin A. Tech use climbs among seniors. Pew Research Center May 17, 2017https://www.pewinternet.org/2017/05/17/technology-use-among-seniors/
  7. Anderson M. Mobile Technology and Home Broadband 2019Pew Research Center June 13, 2019 https://www.pewinternet.org/2019/06/13/mobile-technology-and-home-broadband-2019/
  8. SCAN Health Plan Addresses Seniors’ Desire to Remain at Home With Expanded Benefits, Reduced Costs Nov 14, 2018, https://www.prnewswire.com/news-releases/scan-health-plan-addresses-seniors-desire-to-remain-at-home-with-expanded-benefits-reduced-costs-300750108.html

Reprinted with permission Better Medicare Alliance

Maximizing Great Potential in 2019

As we welcome in 2019 there will be much focus on integration execution for the healthcare mega mergers and the race for rapid iterative, disruptive innovation for the new entrants. For the rest, survival of the fittest will involve reducing consumer friction and delivering value.

The political landscape will always be there as a backdrop. We must leverage the window to influence policy and practice for the good of consumers while avoiding distraction. We must build solutions that consumers and clients want, it’s not always what we think they need. Seniors want to be at home; disadvantaged individuals use technology when barriers are removed; and most would rather be doing something other than spending time in a traditional health care setting.

Where possible, partner, partner and partner. The environment is too complex and changing too rapidly to go it alone. Synergistic opportunities are everywhere that will allow all of us to excel while focusing on what we do best. If you ask any seasoned leader; “Who is your top competitor?” The answer is always the same, inertia or people who think they can do everything themselves.

To maximize the great potential of 2019, let us enter the year with high energy, the fortitude to challenge the status quo and the humility to seek and explore alternative approaches.

Best to all for success in the New Year!
Rose

Population Health Management –Toward a Life Centric Model with Consumer as Co-Creator of Value

Rose Maljanian Chairman & CEO HealthCAWS,  Chairman of the Board Population Health Alliance

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Population Health Management strategies continue to gain recognition as must haves versus nice to haves in order to survive and thrive in a value based health care environment.  The mainstay component parts of upfront analytics, targeted and individually tailored interventions and outcomes1 continue to evolve as new science and technology becomes available.  Each member of the healthcare ecosystem has an important contribution and is poised to be appropriately compensated based on the value that they contribute.

Forward thinking health systems, ACOs and new entrants to the health care space continue to push the boundaries on moving care and support services out of the traditional hospital  environment where possible into the community where life happens.  Like time spent with an accountant filing taxes or a day in the garage getting a car fixed, as an industry we have come to accept that most always a good day for a consumer does not include a trip to the emergency room, hospital, laboratory, or doctor’s office but rather optimizing time spent doing what they like to do, feeling as good as they possibly can.

Furthermore, consumer engagement and experience has taken center stage as consumers publicly rate providers, facilities and health plans and more easily can take their business elsewhere if their needs are not being met.  In addition, the shift to value based payments has aligned incentives for providers to more proactively and effectively engage their consumer patients in their care, leveraging extender digital tools and care team members to take their reach beyond the visit time and beyond the walls of the healthcare environment.

A finer point on the need to engage consumers was made by Alan Weil in his 2016 Health Affairs editorial entitled the Patient Engagement Imperative when he stated- “There is recognition that the patient is co-producer of the outcomes for which the physician is now being held accountable”.  Translated to all stakeholders – the patient, the member, the consumer, the community resident is co-value creator and not only is the physician held accountable but the hospital, the health plan, the employer, the business associate partners all have performance targets to meet related to their roles in optimizing health, cost efficiency and the consumer experience.

As I said to a recent audience of thought leaders gathered to share innovations in population health-“think about this quote- no matter how great you are; no matter how great your programs are; you cannot produce the desired outcomes without the consumer”. 3

If all stakeholders come together around this Life Centric model and partner with consumers as co-creators of value to them and the system overall, we will see movement from a costly, mediocre quality and full of hassle system to one recognized for being a high value, desirable when needed solution, that enhances versus disrupts life.

  1. Population Health Alliance –PHA PHM Framework. http://populationhealthalliance.org/research/understanding-population-health.html
  2. Weil, A. The Patient Engagement Imperative. Health Affairs April 2016.  DOI: 10.1377/hlthaff.2016.0337.
  3. Maljanian R. Impact of Population Health in a Value-based World. SSN Population Health for Medicare Medicaid and Dual Eligible Populations. Keynote May 15, 2018 https://www.pophealthsummit.com/index.php

 

Bringing Focus to Value for Patients-Advancing Engagement in Interactive Digital Portals

Today HealthCAWS CoHosted an event entitled  “Successful Strategies for Electronic Patient Engagement” with the Massachusetts eHealth Institute.

HealthCAWS was joined by affiliates Qualidigm and Redox. Hospital systems and provider groups  gained and shared insights on patient engagement strategies to include advanced interactive patient portal features, integrated clinical workflows and technology integration through APIs.

The ultimate goal is to support hospital systems and provider groups address the growing need to drive value, improve administrative efficiency and cement consumer loyalty.

 

A Invigorating Start to 2018!

The start to 2018 has been an invigorating one.  New partnerships, special events and great attitudes spell the promise for a productive year ahead.  Emphasis on consumer need and preference, comprehensive strategies to address population health and enlightened preparedness to successfully shift to value are in the forefront.

Early year investor presentations were on track  with disciplined approaches and tax relief is freeing up capital to invest in companies, solutions and people making funding new opportunities  more in reach than ever.

Forward progress as always will not be without challenges and keeping up with the pace of change can seem overwhelming to some. Reach out for support to help overcome the challenges, expand your bandwidth and increase your speed to market by partnering with companies like HealthCAWS and others.

This year’s Call to Action –

Lead your organization with the vigor and swift  decision making required to result in a  productive and impactful 2018 for the betterment of the consumers you serve, your employees, your clients, your partners and your shareholders.

Best for success,

Rose

Rose Maljanian, Chairman and CEO HealthCAWS

 

 

 

Founder’s Circle

The holidays are upon us!

Dear Friends and Colleagues,

This holiday season is upon us and there is no shortage of end of year activity on the Hill potentially impacting the healthcare industry from tax reform including release of the individual mandate to Medicare Advantage proposed rules including redefining open enrollment windows and new programs to address the opioid crisis.

In addition, mega mergers of delivery systems, and health plan and retail giants spell new ways of addressing individuals whether referenced as consumers, patients, members or employees, the end game is the same, deliver great quality, affordably, and a great experience or risk losing their loyalty.

We are embracing this challenge. While necessary to keep an ear to the ground for additional changes and the resultant adjustments required adjustments to programs and services, we wish our clients, partners and all of you a season full of joy celebrating with family and friends.

Happy Holidays,

Rose

Welcome to the future of health!

Dear Friends and Colleagues,

Now past the  halfway mark for 2017, uncertainty remains on the policy front but no uncertainty exists in terms of the need to prevent and combat disease, equip consumers with the means to self manage where possible and address the growing senior population in ways and in environments they prefer.  The innovators committed to value and preference based individual and population health solutions will succeed in making a difference. ​

The backdrop of policy change  requires a constant  ear to the ground and much energy and application of resources to navigate.  Given this environment expertise and experience are top of the list to handle the uncertainly versus being paralyzed by it. Seasoned leaders  guiding responsive teams and systems through clearing barriers, crisp decision making and disciplined execution will be the difference between organizations that falter and those that thrive; consumers and providers who feel well supported and those that feel the strain of uncertainty around them.

From planning and design to delivery, emphasize the right guiding principles. Align strategies and tactics with the principles of the HealthCAWS Call to Action:

  • Meet the new consumer where they are on their terms, with the least costly and invasive service and environment possible to achieve their best possible outcome

 

  • Limit unnecessary burden for providers and offer supports to advance value-based care 

  • Reduce system complexity and thus volatility for all stakeholders by simplifying requirements and processes; freeing up critical resources and mind space for innovation

The HealthCAWS principles culminate in  Combining Accountability With Support-“the CAWS™” to get the job done. We invite you to be part of the HealthCAWS solution!

Best for Success,

Rose

Rose Maljanian

Chairman & CEO

 

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