Fourteen years after the Institute for Healthcare Improvement (IHI) introduced the Triple Aim, a framework for improving care delivery in the United States, healthcare organizations continue to strive for improved experience and quality with a lower total cost of care. Providers committed to transitioning away from traditional fee-for-service arrangements have adopted models meant to deliver more value. The disruption to healthcare delivery brought on by Covid-induced pressures has placed organizations with population health management capacities ahead of the pack. Capabilities for predicting and managing groups of patients have allowed health systems to identify, plan for, and communicate more readily. Further, those organizations with investments in data intelligence, digital engagement, and cost/network transparency (capabilities important for success under value-based arrangements) may be positioned to perform better over their peers, and here’s why:
Success under value-based arrangements hinges upon the leadership and actions of the providers that care for patients in a community. Because providers have a first-hand ability to determine and influence clinical decisions, providers need to shape the objectives and approaches of any given population health program. The previous five years have seen efforts to transform primary care models, identify and understand populations of patients, and engage them for the services that they need. Successful programs in 2022 will reimagine clinical decision support to develop clinical and care management pathways that are advanced by automation, analytics, and predictive intelligence. Clinical networks will continue to consolidate while financial and operational objectives more closely align with physician incentives.
Despite the resource constraints and financial pressures of the Covid pandemic, providers will remain the first line of response to aid/assist patients and opportunities in relieving administrative burdens and improving clinical oversight.
Managing the daily operations of a robust population health program requires data intelligence capabilities. The ability to synthesize and prioritize opportunities is paramount for long-term performance improvement success. Without a holistic picture of the business that connects evidence-based guidelines with patient needs plus clinical and financial inputs, clinical leaders are forced to take slow conservative advances towards population health improvements. Organizations with successful population health programs understand the critical nature of their analytics platform and evaluate their population health initiatives in consideration of their platforms’ functionality.
Quick wins aren’t meaningful enough without data-driven approaches that demonstrate the relationship between clinical action, system performance, quality outcomes, and cost containment. 2022 value-based roadmaps should include efforts to bring more functionality into data environments.
Health systems continue to shift the location of care from hospitals to more community-based care centers, intensifying competition among organizations. Primary care practices, hospital urgent care offices, and specialty centers of excellence have been increasingly positioned across suburban communities to deliver lower cost and local care while generating referrals to hospitals. More suburban and local choices for care allow providers to differentiate themselves and attract new patients. While Baby Boomers and Gen X build provider loyalty through existing relationships and previous experiences, Millennials and Gen Z choose providers based upon convenient and easily accessible information and good experience. Innovative population health organizations understand that patient acquisition and retention strategies are not built upon HCAHPS success stories. Covid-19 has shown that providers can successfully interact with patients through a host of diverse channels, including virtual and digital. Health systems should build upon the telehealth success of the pandemic to evolve their patient engagement strategy. A successful population health program will meet patients where they are, whether they are on a digital platform or at the clinic.
Successful population health programs use patient-generated data alongside clinical and claims data to evaluate and anticipate the needs of their patients. Under value-based arrangements, organizations have agreed to manage both the quality and cost of care for defined populations of patients and/or a bundle of health services. Healthcare organizations that are able to look at their data sets and derive key insights can use that information to shape hospital policy, care management programs, patient outreach efforts, site of service management, and contracting strategy. Getting ahead of and predicting patient needs is important to success under these arrangements.
When organizations can proactively plan for wellness and preventative care, they are able to connect with patients earlier and potentially before adverse events happen. For example, the Medicare Annual Wellness visit allows providers to routinely meet with and evaluate a patient’s health-related goals and needs. For complex and chronic patients, integrating patient preferences, health goals, and social determinant factors creates a more holistic and comprehensive view of the patient. When organizations are able to deliver such an informed patient profile to the treating provider, both patients and providers benefit. When providers have insightful context about the patient to build on, they create better experiences of care and contribute to a foundation of trust that supports consumer loyalty and better health outcomes.
Healthcare organizations committed to advancing population health know the pressures created under risk arrangements and the increasing push to shift costs onto provider organizations. The more proficient value-based programs are at predicting and anticipating patient needs, the more opportunities healthcare organizations will have to improve quality of care.
Value-based programs continue to struggle with labor-intensive performance reporting processes. Quarterly and annual chart abstraction efforts rely on manual reconciliations of Medicare and provider data; all too often, the difference between meeting performance thresholds and earning value-based payments. The disconnect between technologies for storing and analyzing Medicare claims data versus commercial clinical and financial data means value-based programs cannot readily view a comprehensive picture of their data, even with population health software products. Instead, organizations manage populations by beneficiary assignment.
However, long-term success under risk arrangements requires the ability to manage the total population and the total cost of care. Value-based programs need more robust capabilities for aggregating, analyzing, and visualizing performance data to fuel decision-making. Those organizations that can connect clinical interventions to improved outcomes and the correlated quality performance measures and can do it at both the patient and population level can more confidently predict value-based reimbursement and shared savings payments.
As value-based programs map out their 2022 digital transformation and population health strategies, they will continue to build on data enablement and engagement investments. The technology stack will increasingly include advanced interoperability and normalization capabilities, analytics, and CRM. By leveraging CRM automations to trigger next best actions for both patients and their clinicians, value-based organizations can advance performance. When organizations have intelligent patient journeys that are predictive and benefit not just from automations that prompt next best actions but also direct interventions when no action is taken, care gaps will be prevented and closed more efficiently.
Creating a control center for managing value-based care performance in 2022 will provide organizations with the data insights and the confidence necessary for taking on more risk. Without a command center, value-based programs will continue to move cautiously even as they face mounting payer pressures. As providers gain deeper insights from data investments and actuarial analysis, risk-sharing arrangements will become more robust. In turn, this will continue to drive investments in better patient experiences and coordinated care.
Rebecca Goldberg is J2’s Director of Solution Strategy, bringing nearly fifteen years of healthcare operations, technology, and value-based program experience to our team.
Rebecca focuses on the intersection of value-based performance management, consumer experience, and data optimization. Her strategic contributions in risk contracting, strategy, and network management will prove valuable as she collaborates with our clients to develop digital strategies that connect consumers to providers, ease the technology burdens on those providers, and enable healthcare delivery quality improvements.