By Joel French, CEO of SCI Solutions
One of my best friends is an orthopedist known for saying to his patients, “I take care of old people and skinny people.” His implication is there are no old people who are overweight, because overweight people tend to die earlier. Think about it. What you do actually matters.
During the next five years, we will see various provider networks and health systems agreeing to accept financial risk for defined patient populations as financial risk shifts from health payers to providers. Many of the vendors and consultants advising these organizations encourage the purchase of a population health management (PHM) technology platform to help manage this risk. At the upcoming HIMSS event in Las Vegas, hundreds of vendors and consultants, large and small, will no doubt proclaim their expertise with PHM. Invariably, after a week of bold marketing declaratives, neon, and hyperbole, the attendees from provider organizations will leave more confused and uncertain as to what they should do. This is why critical thinking is needed.
Deconstructing population health management and its definition
Because we are talking about provider organizations taking on real financial risk for an attributed patient population, perhaps it would make sense to examine the fundamentals. To properly understand the concept of population health management, we should start by defining what words really mean. The word population is a noun, generally referring to a group of individual persons that inhabit a specific group, geography or sharing a quality or characteristic in common. The word health is another noun referring to the condition of being sound in body, mind or spirit; especially the freedom from physical disease or pain. The word management, however, can be used as a noun, adjective or verb. In the context of population health management, what is needed is a verb. To “manage” something is to handle or direct with a degree of skill, to make or keep compliant, to work upon or try to alter for a purpose and to succeed in accomplishing it.
As a first step, providers must know something about their attributed populations. What chronic conditions exist with what level of co-morbidities – this is typically referred to as risk-stratification, and suitable analytic companies exist to perform this service. As a second step, once members are stratified according to chronic disease risks, these members would typically be organized into cohorts by condition for which evidence-based clinical pathways would apply. The care pathway provides recommendations on the ideal way to manage a patient population with a specific condition or set of conditions, which eventually are tailored (using inclusion and exclusion rules) into a personal care plan. To be clear, once these two steps have been completed, no population is healthier or being managed. There are only two fundamental methods of effectively managing care and related costs: 1.) Shaping provider utilization and 2.) Changing consumer behavior. Completing risk stratification and assigning populations to care management cohorts does not improve either provider utilization or consumer behavior.
Illustrating the point
Consider the example of diabetes. According to the American Journal of Managed Care[i] the worldwide prevalence of type 2 diabetes and medical costs of treating it have increased over the past decade.
Most medical costs incurred by patients with type 2 diabetes are related to complications and comorbidities. The mean annualized direct medical cost was $2,465 for a white man with type 2 diabetes who had been diagnosed fewer than 15 years earlier, was treated with oral medication or diet alone, and had no complications or comorbidities. Annualized medical costs were 10% to 50% higher for women and for patients whose diabetes had been diagnosed 15 or more years earlier, who used tobacco, who were being treated with insulin, or who had several other complications. Coronary heart disease, congestive heart failure, hemiplegia, and amputation were each associated with 70% to 150% higher costs. Costs were approximately 300% higher for end-stage renal disease treated with dialysis and approximately 500% higher for end-stage renal disease with kidney transplantation.
This explains why disease-specific care plan execution is so important to containing costs. The management of the condition, risks and costs depends upon effective execution of the care plan, not the care plan itself. In addition to education and lifestyle advice regarding diet and exercise, the type 2 diabetic must manage blood glucose levels, cardiovascular risk (which is typically comprised of controlling blood pressure, lipids and anti-thrombotic treatment). Preventive annual eye and foot care screenings need to take place and any co-morbid condition such as depression should be assessed and treated.
All of these preventive steps are visit-dependent, requiring clinically appropriate patient referrals and appointing. Absent the real ability to actualize a care plan it becomes a care theory. Without the ability to conveniently refer and schedule patients within a network to high-quality providers, based on the care plan protocols, gaps in care will not be closed and potential high-cost admissions may result. This is the verb or “management” component of PHM. Neither the PHM risk-stratification analytic tools nor the electronic health record are tools that can coordinate attributed patients across today’s distributed care networks.
Consider how many advertised weight loss programs suggest an individual can drop pounds without exercising or changing their diet. That target outcome will not be achieved. This is no different than vendors or consultants declaring that providers with risk can successfully “manage” the health of their attributed patient populations without dynamically changing provider utilization patterns and consumer behavior.
What you do actually matters. Population health management requires a verb.
[i] American Journal of Managed Care, 2013 May; 19(5): 421-430