Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Value-Based Care News

Creating a Population Health Management Operating Model

At HIMSS17, an expert stated providers should have functional and operational capabilities as a well as a collaboration model for a population health management operating model.

Providers need to boost collaboration to implement population health management programs that add value to the organization, a speaker at HIMSS17 explained

Source: Thinkstock

By Jacqueline LaPointe

- ORLANDO - “Collaboration is a critical piece,” Steven Merahn, MD, emphasized during his HIMSS17 session on developing an operating model for population health management that functions regardless of payment model participation.

“Collaboration is not a native skill in healthcare,” the Chief Medical Officer at US Medical Management added. “It may be native to certain professions, such as nurses who far better at it. It’s inherent in their model of professional identity. It’s certainly not inherent in the professional model for physician training.”

While physician workflows for population health management may not have the strongest collaborative spirit, Merahn explained that establishing working relationships between all parts of the population health program is key to adding value.

Merahn explained that developing population health management programs based on value-based reimbursement models may not make them sustainable in the face of changing payment structures.

But many healthcare organizations are going down this path because the most common concept of value for population health management is ensuring care delivery is as efficient as possible and providers are working to prescribe the most appropriate healthcare utilization. However, this is more of a payer-focused concept, Merahn pointed out.

READ MORE: What Is Value-Based Care, What It Means for Providers?

“The measures we are accountable for are measures that are determined by the payer who agrees to compensate you to achieve a certain level of performance among that cohort of patients whether they have self-selected for care or not,” he said.

“Typically, this looks like the path to value. You identify the population. You identify the gaps in care. You stratify risk. You engage higher-risk patients. You provide some level of care management for highest-risk patients. You measure the outcomes. You deliver your report cards. You get your value-based reimbursement.”

“This, unfortunately, is not truly the path to value,” he stated.

Basing a population health management program on payer-developed value-based reimbursement models mimics what happened in a fee-for-service environment. If providers segment patients based on the value to the payer, then the program will only be applicable to that specific value-based reimbursement model.

Providers should be developing population health management programs that are also based on adding value to patients and providers. Through that method, population health management programs will be able to work with a range of fee-for-service and value-based reimbursement models.

READ MORE: Are Hospitals Committed to Population Health Collaborations?

For providers, population health management can add value to the organization by aligning professional identities and compensation with a population health management strategy.

To implement a valuable population health management program that aligns with all payment models, providers need to establish new workflows that align with the value-based care provider goals as well as the payer goals.

Providers can develop the population health management workflows fby first understanding the program’s functional requirements, then implementing operating capabilities and a collaboration model.

Merahn identified eight functional requirements for a population health management operating model. Healthcare organizations should have data access, data analytics, population tracking tools, and segmentation and targeting.

Healthcare organizations should also have key care coordination functionalities, including patient engagement, care planning, clinical strategy, and resource managed care delivery.

READ MORE: What Is Healthcare Revenue Cycle Management?

For a successful population health management operating model, providers need a way to account for all functional requirements. But checking off all functional requirements may not be as complicated as it seems, Merahn added.

Some requirements can be accounted for in existing systems, such as practice management system. Other requirements can be as simple as giving front desk staff a script to contact patients that need service.

Once healthcare organizations fulfill functional requirements, they can move onto developing operating capabilities.

“Just knowing how this stuff works is insufficient to performance,” said Merahn. “It’s one thing to have an intellectual understanding to knowing how to actually perform the task.”

Healthcare organizations must account for the following operating capabilities and competencies:

• Organizational capacity

• Workforce readiness

• Clinical processes and operations

• Patient experience management

• Clinical technology systems

• Data analytics and reporting

• Finance and business models

Merahn elaborated on finance and business model changes under value-based care. Cost management will drastically change, he said, because not all services will be reimbursable under value-based reimbursement models.

However, healthcare organizations should develop business models that recognize where the greatest return on investment will be. For example, Merahn’s organizations uses nurses for at-home care even though the service is not reimbursable under value-based care. Deploying nurses for the task may come at a cost for the organization, but using a physician just because they could bill for the service wasn’t necessarily the most appropriate at-home care method. The physician could be used elsewhere in the organization to provide high-quality care.

The business model for the population health management program should be based on the value the patient brings to the organization, he continued.

“This is how payers think,” he said. “Payers invest significant amounts of money in things they are not reimbursed for because they know at the end the total value of that member to the organization will be positive.”

The final key to developing a successful population health management operating model is implementing a collaboration model. Merahn explained that the model involves “orchestrating and optimizing goal-directed collaboration, operating relationships and knowledge management between the programs, platforms, partners and personnel that comprise a patient’s health-resource community.”

The collaboration model for the population health management initiative allows for the healthcare organizations to test how the new initiative works in the real-world with real patients.


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