My past week has been filled with many discussions about the challenges of population health management, integrated care coordination, and value-based reimbursement – from both the payer and provider perspective. The field is at an early stage in the evolution of this market shift, and I am convinced that the “competition” is going to be between the organizations with the best data – and the management teams that know how to use it (see The Value-Based Reimbursement Steeplechase).
We recently wrote about the exciting results from the Robert Wood Johnson Medical School research on the geographic density of the group of high-needs consumers and the medical neighborhood concept (see Hot Spotting, Medical Neighborhoods & New Business Opportunities) – a definite “next step” in managing populations. These advanced analytics includes the use of population segmentation (see Looking Beyond The Superutilizer Umbrella and New Research Identifies Six Core Competencies For ACO Readiness) and hot spotting (see Using Technology To Move Human Services From A Program Focus To A Consumer Focus and Think Hot Spotting & Automated Hovering).
The medical neighborhood concept is one we’re going to see more of in the years ahead, with its potential to both deliver more cost-effective care and to address social determinants of health. A great report from the Patient-Centered Primary Care Collaborative (see Managing Populations, Maximizing Technology: Population Health Management in the Medical Neighborhood) explains the concept: “The purpose of the medical neighborhood is to serve as a continuous and coordinated ecosystem that begins with the patient’s PCMH [Patient-Centered Medical Home (PCMH)], and links to the broader community, while accounting for the social and environmental factors that impact health.”
To make this an operational reality, the report authors emphasize the importance of identifying subpopulations of consumers who will have a measurable benefit from specific interventions; the ability to monitor detailed characteristics of identified subpopulations over time; and the ability to efficiently link selected consumers to those specific interventions.
What I found most interesting in the report was the short list of recommended health care technology tools needed to optimize population health management. Their list included:
- Electronic health records
- Patient registries
- Health information exchange
- Risk stratification
- Automated consumer outreach
- Referral tracking
- Patient portals
- Remote patient monitoring
- Advanced population analytics
It wasn’t that any of these technologies were a surprise to me. But seeing the list in its entirety made me think about the ecosystem of consumer information that we’re going to see in organizations successful at navigating the “next generation” of value-based contracts. Only organizations that are able to quantify their performance and then make the adjustments to improve that performance, will stay competitive.
For more on building your next generation framework for value-based reimbursement, check out these resources:
- Telehealth & Remote Patient Monitoring Use in Medicare & Selected Federal Programs
- 1 Million Consumers Used Remote Monitoring, Connected Medical Devices In 2016
- Forecast The Future With Predictive Analytics To Improve Your Child Welfare Outcomes: The Heartland For Children Case Study
- Remote Monitoring Of People With Heart Failure Yielded 45% Drop In Hospital Admission Rates
- Taking A Functional Approach To Succeeding With Value-Based Reimbursement
- New Technology & New Science Remake Health Care From The Bottom Up
- The On-The-Ground Reality Of Making Telehealth Work
- Finding Competitive Advantage In Consumer-Directed Health Information – Genomics & More
- Do You Need An EHR ‘Makeover’?
- Your Tech Functionality Checklist For Value-Based Reimbursement
And for even more, join OPEN MINDS Market Intelligence Manager, Athena Mandros on August 17 for the session, “Best Practices In Care Coordination: Health Homes, Medical Homes, & More” at The 2017 OPEN MINDS Management Best Practices Institute, in Long Beach.