Population Health Management Tactics to Succeed in Medicare Advantage

Population health. Many of us in the industry speak those words often without truly thinking about what it really means to us as a health plan or as a provider group, and often times, what it means to our data collection and analysis processes.

For many Organizations today, success in the Medicare Advantage market space is critical to our existence. This success will require many Organizations, whether plans, provider groups, or even vendors, to examine their capability to collect data, the process by which they examine data, and then how they tailor interventions to manage the results of that data for sustained improved health outcomes. After all, isn’t that why we have chosen our careers and are in this industry or taking care of folks to make a difference and hopefully improve results? I believe that is the case for many of us.

Population data management is key for many organizations as we drive to value-based care agreements within our provider networks. Providers need to be able to track their assigned member populations, the population health outcomes, the data associated to the Healthcare Effectiveness Data and Information Set (HEDIS®) measures, and quality measures, all while managing assigned risk.

In this writing, let’s focus on a few points to consider in your population health management tactics:

The whole population: While many of us segment data to focus on certain diagnoses, utilization, or measures for a targeted population, we leave out many patients/members who still have needs or influence healthcare spend. Focusing on an entire population, similar to how a plan defines a target population to enter a Special Needs Plan market, allows a plan to manage an entire group of people, their conditions/disease states, and respond to the group’s needs rather than a small segment. Using registries that identify and track a population over time allows a plan to view the total overall care received and identify gaps/trends. Looking at an entire population will also allow you to track improvements for overall health outcome measures while comparing for demographics, provider groups, benefit structure, and access.

Evidence-Based Clinical Guidelines: Today, one of the most important tools used in managing populations is the electronic medical record (EMR). Many health plans adopt different types of evidence-based clinical guidelines, which they apply to the administration of benefits filed within their bids. Evidence-based clinical guidelines are often times the guiding point for population management and the path followed for treatment decisions within the delivery of care. Providers need to utilize this guidance in order to treat a clinical problem, however, it is not readily available at their fingertips within the EMRs to manage patients/populations as desired by a plan. Embedding these guidelines with applicable decision trees within an EMR can allow a provider to best apply treatment options and enables the provider to manage a population aligning with projected costs/outcomes, which results in effective care planning and treatment adherence.

Overlay the above two tactics with correct identification of at-risk patients through appropriately defined criteria, which includes behavioral health attributes and accounting for the variation in the care delivery models and the associated patterns of utilization, will enable better designed care planning across the care continuum.

 

 

Resources:

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe

Jane Scott
Jane Scott

Jane Scott is Senior Vice President of Population Health Management and Clinical Innovations at Gorman Health Group (GHG). In this role, she is responsible for leading GHG’s Clinical Innovations practice area. Jane brings GHG clients 37 years of experience in healthcare as one of the industry leaders on the topics of the Centers for Medicare & Medicaid Services (CMS) Special Needs Plans (SNPs), development and implementation of Models of Care (MOCs), as well as the Star Ratings Quality Bonus Payment Program. Her experience expands to the areas of quality improvement (QI), utilization and medical management, claims operations, and provider/associate education.

No Comments Yet

Leave a Reply

Your email address will not be published.