Taking the Pulse of Your Population

How well do you know your members? Member segmentation, or stratification, is the foundation of your population health management strategy. Member wellness, healthcare facility utilization, and provider patient management are some of the metrics that not only meet the needs of accrediting bodies (e.g., NCQA) but also help you manage your member population efficiently, and most importantly, effectively.

Plans have tremendous amounts of data and varying levels of actionable information developed from that data. Effective stratification techniques are built on multiple data sources and types – quantitative data like lab results and claims data can identify those chronic conditions driving low quality of life and high utilization, while qualitative data derived from surveys and physician/member communication often drives discovery of behavioral health and socioeconomic issues and pre-emergent conditions that are not detected through impersonal routine testing. A combination of the two data types is the key to effective membership stratification.

The Science of Stratification: Claims-based data is most effective at generating the “big buckets” – identification of multiple chronic conditions, high utilizers of emergency facilities, little or no PCP utilization, etc. Those buckets can be further prioritized based on combinations of quantitative factors (one factor, two factors, three or more factors) and multiplied by demographic and socioeconomic issues that complicate member care.

The Art of Stratification: Combining these risk factors into something tangible. What does it mean when a member is over 65, has two chronic conditions, sees his or her PCP fairly regularly, and is not “low S.E.S.” versus a member is who over 65 but has only one chronic condition, is “low S.E.S,” and uses an emergency room as his or her PCP? This is known as the “we have data, we have reports, now what do we do to make sense of it all?” stage.

This is where population health professionals can help you to not only identify your target member populations but can also help isolate information gaps and provide effective methodologies for successful engagement with targeted members. Each plan has a unique membership, often in a unique geographic region or regions. Stratification and engagement techniques that work in New York or Connecticut will often not work in Georgia, Kentucky, or California; effective member management begins and ends with YOUR data. With population health professionals providing meaningful insights and facilitating measurable performance gains year over year, the “now what do we do” component of member management and engagement can become a non-issue, turning instead to “what can we do next.”


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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.

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