Achieving a Consumer-Centric Approach to Population Health using Clinical Optimization

Co-authored by Suzanne Kunze, RN, CCM, MBA and Norita Wilson, RN BSN

Population health is advancing as the health care industry shifts from fee-for-service to value-based care. As population health evolves, we are seeing the merging of care management (CM), disease management (DM) and utilization management (UM).

With the final NCQA Population Health standards targeted for release at the end of the fourth quarter this year, we wanted to explore what a more consumer-centric approach to population health will look like when all systems are clinically optimized.

NCQAs PHM standards are a noted change for payers, as the standards combine data analytics with wellness and add complex case management standards. In addition, the PHM standards eliminate the NCQA’s DM standards and some practice guidelines.

Moving forward the PHM standards will include:

  • PHM 1: PHM Strategy
  • PHM 2: Population Identification
  • PHM 3: Delivery System Supports
  • PHM 4: Wellness and Prevention
  • PHM 5: Complex Case Management
  • PHM 6: Population Health Management Impact
  • PHM7: Delegation of PHM

A consumer-centric approach to care

For many years we’ve heard that CM and DM were going away, merging into a consumer-centric population health approach to care. As we perform gap analysis with our clients, we look at the health plan’s system limitations, such as are there financial issues or any other workflow implications?

We offer recommendations for optimizing the clinical workflows and processes, while supporting a value-based care strategy. The analysis is a good way for the health plan to determine what enhancements, remediation or replacement of existing systems are needed to improve the organizations population health infrastructure.

A clinical optimization gap analysis would be similar to other client engagements in determining how far the health plan is from achieving its clinical optimization goals.

What’s the effect on health plans?

The changes that merge DM/CM standards will affect health plan operations, as NCQA is requiring all health insurers to have a transition strategy that adheres to the new PHM standards.  This change represents a shift from evaluating a single-disease state and moves towards a holistic approach for the member and thereby removes outdated standards for DM and practice guidelines.

This change will:

  • Transform standards from the Quality Management and Improvement and Member Connections categories
  • Eliminate DM, Practice Guidelines and Support for Healthy Living categories
  • Provide evidence of oversight for the delegated activities for PHM

Care management/Disease management

Organizations were preparing for the merging of DM/CM under population health but didn’t know how the final standards would affect their organizations.

Many organizations are already moving away from CM/DM, looking at specific diseases and things that are prevalent to a particular population.

Health plans will now examine a consumer and their specific care management needs — whether it’s treating a disease, an injury or smoking cessation.

By merging DM and CM into a new PHM standard, the expectation is that there will be more efficiencies in the care that’s being delivered.

The intent of the new PHM standards is not necessarily to drive efficiencies by merging DM/CM, but about getting a better handle on all of the populations and efficiencies in care.

As David Nash, MD, MBA, the Founding Dean of the Jefferson College of Population Health, and professor of Health Policy at Thomas Jefferson University in Philadelphia notes that focusing on the population’s needs and evaluating them through state Medicaid and other programs or running claims analysis, can determine which would be the most prevalent diseases to treat for a particular population.

From this analysis, we can then determine the best ways to treat the population. For example, the analysis examined high rates of diabetes in one Florida county. Such analysis looked at the demographics and determined the effect diabetes was having on members living in that particular county.

While smoking is not a disease, it’s managed as a condition, and developing a smoking cessation program as part of the member’s overall wellness is now a part of PHM.

In a Milbank Memorial Fund survey from 2017, researchers showed how State Population Health strategies make a difference. The study’s authors looked at performance improvements that can be attributed to specific policy actions in population health.

Rather than looking only at the states that consistently had the best health outcomes or focusing on a specific program, Milbank wanted to identify which states had improved in one or more population health outcome measurement—and see how and why the improvements occurred.

All of the programs were evaluated in terms of setting targets, establishing multi-sector ownership for steady and sustainable progress, measuring and analyzing, focusing on disparities, location, and the overall coordination of care.

Population 360 maturity model

To understand the population, HighPoint Solutions performs an analysis that looks at where the health plan is today and where it wants to be in the future.

  • We look at whether they’re NCQA certified?
  • If they have had a recent audit by NCQA, what things were noted that needed improvement?
  • Were there any health plan performance issues identified and where is the health plan in terms of addressing or resolving these issues?
  • Does the health plan have a wellness program?
  • Is it recently created or mature? Does the organization have a DM program and what level of maturity is the program?

Our goal is to help move the health plan from Point A to Point B.

Co-authors: Suzanne and Norita are associate directors with HighPoint’s Population Health Management practice.