Population Health Management and Medicare Advantage

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In the past decade the Medicare fee for service have seeing several changes, leading by programs that seek to create higher quality and more affordable care for Medicare beneficiaries. A common feature across these programs is the increasing emphasis on Population Health Management and an increasing expectation that providers accept and manage the health and health care of defined populations.

These include identifying and stratifying risk, promoting health and wellness, implementing targeted programs based on identified risk, integrating community and other resources in managing patients, and monitoring health and quality of life outcomes on an ongoing basis.  While some providers have the capability to implement Population Health Management practices, many organizations have a fairly steep learning curve and will likely need training and assistance with specific functions that are viewed as being central to population health.

Examining practical experience with Population Health Management can provide useful lessons.  Since the inception of what is now known as the Medicare Advantage program, health plans have developed and implemented programs that are designed to manage the health of a defined population.  Given the increased interest and focus on Population Health Management, an understanding of the approaches used by Medicare Advantage to manage their enrollee population can be useful to others who might be considering similar efforts.

Key Components of Population Health Management

Wellness promotion.  Promote health and wellness among all individuals, and extensive activities directly for members, including smoking cessation, wellness discounts, and the promotion of healthy lifestyles, exercise and nutrition.  In addition to promoting wellness, Population Health Management requires monitoring of population risk and designing and implementing programs that manage sub-populations based on their risk.  Health risk assessments serve to segment populations at risk for disease.  For patients identified as being at risk for chronic conditions, common interventions include targeted health education or outreach to engage members in activities intended to reduce risk factors, enrollment in care management programs, and working with nurses in health education.

People with multiple chronic conditions.  Beneficiaries who have been diagnosed with either single or multiple chronic conditions are typically viewed as high risk in the Population Health Management framework and are usually in need of more intensive services such as disease or case management. Offering case-management programs for patients with chronic conditions.  In addition to nurse hotlines and telephone visits, plans also make social services available and take an active role in care coordination. The focus is not only on disease management, but also on identifying and addressing the psychosocial needs of these patients, another key aspect under Population Health Management.

The delicate elderly.  An important sub-population in the Medicare program is the delicate elderly because of their complex medical and psychosocial needs. Integrated care and case management can lead to beneficial outcomes in this population. Designing and implementing targeted interventions for this sub-population will be critical. The purpose of the care

management is to identify clinical issues, functional status, quality of life, and to ensure that the needs of these members are being met.

Reducing hospital readmissions.  Medicare beneficiaries in traditional fee for service see an average of five physicians, and this greatly underscores the need for care coordination, a core Population Health Management intervention. Addressing readmissions through the use of multi-pronged approaches as patients leave the hospital, including nursing, social services, and home-health visits. Also helpful is medication reconciliation, coordination of home health services, follow-up care, house calls, and post-­discharge home visits to be effective in reducing readmissions.

Provider support and incentives.  Population Health Management through is reinforced by efforts to support and incentivize providers.  Support to providers includes provision of data and reports from patient-specific alerts to more aggregate forms of performance data.  In addition to data and information, a large majority of HMO’s used payment incentives to encourage providers to alter practice patterns, including use of global risk arrangements, practicing value- based care, and shared savings models.

Population Health Management involves design and implementation of both extensive and intensive services to manage the needs of a complex population.   Ultimately what matters is the extent to which these interventions are successful in improving quality and reducing costs.