First steps in population health management: Setting up a population health management team

Aug. 3, 2016 / By L. Gordon Moore, MD

Let’s assume you’re about to sign a contract to manage a population of several thousand.

The goal of the contract is to improve care delivery, improve outcomes and reduce the unnecessary use of medical resources so that you decrease risk-adjusted total cost of care.  Now, let’s imagine that, in this scenario, there are upfront care management payments and year-end quality bonus payments Let’s also assume the care management and quality payments are adjusted each subsequent year based on risk-adjusted total cost of care performance.

Side note:

Total cost of care is the sum of the health plan “allowed” expenditures plus the out-of-pocket deductibles and copayment of the defined (attributed) population for any and all care received in any and all health care delivery systems.  This is not “the true cost of care delivery,” “charges,” nor facility based costs.  Reducing facility costs for a cardiovascular care bundle is excellent work that should happen parallel to the work of reducing the rate of cardiovascular events.

The first step is to create a clinical leadership team that includes key functionality: 

• Clinical leadership – understands the factors that improve outcomes and is credible to the physicians and other clinicians
• Organizational leadership – knows how to make things happen in the organization and manage a business
• Analyst – understands data structures, analytics and information systems, and can translate between data/IT and clinicians
• Improvement specialist – expert in rapidly testing, learning, adjusting and scaling

This team must have the support of the organization to create a framework for achieving goals, rapidly testing and altering course and creating and disseminating new models of care.

This team needs:

• Adjudicated claims data with a total illness burden methodology so that they may identify risk factors and patient segments who might benefit from interventions
• Clinical data to identify gaps in care and other risk factors
• Reports that identify variation on multiple variables by physicians, practices, groups, facilities and patient segments
• Tools that combine the clinical and claims data into a comprehensive view of each patient that can act as a care management plan
• The ability to push prioritized alerts to care teams ready to use those alerts to improve outcomes – ideally across widely variable primary care electronic medical records
• Prepared and proactive care teams ready to engage in outreach, care coordination and care management

It is often difficult to discern the impact initiatives have given the number of simultaneous changes happening in health care, so it is important that the population health management team create pilot programs that rapidly test improvement concepts against specific goals:

• Can we identify a population segment with actionable risk factors?
• When we reach out to these people, will they respond to our interventions?
• Are we able to coordinate this work with that of the PCP, specialists and hospitals?
• Did outcomes improve?
• Is the program financially viable?

As the team rapidly tests and modifies the intervention to achieve the goals, it can then create a standard approach that will scale across your enterprise.  This scaling will require the development of new standards of care, documentation practices, new EMR templates and/or alerts, and the dissemination of standards across all clinicians via medical directors, clinical councils, etc.

This is just one approach to developing a population health management team within an organization.  These recommendations are based on my observation of many high and low performing teams across multiple organizations and are meant to be informative but not prescriptive.

L. Gordon Moore, MD, is senior medical director for Populations and Payment Solutions at 3M Health Information Systems.