Population Health Management eBook
The Start-to-Finish Population Health Management Guide
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Patient Complexity Driving Increased Spending
The United States spends $10,348 per person per year on healthcare. This is highest in the world and 31 percent more than the next wealthy country in this ranking, and chronic illness is driving much of these costs. The medical treatment spending and lost productivity attributed to chronic conditions is expected to reach $42 trillion by 2030. Reducing these costs is the heart of value-based care payment models that government and commercial healthcare payers are introducing at a rapid pace.
However, high-quality care inside the four walls of a healthcare organization is only a portion of what delivers better patient outcomes. Rather, driving stronger Population Health Management and helping patients stay adherent to their personalized care plans is the essence of effective PHM. In many cases, improving engagement and adherence involves overcoming patients' behavioral, economic and physical environment, in addition to other social obstacles. One study estimates that more than 80 percent of outcomes are influenced by these social determinants of health.
“Population health management (PHM)… helps organizations more efficiently track and intervene with high-risk and potentially high-cost patients.”
Data Analytics Technology Leveling The Playing Field
In past decades, managing complex patient populations with both chronic conditions and challenging social determinants of health was labor-intensive, if not impossible, due to lack of available data and tools for providers. Despite these challenging historical issues, newly available PHM data-analytic technology platforms and enterprise-wide integrations of data systems have leveled the playing field.
Centralized databases combined with intelligent, automated tools help care managers monitor high-risk patients in ways that were inconceivable 20 years ago. Thanks to access to numerous other commercial and consumer databases, care managers within integrated healthcare organizations can now track patient behaviors in near real-time both throughout the care continuum and between visits.
This comprehensive care perspective enables timely interventions, which is crucial particularly among the five percent of the population that account for an estimated 50 percent of healthcare spending. Preventive interventions can divert patients from high-cost emergency department visits that may lead to an even costlier, and potentially unnecessary, hospital admission and associated inpatient care.
Automation And Real-time Data And Is Essential
Even with automated patient data capture and analytics, PHM can still be highly labor-intensive with manual report creation, data searching and patient outreach. Sophisticated PHM platforms, however, are taking automation a step further by instantly generating dashboards showing performance on key metrics. Platforms are also automatically initiating patient outreach through text messages, phone or secure patient-portal messages based on pre-determined criteria and patient preference from the care manager or healthcare organization.
Automated communication from the healthcare organization is designed to remind, notify or encourage patients to adhere to their care plan and take positive action. The goal is the same: to modify behaviors and overcome social determinants of health that are driving them away from optimal outcomes. Real-time data ensures automated interventions and communication are more relevant, effective and focused on prevention.
- 1: Cox, Cynthia and Sawyer, Bradley. "How does health spending in the U.S. compare to other countries?" Peterson-Kaiser Health System Tracker. February 13, 2018. Accessed May 15, 2018. https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/?_sf_s=health+spending#item-start
- 2: Partnership to Fight Chronic Disease. "What Is The Impact Of Chronic Disease On America?" Fact Sheet. 2016. Accessed June 11, 2018 http://www.fightchronicdisease.org/sites/default/files/pfcd_blocks/PFCD_US.FactSheet_FINAL1%20%282%29.pdf