Population Health Management has been an industry concept for decades, though it has not been fully embraced by the industry. Now the Affordable Care Act has created multiple incentives that may cause wider adoption of Population Health Management concepts. Population Health Management has the promise to:
- Make care proactive – by managing populations care can be focused beyond just the individuals who show up at the physician’s office. Resources can be more carefully planned to provide more proactive care
- Make care more coordinated – by focusing on populations care can be managed across the continuum
- Make care more customized – interventions can be tailored to specific population’s needs and the needs of the individual within the population
Analytics is an important component of enabling the promise of Population Health Management.
A first consideration of Population Health Management and the associated analytics are how to define populations and sub-populations. Many of these are driven off of financing or care processes and may include:
- Disease (i.e. Cancer, Diabetes, CHF)
- Geography / Community (i.e. St. Louis Metro Area, Marshfield WI Hospital Referral Region)
- Demographic (i.e. Pediatric, Women’s Health)
- Payer (i.e. Medicare, Safety Net, Commercial)
- Network / Provider Groupings (i.e. Accountable Care Organization, Medical Home, Clinic)
These defined populations can have widely divergent healthcare needs.
Once the population/sub-population is defined, a core set of metrics should be developed for identifying opportunities and measuring performance. Below is a balanced set of metrics for managing diabetes. The examples shows trends but comparison to benchmarks is also important.
|
Measure Category |
2010 Results |
2011 Results |
% Change |
|
Patient Composition (% of entire population) |
|||
|
– Adult Diabetics |
8.3% |
8.4% |
1.2% |
|
– Pre diabetics |
3.2% |
3.1% |
-3.1% |
|
Patient Experience |
|||
|
– Easy to understand instructions |
75.3% |
79.1% |
5.0% |
|
– Ease of making an appointment |
34.8% |
41.8% |
20.1% |
|
Prevention Measures |
|||
|
– Blood pressure control (<140/90) |
63.7% |
62.5% |
-1.9% |
|
– Eye Exams |
58.3% |
62.1% |
6.5% |
|
– HbA1c Screening |
90.3% |
91.4% |
1.2% |
|
– HbA1c Control (<8.0%) |
65.4% |
68.3% |
4.4% |
|
– LDL Cholesterol Screening |
75.9% |
77.8% |
2.5% |
|
– LDL Cholesterol Control (<100 mg/dl) |
49.2% |
52.3% |
6.3% |
|
– Monitoring nephropathy |
86.7% |
85.6% |
-1.3% |
|
Avoidable Events (per 100,000 diabetics) |
|||
|
– Diabetes Short-term Complications Admission Rate |
1,164.13 |
1,138.10 |
-2.2% |
|
– Diabetes Long-term Complications Admission Rate |
1,546.73 |
1,489.13 |
-3.7% |
|
– Uncontrolled Diabetes Admission Rate |
330.88 |
329.25 |
-0.5% |
|
– Lower Extremity Amputation Rate among Diabetics |
186.71 |
174.34 |
-6.6% |
|
Costs |
|||
|
– Total Allowed PMPM |
$866 |
$837 |
-3.3% |
|
– Inpatient Allowed PMPM |
$197 |
$173 |
-12.2% |
|
– Hospital Outpatient Allowed PMPM |
$215 |
$224 |
4.2% |
|
– Physician Allowed PMPM |
$225 |
$228 |
1.3% |
|
– Pharmacy Allowed PMPM |
$184 |
$166 |
-9.8% |
|
– Ancillary |
$45 |
$45 |
0.0% |
|
Utilization Rates |
|||
|
– Inpatient Admits per thousand |
138.1 |
117.2 |
-15.1% |
|
– Emergency Room Visits per thousand |
260.0 |
252.9 |
-2.7% |
|
– Office Visits per thousand |
5,861.5 |
5,980.2 |
2.0% |
|
– Pharmacy Scripts per thousand |
26,332.9 |
23,610.1 |
-10.3% |
|
Program Participation |
|||
|
– Disease Management Program (of diabetics) |
8.5% |
8.7% |
2.4% |
|
– Diabetes Social Network Visits (per 1,000 diabetics) |
15 |
27 |
80.0% |
These metrics should support the population care strategy and tactics; they are a great first step in making care more proactive, coordinated, and customized.