1. Population Health John Studebaker, MD, MS Forward Health Group, Inc.

2. Objectives Describe the concept of population health management Identify the importance of population health management in today’s healthcare climate List the approaches to implementing and using population health management

3. What is population health? “The health outcomes of a group of individuals, including the distribution of such outcomes within the group.” --Kindig, DA, Stoddart G. (2003). What is population health? American Journal of Public Health, 93, 366-369What is population health?

4. Individual health

5. Panel

6. Clinic or System

7. Public Health

8. The space between individual health and public health Responsibility for a group of patients NOT restricted by a disease, nor by a demographic, nor by geography

9. Population health management A collection of physician-supervised interventions, implemented for populations defined by a healthcare need or condition, that help patients and caregivers optimize care, prevent future complications, and maximize opportunities for wellness

10. Why is population health important now? Evolution Risk Quality Management

12. Evolution Current growth rate in health care spending is not sustainable Current system rewards treating illness much more so than preventing it Payers (including CMS) are motivated to try different approaches

13. Improving the patient experience of care (including quality and satisfaction) Improving the health of populations Reducing the per capita cost of health care

14. Evolution Groups that learn how to operate efficiently and effectively will have a distinct advantages – Negotiating power – Marketing advantage – Improved margin – Healthier patients

15. Risk Increasingly payers are shifting towards shared risk plans Healthy patients cost less to care for Financially rewards both the payer and the provider when patients stay healthy

16. Concept of risk is well established How do we apply to health care? – Diseases? – Hospitalizations? – Utilization patterns? – Genetics? Must have data

17. Quality Payers (including CMS) are examining methods to encourage improved quality Incentives to providers (and sometimes patients) who meet certain criteria Effective for process measures, more challenging for outcome measures

18. What is Quality? Determined by payers and national experts? Determined by health systems? Determined by patients?

19. Management How can risk be measured and managed? How can quality be measured and managed? How can compensation strategies engage providers and care teams?

20. Timing is Everything

21. Timing is everything Transition from volume-based revenue models to value-based revenue models Practices must navigate carefully as the pendulum swings Must leverage available resources – People – Data – Dollars

22. What approaches are available to use/implement population health? Data Analytic tools Health care delivery methods Reimbursement to support

23. Data Practice management systems Claims Electronic records Health information exchanges Registries

24. Analytic Tools Collect and organize “Digest” Identify and Display Enable workflow Engage clinical team

25. Data = Analytic Tools? Data is the input or analytic tools Many try to use IT resources to yield analytic capacity Not scaleable Not sustainable

26. Analytic tools for population health Use data from all your available sources Common resource for your users Organize into views that make sense Track indicators of interest – measure what you want/need to manage

32. Delivery Shifting from high volume to high value Patient centered medical home (PCMH) Population health nurses Non-traditional “visits”

33. Reimbursement New structures - ACOs Partnering with payers Understanding risk-sharing contracts Incentive programs

34. So, how do I implement population health management? Receptive leadership – Vision Engage the delivery team Assemble the tools – Data collection and analysis – Workflow support Align incentives – Compensation – Revenue streams

35. W. Edwards Deming

36. Deming It does not happen all at once. There is no instant pudding. In God we trust, all others bring data. It is not necessary to change. Survival is not mandatory. Does experience help? NO! Not if we are doing the wrong things.

37. Improvement Approaches Lesson from Manufacturing – “The Toyota Way” – Lean – 6 Sigma

38. PDSA Cycle Identify opportunity Plan change Implement change Integrate Standardize Collect data Analyze data

39. Summary Health care is evolving Must be able to measure and manage risk for your population(s) Population health management is a necessary element