Insight: Three Reasons Population Health Could Fail

John Gallagher, Senior Innovation Consultant at Simpler Consulting, offers potential complications that could doom population health efforts: "The business of care delivery must change."

As the healthcare industry continues to shift away from a fee-for-service delivery system and move toward a value-based payment model, more organizations are adopting population health management programs in even greater numbers.

While population health management is extremely beneficial to both hospital organizations and their patients, there are key barriers health systems must address in order to truly reap the benefits. Even the most established health organizations can struggle with shifting from fee-for-service to value-based care if they aren’t properly prepared to tackle these three key challenges:

1) Data quality and access

Culling data from multiple providers and presenting it in a way that’s clear and action-oriented is a seemingly constant struggle for health systems. An abundance of health systems continue to have self-governing, siloed and incommunicative business models that are proving detrimental to patients and hospital leaders alike.

Streamlined IT capabilities are crucial to enabling all providers involved in a patient’s care to make the soundest, most informed care and treatment determinations. An advanced IT framework, including an extensive electronic health records system, data exchange capabilities, case management software and analytics programs, is critical to upholding patient care quality as well as laying the foundations for a population health management model.

2) Fragmented ownership across the care continuum

Lack of total care system ownership and integration can lead to problems within a system’s IT and financial infrastructures and ultimately impact the quality of patient care. For example, a health system may purchase a primary care practice network and acquire elderly patients.

However, if they do not own a home health/hospice agency, rehabilitation facilities or specialty care resources, the health system must outsource and send patients elsewhere for that care. In some cases, the various facilities involved may not have a financial arrangement or similar electronic infrastructure, which can cause important details about a patient’s history and care plan to get lost in translation in between providers, physicians, caretakers and medical facilities.

Mapping the entire continuum of care is a key first step toward averting care ownership and miscommunication challenges. By doing so, hospital executives gain a full understanding of all patient touchpoints and interactions, and begin designing plans to close information gaps and foster patient relationships throughout the process.

Once systems understand the entire care continuum, and their role in each, then they can move toward a coordinated care model to foster communication across departments, specialties and practices.

3) Current payment models

The healthcare industry is set up as a fee-for-service delivery system—a system whereby the more patients you see or procedures you do, the more money you will make. Shifting to a value-based payment model works hand-in-hand with better population health management. In value-based care, providers may be paid based upon the outcomes of care they deliver rather than the number of visits or tests they order. In theory, this shift encourages collaboration; outcome-based payments; and a new benefit design to align providers, members, employers and payers.

Focusing on improving value and outcomes is the key to delivering the best care for all demographics of patients. Tracking patient complications, hospital-acquired infections (HAIs), hospital readmissions (specifically 30-day readmissions), and employee and patient satisfaction provides hospitals the insights they need to most effectively evolve and improve to best serve patients.

While still in its early stages, the healthcare system-wide migration from a fee-for-service to a value-based payment model is one that won’t be ending soon.

Horizontal shift

For true population health success to occur, the business of care delivery must change. Organizations will have to coordinate care horizontally across the continuum, rather than vertically in siloes. IT capabilities must improve to pull data in a timely manner and payment reform must occur. Finally, organizations must make all these things happen without over-burdening those who provide the care to the patients.

John Gallagher is a Senior Innovation Consultant, Simpler® Consulting, an IBM Watson Health™ company.