Population Health Management for the Win | Geneia

Population Health Management for the Win

May 23, 2017
Shelley Riser, Vice President Consulting Services and Clinical Innovations


Everyone knows that data-driven insights are a big part of healthcare. What is less understood is the process of turning insights into actions that matter to people and doing it in the most effective manner and within a meaningful timeframe.

Enter population health experts. We bring together health plans, providers and employers to find common ground and success in coordinated, value-based care. You probably think herding cats would be easier. And in some ways, it probably is. However, the mounting pressure on everyone to control costs, manage risk and improve quality of care is a strong impetus to show up with open minds and a spirit of cooperation.

A goal of population health is to reach people upstream, before negative health events occur that warrant a call to the doctor and care is reactive and expensive. Predictive analytics helps identify who needs care the most and whose risk for care is rising, but that isn’t enough. We also use analytics to identify who is ready to engage and which channel is most likely to be successful in that engagement. But that still isn’t enough. We need the cooperation and active participation of those on the frontlines of care to put it all into action along with the ongoing support of employers. That’s where population health consultants step in – we help connect the dots between data and action.

Grassroots Approach

We take a grassroots approach to population health. This means each person or group comes to their monthly clinical meeting ready to share information and ideas from their unique perspective and ready to work together to develop coordinated collaborative plans. As population health experts, our strength rests on data-driven insights and clinical expertise, but we are two steps removed from patients. The reverse is true for providers and employers. They are closer to patients/employees, but often don’t have the time to dive into the shared data to apply the insights. By pooling our strengths and resources, everyone wins, especially patients/members.

Collaborating to address high prevalence of increased BMI

Earlier this year at one clinical meeting, data-driven insights from Geneia’s Theon® platform revealed the prevalence of increased BMI (Body Mass Index) was 15 percent higher than comparable regional populations and 22 percent higher than national benchmarks.

A BMI well above norm indicates obesity and is a major risk factor for many medical conditions and negative financial outcomes. For patients, it can exacerbate other conditions such as hyperlipidemia, hypertension and diabetes, which must be properly managed before they turn into chronic conditions. According to the National Institutes of Health, obesity contributes to lowered productivity, increased absenteeism and workplace injuries. All of which contribute to higher risk pools and premium rates. For providers, leaving this group unattended will drive up costs, lower performance metrics and reduce shared savings.

As a team, we used the Theon® platform to discover (within the obese population):

  • People unseen by their PCP in the previous 12 months
  • People visiting out-of-network emergency departments or urgent care, but not their PCP within the previous 12 months 
  • People with high-risk conditions who have not responded to case or disease management outreach
  • People with open care opportunities such as mammograms and colonoscopies, essential preventive services that may help prevent future high-cost conditions

Altogether, the Theon® platform distilled this (and other) data to stratify the population into patients:

  • With the highest risk for obesity-related medical conditions and co-morbidities
  • With rising risk for obesity-related medical conditions

Recognizing the overarching negative medical and financial impact, the team decided on several concrete actions:

  1. On the spot, we determined what needed to be acted upon with the providers, who incorporated specific activities into their workflow for personalized follow-up. Physician follow-up is especially important for those who didn’t respond to case or disease management outreach. Detailed notes ensure specific gaps in care (such as preventive services) can be addressed the next time the patient comes into the office. 
  2. Within the next three weeks, the provider group and health plan sent out a joint mailing (print and email) to raise awareness of existing educational opportunities such as healthy cooking and weight management classes.
  3. Physician leadership offered online, on-demand micro-courses to all clinicians on motivational interviewing techniques to help refresh and improve their ability to coach patients in the often sensitive nature of weight management.
  4. The employer added weight management and fitness incentives to its employee healthy rewards program. They also started a lunch-time walking club and evaluated the nutritional offerings available at the company cafeteria.
  5. The health plan’s wellness team developed and delivered onsite and online awareness, education and training classes for employees.

The Win

Because clinical meetings occur on a regular monthly schedule, the team kept a close watch on the impact of their decisions. Within a few months, we could see our decisions were paying off – the Theon® platform revealed significant reductions in the number of open care opportunities (gaps) and in the number of patients who had not seen their PCP in the previous 12 months, including those who sought emergency or urgent services. The platform revealed an increase in enrollment for case and disease management programs.

Everyone benefits. The employer is pleased with employee response to healthy reward incentives, walking-club participation and to the new health-oriented cafeteria options. As more employees receive preventive services and actively engage in their healthcare, related absenteeism and workplace injuries decline and the employer is well-positioned to control premium rate increases and maximize healthcare spend. As providers deliver those preventive services and help people control related conditions, their contractual performance metrics and shared savings improve

Population health experts help health plans, employers and providers gain line-of-sight into the needs of their populations and help develop effective, coordinated cost-controlled, high-quality care.

At a time when margins are shrinking, and everyone is asked to do more with less, population health experts are the ‘secret sauce’ that tie everything together and help each constituent turn analytical insights into actions that matter.


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