Targeting High-Risk Patients: A Population Health Strategy

By Chris Gibson, Greenway Health

Population health is a hot topic within the healthcare industry, as providers move from traditional fee-based to value-based models. In the annual Numerof State of Population Health Survey, 95 percent of the U.S. C-suite healthcare executives surveyed ranked population health as “moderately” and “critically” important.

According to the report, even though population health is considered crucial, most organizations still have difficulty incorporating a clear strategy into their business models because of institutional hurdles and financial concerns. In fact, about 25 percent of survey respondents said threat of financial losses were a barrier to moving to a risk-based model, while 12 percent cited uncertainty about timing and issues with systems like IT, tracking and management.

Getting over these challenges may seem insurmountable for your practice — but it’s not impossible. First, start by considering your goals and evaluating existing resources. Next, take a step back to better understand patient demographics, and which group(s) can benefit most from additional care. Often, the highest risk patients offer the highest value proposition for improving outcome. Then, begin developing a strategy for addressing patient needs in a way that best aligns to your business goals, delivering a significant positive impact for patients. This also will help drive revenue you need to extend population health initiatives across your practice.

Getting Started: Identifying Those Most at Risk

For most practices, there are many different population health targets, which makes it difficult to figure out where to aim. However, placing a focus on those patients in your practice who may be at the highest risk is a great place to start.

As you develop your population health strategies, there are four key questions to address — and answer “yes” to — to ensure you’re getting the most benefits for both your patients and your practice:

• Does it reduce medical costs?
• Will it improve the patient care experience?
• Will it improve population outcomes?
• Can it help streamline processes and address physician burnout?

These questions are a solid baseline for measuring how successful your practice is currently, as well as assessing impact of future changes.

Detecting High-Value Patient Populations

Improving population health will require practices to start thinking with a business and analytical mentality, rather than doing things the way they’ve always been done. Practices now have to question whether they’re focusing on the right programs to move the needle on performance, whether that’s financial or patient outcomes. Of course, you will want to reach all patients, but that’s simply not possible or practical. Instead, focus on a small pocket of patients to target, where the impact will be the greatest.

Research shows practice performance can dramatically increase by improving outcomes in just the top 3 percent to 5 percent of high-risk patients. But how do you determine exactly who these patients are?

Many practices may have a good sense about the top two chronic conditions that impact these patients but are often surprised to discover that other diseases may rank higher than initially thought. This is where analytical tools come in, as they help you gain objective and impactful insights into the prevalence of chronic conditions among high-risk patients.

This knowledge also will help you develop strategies to deliver the best care to high-risk individuals. For example, you may want to target this patient population for annual wellness visits, so you can monitor their health and ensure that they receive additional needed care. This focused care can help achieve a better patient outcome, but also potentially increases practice revenue.

Putting the Pieces in Place

To succeed in effectively targeting high-risk patients as part of a population health initiative, its crucial you have the three core components in place:

• People – The success of a program targeting high-risk patients is highly dependent on a practice’s human resources. To kick off and sustain a great population health strategy, you’ll need a lead physician who champions change across the practice. You should also consider having the following:
  • A program compliance champion, who has a strong understanding of programs in which you can take advantage
  • A clinical workflow champion, who is proficient with clinical data coding
  • An analytics leader, who identifies the highest-value opportunities
  • A care manager, who proactively engages with patients

For small practices this may seem daunting, but one individual could potentially handle multiple roles, depending on how the practice is set up and with use of enabling technology.

• Process – Practices are faced with a vicious cycle — they need more staff to take care of more patients to make more money, but they need more money to hire staff. That’s why process is so important. Consider starting small, using your existing resources to serve those most at need. As mentioned above, by focusing energy on wellness visits and follow-up care for the top 3 to 5 percent of high-risk patients, the total value of these patients’ visits increases. By addressing these valuable patients, you can make the most impact on health and can bring in more revenue, which can then be used to fund resources to expand population health efforts to additional groups.
• Technology – Electronic health records are just the tip of the iceberg for an effective population health initiative. You should also consider integrating other complementary technologies, such as analytics tools, practice and revenue cycle management, patient engagement and care coordination solutions that enable you to identify and reach select high-risk patient populations, ensure continued engagement and maximize revenue. By adopting these types of solutions, you can gain insights into your patients and the services you can offer in ways not previously possible, relying on the technology to truly streamline processes and make staff and doctors more efficient.

It's clear that healthcare providers believe improving population health is an important goal but getting there is proving to be quite a challenge for resource- and time-constrained practices. So, while working to first target the highest risk patients seems small, it will have a big impact in both the lives of the patients and your practice, setting all up for future success.

About the Author

Chris Gibson, product analyst of population health solutions at Greenway Health, has been a member of the Greenway team for six years. Chris focuses on driving development of the company’s population health solutions and is responsible for ensuring practice success and compliance in value-based programs. He has a passion for improving patient outcomes and lowering the cost of care.