Archive for the ‘Population Health Management’ Category

Infographic: Children’s Health and Neighborhood Amenities

May 7th, 2018 by Melanie Matthews


Ten percent of children nationwide (approximately 7,059,000 children) lived in neighborhoods with no amenities in 2016, defined as a neighborhood without any parks, recreation centers, sidewalks, or libraries, according to data from the U.S. Census Bureau’s 2016 National Survey of Children’s Health (NCSH), which was recently released.

A new infographic by the Robert Wood Johnson Foundation’s State Health Access Data Assistance Center highlights state-specific findings from the 2016 NCSH on measures that illustrate where states are closer to achieving a culture of health and where improvements can be made.

Innovative Community Health Partnerships: Clinical Alliances to Reduce Health Disparities in Underserved PopulationsAs one of the poorest urban congressional districts in the country, the Bronx, a New York City borough, was also rated as the last county (#62) in New York for health outcomes and health factors by the Robert Wood Johnson Foundation. In reaction, the Bronx Health REACH initiative formed the “#Not62,” campaign to transform the health of the community.

Innovative Community Health Partnerships: Clinical Alliances to Reduce Health Disparities in Underserved Populations highlights the models of change and key initiatives developed through Bronx Health REACH’s community health transformation project.

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Infographic: Seven Essentials Steps to Effective Care Coordination

April 30th, 2018 by Melanie Matthews

Understanding and removing barriers to health and coordination is the key to successful care coordination, according to a new infographic by Optum.

The infographic examines seven essentials steps to removing these barriers.

Care Coordination in an ACO: Population Health Management from Wellness to End-of-LifeWhen acknowledging its position as a top-ranking Medicare Shared Savings Program (MSSP), Memorial Hermann is quick to credit its own physicians—who in 2007 lobbied for a clinically integrated network that formed the foundation of the current Memorial Hermann accountable care organization (ACO). Now, eight years later, collaboration and integration continue to be the engines driving the ACO’s cost savings, reduced utilization and healthy patient engagement rates associated with Memorial Hermann ACO’s highest-risk population.

Care Coordination in an ACO: Population Health Management from Wellness to End-of-Life details Memorial Hermann’s carefully executed journey to quality and the culmination of the ACO’s community-based care management program.

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Mounting Pressure from Value-Based Reimbursement Models Drives Clinical Improvement Strategy at Allina Health System

April 17th, 2018 by Melanie Matthews

Value-Based Reimbursement Models Drive Clinical Improvement Strategy

As a greater percentage of hospital payments are through value-based contracts, hospitals that reduce costs while maintaining quality will survive, predicts Pam Rush, cardiovascular clinical service line program director at Allina Health.

“How do we improve outcomes and decrease costs?” Rush asked participants in the March 2018 webinar, Predictive Healthcare Analytics: Four Pillars for Success. “We need to start to look at the world differently.”

How can we be more creative and do things differently? How can we use different members of the healthcare teams in new ways, such as nurse practitioners or advanced practice providers, she added. In addition, “we need to invest in data analytics and data resources and have data analysts who can pull the information for us so we can find the variation. We need to invest in physician and caregiver time to look at the data, to make changes in how they improve care, to monitor and see what is working and what doesn’t work.”

These four pillars…population health management, reducing clinical variation, testing new care processes and new models of payment, and leveraging cutting edge technologies…have been critical to the work at Allina Health System’s Minneapolis Heart Institute Center for Healthcare Delivery Innovation, said Rush.

In population health management, we’re looking at how can we focus on adherence to guidelines, identify where there are gaps in care and partner with people across the system, primary care and specialists, to improve consistency and adherence to guidelines, she explained.

Allina is reducing clinical variation by looking at unnecessary variations in care where there is inconsistent care without an influence on outcomes.

“We’re also looking at new ways of doing things. How can we use our nurse practitioners, how do we care for patients once they’re discharged from the hospital and bring them back in for clinic visits? It’s really looking at the care model and how we can do things differently to reduce total cost of care,” she said.

In cardiology, there are so many new devices, procedures and techniques to monitor, said Rush, but we need to figure out who are the right providers to do that monitoring, who are the right patients to do these expensive procedures on and who achieves the best outcomes, because we can’t afford to do all of this new technology to every single person.

Allina looks at these four pillars across the continuum. Starting in primary care to partner on prevention strategies, moving to who gets referred to cardiology, and when they’re referred to cardiology, what are the set of tests or treatments and guidelines to adhere to along the continuum to subspecialties, emergency services and all the way up through advanced therapies, such as transplant.

During the webinar, Rush along with Dr. Steven Bradley, cardiologist, MHI and associate director, MHI Healthcare Delivery Innovation Center, shared these four pillars of predictive analytics success along with details on creating a culture of quality and innovation, building performance improvement dashboards, as well as several case examples of quality improvement initiatives contributing to these savings and much more.

Listen to Ms. Rush describe how MHI leveraged an enterprise data warehouse to identify care gaps and clinical quality improvement opportunities.

Infographic: Unlocking the Power of Population Health

April 16th, 2018 by Melanie Matthews

Population health management is one of the primary strategies for achieving greater value in healthcare, according to a new infographic by leidos.

The infographic examines how healthcare organizations can create effective and sustainable population health programs.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Infographic: How Much Is Your Unmanaged Population Costing You?

February 23rd, 2018 by Melanie Matthews

Population health management programs are a key factor in a healthcare organizations’ ability to improve health outcomes and lower healthcare costs, according to a new infographic by Conifer Health Solutions.

The infographic follows the journey of two health plan members for the cost and quality impact of implementing a successful population health management strategy.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Population Health Tactics to Boost an ACO’s Medicare Annual Wellness Visit Rates

February 9th, 2018 by Patricia Donovan

One of the most important revenue opportunities for primary care physicians, and for population health nurses under their direct supervision, is the Medicare Annual Wellness Visit (AWV), advises Tim Gronninger, senior vice president of development and strategy, Caravan Health. The AWV offers an opportunity to check a number of Medicare quality boxes, including preventive check-ins, vaccinations and health screenings, to help make sure that a beneficiary’s medical needs are being met.

Here, Gronninger suggests ways that physician practices can improve all-important AWV rates.

Much of increasing annual wellness visit rates is about how to manage expectations of the practice and of the patient. You’ll be chasing your tail a lot if you are looking at your data and saying, “Well, these 1,000 patients haven’t had an annual wellness visit. I’m going to make a thousand phone calls, and then I’m going to make a thousand follow-up phone calls to try to schedule them all.”

It is very important for a practice to create a process where you have the time, the space and the plan, so that when a patient comes in the door for an Evaluation and Management (E&M) visit, the patient is handed off seamlessly to a nurse coordinator to complete an annual wellness visit at the same time. Obviously, different patients will require different handling. But we have found a very high acceptance rate from that approach among patients of clients that we work with.

It’s something that many patients take for granted, that their clinician knows this about them already. However, many times, the physician in practice doesn’t know whether the patient is up to date on their mammograms or other types of screenings.

Editor’s Note: Caravan Health’s ACOs saved more than $26 million in the Medicare Shared Savings Program (MSSP) and achieved higher than average quality scores and quality reporting scores in 2016.

Source: Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success

ACO population health

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

In Successful ACOs, Population Health Focus Paves Way for Shared Savings Payouts

January 25th, 2018 by Patricia Donovan

Physician practices toiling in fledgling ACOs and obsessing over shared savings that have not yet materialized, take heart: population health offers multiple revenue streams for accountable care organizations waiting for the “gravy” of accountable care.

“Gravy” is the way Tim Gronniger, senior vice president of development and strategy for Caravan Health, refers to ACO shared savings payouts, which he says can take considerable time to accrue.

“It is literally two years from the time you jump into an ACO before you have even the chance of a shared savings payout,” Gronniger told participants in Generating Population Health Revenue: ACO Best Practices for Medicare Shared Savings and MIPS Success, a January 2018 webcast now available for replay.

Obsessing over shared savings is one of the biggest mistakes hospitals in ACOs can make, he added.

This delay is one reason Caravan Health urges its ACOs to adopt a population health focus, whether pursuing the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) Merit-based Incentive Payment System (MIPS) or the Medicare Shared Savings Program (MSSP).

Gronniger’s advice is predicated on his organization’s experience of mentoring 38 ACOs. In 2016, Caravan Health’s ACOs saved more than $26 million in the MSSP program and achieved higher than average quality scores and quality reporting scores, according to recently released CMS data.

Walking attendees through a MACRA primer, Gronniger underscored the challenges of the MIPS program, one of three tracks offered under the Quality Payment Program. “Barring a really exceptional performance on MIPS, you can’t even break even over the next few years on physician compensation,” he said.

In the meantime, ACOs should utilize recently rolled out Medicare billing codes, from the annual wellness visit (AWV) to advanced care planning, to generate wellness revenue. With proper planning, reengineering of staffing and clinical work flows, a practice could generate anywhere from five hundred to one thousand dollars annually per eligible Medicare patient, Gronniger estimates—monies that offset the cost of constructing a sustainable ACO business model.

To back up this population health rationale, Gronniger pointed to data from an ACO client demonstrating the impact of a cohesive PHM approach, including the use of trained population health nurses, on completion rates for preventive screenings. For less top-of-mind screenings like falls assessment and smoking cessation, completion rates rose from negligible to near-universal levels, he said.

“These are recommended sets of screens that are required by CMS, but that also help ACOs with quality measures,” he added.

Gronniger also shared examples of dashboards, scorecards and roadmaps Caravan Health employs to help keep client ACOs on track. An ACO success strategy involves “a lot of dashboarding, checking in, and discussion of problems and barriers, discussion of solutions, and monthly and quarterly measurement and reporting back,” he said.

Beyond coveted shared savings, ACO participation offers significant non-financial benefits, including quality improvements under both MSSP and MIPS standards, availability of ACO-specific waivers, and access to proprietary performance data.

Overall, ACO participation can make providers more attractive both to commercial contractors and to potential patients perusing Physician Compare ratings in greater numbers.

Gronniger ended by weighing in on the recent recommendation by the Medicare Payment Advisory Commission (MedPAC) to repeal and replace the MIPS program.

Infographic: Reducing Childhood Obesity Through Medicaid-Public Health Collaboration

January 5th, 2018 by Melanie Matthews

Nearly one in six children in the U.S. is obese, representing a serious public health problem. Children covered by Medicaid are particularly at risk, with this population nearly six times more likely to be treated for obesity than those who are privately insured. Partnerships between public health and Medicaid can leverage each entity’s strengths to advance interventions aimed at reducing obesity, according to a new infographic by the Center for Health Care Strategies (CHCS).

The infographic describes cross-sector interventions tested by five states participating in CHCS’ Innovations in Childhood Obesity initiative, as well as opportunities for the field.

Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community ServicesLeveraging the experience of several physician practices already screening patients for social determinants of health (SDOH), Montefiore Health System recently rolled out a two-tiered assessment program to measure SDOH positivity in its predominantly high-risk, government-insured population.

Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community Services outlines Montefiore’s approach to identifying SDOH markers such as housing, finances, healthcare access and violence that drive 85 percent of patients” well-being, and then connecting high-need individuals to community-based services. Click here for more information.

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2018 Success Strategy: Differentiate to Survive Next Wave of Healthcare

January 5th, 2018 by Patricia Donovan

Are supermarkets the next wave of healthcare?

Perhaps not, but if a health insurer can move into the community pharmacy, why not the local grocery store?

On the heels of the recent non-traditional CVS Health-Aetna merger and amidst other swirling consolidation rumors, industry thought leaders are encouraging healthcare organizations to embrace similar partnerships and synergies.

And given the presence of pharmacies inside many supermarkets, “there is potential for greater synergies around what we eat, what we buy and how our healthcare is actually purchased or delivered,” suggests David Buchanan, president of Buchanan Strategies.

“The bonanza [from this merger] might be where data can be shared between CVS’s customers and Aetna’s customers and whether we can steer those CVS customers to Aetna,” he added.

Buchanan and Brian Sanderson, managing principal of healthcare services for Crowe Horwath, sketched a roadmap to help healthcare providers and payors navigate the key trends, challenges and opportunities that beckon in 2018 during Trends Shaping the Healthcare Industry in 2018: A Strategic Planning Session, a December 2017 webinar now available for rebroadcast.

Key guideposts on the road to success: data analytics, consolidation, population health management, patient and member engagement, and telemedicine, among other indicators. Also, organizations shouldn’t hesitate to test-drive new roles in order to differentiate themselves in the marketplace.

“If you are not differentiated, you will not survive in what is a very fluid marketplace,” Sanderson advised.

Honing in on the healthcare provider perspective, Sanderson posed five key questions to help shape physician, hospital and health system strategies, including, “What are the powerful patterns?” Industry mergers, an infusion of private equity money into areas like ambulatory care and emerging value-based payment models fall into this category, he suggested.

These patterns were echoed in four primary trends Sanderson outlined as shaping the direction of the healthcare market, which faces an increasingly “impatient” patient. “I could tell you the market wants care everywhere,” he said. “In the same way we have become impatient with our commoditized goods, so have patients become impatient with accessing care.”

Among these trends are “unclear models of reimbursement,” he noted, adding that after a self-imposed “pause” relative to healthcare reimbursement at the start of a new presidential administration, the industry is ready to “restart with some new sponsors now.”

Notably, Sanderson advised providers to embrace population management. “Don’t think population health, think population management. It’s no longer just the clinical aspects of a patient’s or a population’s health. It’s the overall management of their well-being.”

Following Sanderson’s five winning strategies for healthcare provider success, David Buchanan outlined his list of hot-button items for insurers, which ranged from the future of Obamacare and member engagement to telemedicine, healthcare payment costs and models and trends in Medicare and Medicaid.

Healthcare payors should not underestimate the value of engaging its members, who today possess higher levels of health literacy, he stated. “The member must be an integral part of healthcare transactions, as are the provider, the facility and the insurer. The member must have a greater level of personal responsibility and engagement in the process.”

Offering members wearable health technologies like fitness trackers is one way insurers might engage individuals in their health while creating ‘stickiness’ and member allegiance to the health plan.

Telemedicine, the fastest growing healthcare segment, is another means of extending payors’ reach and increasing profitability, he adds. “Telemedicine is not just for rural health settings anymore, but is finding another subset of adopters among people who can’t fit a doctor’s visit into their busy schedule.”

Payors should expect some competition in this area. “I believe the next wave [of telehealth] will be hospitals expanding into local telehealth services as a lead-in to their local clinics,” Buchanan predicted.

The use of artificial intelligence (AI) and robotics in healthcare is growing, but Buchanan and Sanderson agree that adoption will be slow. On the other hand, expect more collaboration between digital players like Amazon, Google and Apple and larger health plans.

“You will see [synergies] when you can put those two players together: the company that can bring the technology to the table as well as those companies that bring the users to the table,” concluded Buchanan.

Listen to a HIN HealthSounds podcast in which David Buchanan predicts the future of mega mergers in healthcare, the impact of the CVS-Aetna alliance on brand awareness, and the real ‘bonanza’ of the $69 billion partnership, beyond bringing healthcare closer to home for many consumers.

From Last Place, Bronx Communities Now Prize Culture of Health

December 7th, 2017 by Patricia Donovan

Barely eight years ago, the Bronx landed at the very bottom of the first county health rankings issued by the Robert Wood Johnson Foundation (RWJF) —the least healthy of 62 New York counties, to be exact.

It didn’t help that as a borough, the Bronx topped a few other lists compiled by New York officials, including the highest prevalence of obesity and diabetes and the top consumers of sugary drinks.

Rather than discourage this diverse borough, however, these rankings galvanized residents and a number of Bronx organizations, including the Bronx Institute of Health, to partner and examine facets of community life to see where health might be improved. Under the hash tag and rallying cry of #Not62, the coalition’s reach has extended into Bronx schools, housing and even local food stores known as bodegas as it attempts to reimagine and enhance community health.

During Innovative Community-Clinical Partnerships: Reducing Racial and Ethnic Health Disparities through Community Transformation, a November 2017 webcast now available for rebroadcast, Charmaine Ruddock, project director, Bronx Health REACH, charted the path to some of the innovative community health partnerships forged by her organization.

Formed in 1999 with a grant from the Centers for Disease Control and Prevention (CDC), Bronx Health REACH (shorthand for “racial and ethnic approaches to community health”) is charged with eliminating racial and ethnic disparities in health outcomes, particularly those related to diabetes and heart disease, in Bronx populations. Since its inception, Bronx Health REACH has grown from five to more than 70 community-based organizations, schools, healthcare providers, faith-based institutions, housing, social service agencies and others.

“Those founding partners were particularly concerned that Bronx Health REACH not be seen as a program per se, but as a catalyst for creating a movement around health and well-being in the community,” explained Ms. Ruddock.

From early focus groups, Bronx Health REACH determined that community members not only felt disrespected by the healthcare system, but also powerless to advocate on their own behalf for better services. Those findings helped to shape the Bronx Health REACH mission and subsequent efforts.

Outreach began at the organizational level, such as examining the way a local church provided meals at church events. The coalition brainstormed ways to prepare those meals in a healthier manner, supplementing the church’s work with nutrition training that quickly spread throughout the faith community. From there, the program applied that approach to the food offered during school meals and via vending machines, and eventually within the local food retail environment, which consists principally of bodegas.

Today, the scope of Bronx Health REACH is broad, encompassing street safety, physical activity and overall wellness, among other areas. Its early work with bodegas has grown from demonstrations and tastings of healthy foods to the formation of a Bronx bodega work group and a new Healthy Bodegas marketing initiative. It has engaged farmers’ markets in its objective of increasing healthier food options. To that end, healthcare providers now issue “prescriptions” for fruits and vegetables that are accompanied by ten-dollar coupons.

The transformation is visible in the community, Ms. Ruddock notes. Today, some previously padlocked playgrounds are open; murals by visiting artists that adorn the walls of local housing are left alone for all to enjoy.

However, a great deal of work remains. “We have given ourselves as a goal that by 2020, we will establish a multi-sector infrastructure working with housing groups, economic development groups, and others as the first step in addressing many of the health-related factors and issues,” explained Ms. Ruddock.

But for now, the enthusiasm and contributions of Bronx residents have not gone unrewarded. In 2015, just five years after receiving its disappointing health ranking, the Bronx was one of eight recipients of the RWJF’s Culture of Health prize. The prize is awarded to communities that work to ensure residents have the opportunity to live longer, healthier and more productive lives.

Listen to Charmaine Ruddock explain how early findings from focus groups helped to shape Bronx Health REACH initiatives.