In late 2011, the Care Continuum Alliance, an advocate for population health management, surveyed industry leaders to assess the market and predict key issues for 2012. According to the alliance’s white paper, two predominant themes were brought to light as a result of the survey.
“First, significant market movement will occur toward accountability and value creation in healthcare, driven partly by new physician-guided and collaborative models,” according to the report. “And second, population health management is well-positioned to add value to and support these emerging models, but must continue to build the case for wellness and prevention.”
Here are eight additional key issues, identified in the report, that currently affect population health management.
1. Accountable care and the Medicare Shared Savings program. Many comments from survey respondents centered on accountable care and collaborative models, as well as federal support for both. According to the report, population health has a lot to offer collaborative care, such as health risk assessment and predictive modeling, HIT infrastructure, data analytics, care coordination and other core competencies. “But tempering optimism around accountable care models were caveats,” the report noted.
2. Consumer use of mobile and eHealth technologies. According to the report, population health management has been both a driver and benefactor of the rise in eHealth and mHealth technologies. The demand for these technologies, said one respondent, will drive healthcare “to adopt … a patient-centered, consumer-empowered, pull-rather-than-push model, which has already been realized in the music, travel, book and news industries.” The importance of social media was also noted by those surveyed, and when coupled with mobile technology, will be used as a tool and patient engagement and shared decision-making.
3. Reducing avoidable hospital readmissions in Medicare. The Hospital Readmissions Reduction Program (HRRP) could be a “big opportunity for companies who have developed proven strategies for reducing hospital readmissions,” wrote one survey respondent. The program includes Medicare tracking readmissions for three conditions – heart failure, acute myocardial infarction and pneumonia – within 30 days on or after Oct. 1, 2012. Medicare will then reduce payments to hospitals to account for excess readmissions.
4. Quality improvement in Medicare advantage. The Medicare Advantage’s (MA) “stars” rating system was another topic of discussion. The program will award bonus payments to plans under the stars system to assess performance on a myriad of measures. “The developing stars system appears [to be] headed toward a structure consistent with industry-advocated changes, including additional wellness and prevention measures and retirement of process-related measures,” the report read. It added that, combined with continued growth in the Medicare Advantage population, the need for plans to demonstrate improvement in wellness and chronic care measures will drive “expanded opportunities” in the Medicare managed care market, according to industry experts.
5. Opportunities to support insourced programs. “An industry challenged at times by payer decisions to build rather than buy care management programs could face additional competitive pressure in 2012,” read the report. An industry leader added that the market will continue challenging the value of each program and, with the consolidation in the [managed care] industry, will continue looking at insourcing versus outsourcing. “ACOs may be a greater opportunity, but … these groups will often favor their own solutions rather than those from the outside,” he added. To that point, the report said, many components of population health management will likely prove especially valuable to health plans in 2012, regardless of the build or buy decisions.
6. Improving care coordination for dual eligibles. Dual eligibles, or those eligible for both Medicare and Medicaid benefits, “attracted significant attention from policymakers in 2011 as economic pressures created an imperative for savings in both programs,” the report read. The need to reduce costs associated with this population is high, and as one respondent put it, “focus on improved care coordination for complex, multi-morbid patients is a must.” The report added Congress and the administration recognized the savings possible through better care coordination for dual eligible by formalizing federal oversight of the population in the ACA. “This heightened federal recognition … places a premium on care coordination services, such as those population health management provides.”
7. Federal support for prevention and wellness. Although the ongoing deficit reduction debate in Congress has jeopardized federal support for wellness and prevention, said the report, industry leaders are optimistic about federal program opportunities. “The $15 billion Prevention and Public Health Fund … is an important part of the deferral effort, but only one element of a broader prevention and wellness strategy encompassed by the ACA,” according to the report. Since the law’s passage, Medicare has added annual wellness visits and expanded coverage of obesity and cardiovascular disease prevention services, “and the federal government has made significant grant funding available to states and communities for prevention and care coordination initiatives.”
8. Development of ACA health insurance exchanges. According to the report, development of the reform law’s health insurance exchanges – scheduled to open their doors in 2014 – will draw significant attention in 2012. “Especially with respect to how CMS structures the essential benefits package all participating plans must offer,” it said. Industry leaders said the challenge is ensuring the package is comprehensive and plans don’t dilute population health services to maintain competitive pricing in the exchange market.