Though the US Affordable Care Act has extended health insurance to millions of previously uninsured consumers, recent research found that providing health insurance to those not previously covered did not improve the patients’ health and outcomes:
"The study seems to indicate that greater access to health insurance, in and of itself is not enough to improve outcomes for patients with chronic disease," said lead author Tomasz P. Stryjewski of Massachusetts General Hospital.
Expanding health insurance is only part of the answer. The other part is supporting consumers and patients in their attempts to embrace a sustained behavior change over the long term. The Centers for Disease Control and Prevention (CDC) reported that 75 percent of health care costs go for the treatment of chronic disease. Patients struggle to manage their health and wellness even with health insurance. For instance:
- Obesity: Obesity results in an additional $190 billion a year in medical spending or 20.6 percent of US health care expenditures. Over two-thirds of adults are overweight or obese, and one in three Americans is obese. There are upwards of 108 million people on diets in the US, and dieters typically make four to five attempts per year.
- Medication adherence: Half of the 3.2 billion annual prescriptions dispensed in the US are not taken as prescribed. The IMS Institute for Healthcare Informatics estimated that implementing improvements in medication adherence could mitigate $105.4 billion in avoidable costs.
- Smoking: Smoking results in an additional $133 billion in direct medical care for adults in the US annually. In 2011, 69 percent of adult smokers wanted to stop smoking and 43 percent had made an attempt to quit in the past year.
Changes in the US health care system are underway that further incentivize delivering high quality, coordinated care. What’s missing is a clear path on how to accomplish the end goal. Fortunately, the Centers for Medicare & Medicaid Services (CMS) has assessed the need for additional patient support outside the clinical setting. It’s now implementing the Chronic Care Management (CCM) Services program scheduled to go into effect in 2015.
This program will allow providers to bill CMS $42.60 per month per patient for providing 20 minutes or more of chronic care management services to those Medicare patients with at least two chronic conditions expected to last at least 12 months, or until the death of the patient. The conditions must place the patient at significant risk of death, acute exacerbation/decompensation or functional decline. As this affords providers a direct mechanism to bill for patient interactions outside the clinical setting, they must now find approaches to supporting these patients outside the clinical setting. One way to accomplish this is through using technology and automation to engage and support patients at scale. This is one aspect of population health management.
By gathering and analyzing all types of patient data collected in and outside the clinical setting – with automation where appropriate – providers can create a 360-degree view of the patient in a cost-effective manner. Providers can then use this view to risk-stratify the patient populations to understand risk at both the cohort and individual patient level. Armed with this information, providers can identify specific types of interventions for specific consumers and patients and deliver the appropriate care.
In addition to identifying types of interventions, how can providers make better decisions on how to efficiently allocate resources for support and intervention tactics? Not every patient requires additional support to manage their health. Identifying which patients, and how much additional support would be effective, can be solved with advanced analytics applied to the tremendous resource of data collected about the patients. Finally, monitoring patients’ behavior over time to understand who responded to which interventions allows for more informed decisions through response profiling to understand which intervention will work for which patient. This all needs to take place “at scale.”
One population health management company focused on aggregating a broad spectrum of patient data, aggregating this data, and risk-stratifying the patient population is Geneia. They use SAS® to power their Theon platform where they integrate disparate data sources that include EHR data, claims data, psycho-social data, activity tracker data and device data to create a comprehensive view of the patient both inside and outside the clinical setting. With this Big Data asset, their CareModeler module can support risk stratification of the patient population to allocate resources to close care gaps and/or support patients’ behavior change outside the clinical setting.
Population health management organizations are using automation of data management and advanced analytics to identify those patients that have care gaps and would benefit most from additional support. The automation and advanced analytics also enable targeted outreach to specific patients at the optimal time for the given patient’s status relative to the management of their disease, based upon data entering the patient’s records. Patients desperately need on-going support outside the clinical setting for sustained behavior change relative to managing their health. And providers, at least for a portion of their patient population, now have solutions available and a mechanism to bill for care management outside the clinical setting.
So, how will all this be put together? Analytics will be key in identifying high-risk patients, allocating resources most efficiently, and aligning the various care management services and follow-up with each individual patient that will be most receptive. Technology and automation will pave the way for these services to be delivered at scale – exactly when they will deliver the most benefit – and capture the critical data surrounding the interaction for analysis and refinement of future care management services. We now have the incentives, health analytics, technology and automation to cover the last mile into the patient’s home and workplace in support of sustained behavior change.