Contributed Commentary by Saeed Aminzadeh 

February 12, 2015 | As the Affordable Care Act (ACA) moves into its second year, the healthcare industry is taking stock of what works and what doesn’t.  According to a New York Times article, Is the Affordable Care Act Working?,  the ACA has reduced the number of uninsured Americans, helped the healthcare industry by providing new paying patients and insurance customers, and contributed to a slowdown in healthcare spending “around the edges.”

However, the same article points out that the Affordable Care Act has not, to date, measurably impacted the affordability health insurance or health outcomes.

As healthcare becomes more consumer-driven, the industry should take a look at how the centers for Medicare and Medicaid services (CMS) has used the 5-Star Rating program for Medicare plans to improve these two metrics. The most successful Medicare plans have implemented focused population health management practices that help to improve health outcomes by impacting the clinical, socio-economic, and behavioral determinants of those outcomes.  In other words these plans have deployed population health management programs to get at the root of the problem, improving health and minimizing the need for expensive interventions.

Under the Medicare 5-Star Rating program, plans are rated and reimbursed across several metrics spanning quality of care, satisfaction, member retention, and customer service.  If we look at the Medicare Star measures in the context of population health management, we will quickly see that the Star measures, by design, try to address all of the determinants of improved health outcomes described above: improving process outcomes, boosting clinical outcomes, increasing satisfaction, and minimizing mental and physical decline. Medicare plans have found that the key to consistently delivering sustained improvements in Star ratings is constructing population health management programs that are focused on the member (not the measure), and address the greatest barriers to engagement.

Though still relatively new, the Medicare 5-Star Rating program is driving plans to be more efficient than ever before.  At the same time, it is impacting patient outcomes, and helping to drive efficiency and health literacy.  Clearly, Exchange plans could learn a thing or two from the Medicare 5-Star system.  Here are two things that would help improve health outcomes and drive unnecessary costs out of mainstream healthcare management.

Addressing and Enhancing Patient Engagement 

If we define engagement as an individual’s emotional involvement with their health and the healthcare system, enhancing patient engagement is at the core of improved outcomes, loyalty, and satisfaction.

To date, most health plan strategies around population health, quality improvement, and member engagement have typically been reactive, and designed to target compliance with evidence-based guidelines. Though this approach provides incremental improvement, it is inefficient and does not produce a sustained and long-lasting impact on quality, loyalty, and use because it lacks many of the key components necessary for success, including:

• Identification of behavioral and engagement risk – Today, most population health management programs have analytical underpinnings designed only to identify clinical risk and severity.  Empirical evidence suggests, however, that member behavior and engagement are two of the most significant contributors to undesirable clinical behavior and outcomes.  To address these factors, plans must employ strategies to identify and address the behavioral and engagement risk associated with undesirable outcomes.
• Member prioritization – With a limited budget and resources, plans simply cannot reach every member for every issue with the same intensity.  Recognizing that members vary in terms of their predicted behavior relative to quality, loyalty, and utilization, plans must deploy their limited resources in a way that maximizes the impact to their members’ outcomes and plan performance.
• Relevance of outreach to members – To effectively change behavior and improve quality, loyalty and utilization, member outreach and communications must be personalized in a way that addresses the member’s specific barriers to engagement and compliance.
• Intensity and channel mix – The intensity and channel selection should be based more on a data-driven understanding of channel preference and likelihood of success, and less on the proximity to the end of the measurement year and the number of open gaps.
• Focus on more than just compliance with evidence-based guidelines – Improving performance and sustaining excellence is more than improving compliance and adherence rates. A smart, data-driven approach to improve engagement is critical to long-lasting quality improvement and loyalty, and will have a more sustained impact on costs.

Creating a Continuous Learning Model 

Part of implementing any population health management model is to be ready for some sort of failure.  We need to think of failures as opportunities to understand what worked and what did not work.  The fact is, very few things are complete failures, and it is important to analyze the impact of programs in the context of where they succeeded, and the potential reasons for where they failed so that you can modify the programs to create long-lasting success.  An initiative to improve diabetic medication adherence, may have failed to improve adherence in the aggregate, however, it’s important to analyze the member segments and sub-segments for which adherence was improved and not improved, and continually retain or discard certain portions of the program to optimally improve performance.

At the end of the day, efficiently delivering positive outcomes across key, disparate health and clinical domains is one of the most complex challenges facing healthcare organizations today.

Organizations that adopt a population health management strategy with analytic underpinning focused on sustained member engagement will be well on their way to achieving both clinical and financial success.

Saeed Aminzadeh is Chief Executive Officer of Decision Point Healthcare Solutions.