An Employer's Dilemma: Integrating Existing Population Health Management Programs with Evolving Health Care Delivery Models

The Employer's Dilemma

There are 2 central issues. First, employers have a need to provide health management services that generate value at a reasonable cost without redundancy. Second, for these programs to be successful, sustained engagement of eligible employees and family members has to be at a high level. On a theoretical level, PCMH, ACO, and population health management programs have significant potential to improve health care outcomes and lower health care costs. But on a practical level, each of these models faces challenges and unanswered questions.

Employers are likely to choose the health care delivery options that provide the greatest potential value. But unfortunately, determination and quantification of value has been difficult. Employers have tended to view reduction in health care costs as the primary source of value, while recognition of the value of improved workforce productivity due to enhanced employee health has not been consistently incorporated. ⁶ Complicating the measurement of value is that other factors, including the work environment, incentives, and organizational philosophy, may influence overall program participation, as well as effectiveness.

Population health management providers have come a long way toward creating a consistent methodology for quantifying program value. ⁷ Numerous reports now demonstrate improved outcomes and lower costs. ⁸ The methodologies population health has developed for outcomes reporting have not only helped bring credibility to the population health management industry, but should be leveraged by the new and emerging models of care, as they too work to demonstrate outcomes in a consistent fashion.

But at the same time, many employers have developed a healthy skepticism regarding engagement of individuals in currently available population health management programs and the effectiveness of traditional care management strategies in the wider population health arena. Less than optimal engagement of eligible individuals in telephonic population health management programs has been identified as a significant concern that has limited overall program effectiveness. ⁹ In contrast, face-to-face programs, such as in a PCMH setting, may generate enhanced patient involvement. In support, study of disease management in a workplace setting has been shown to achieve considerably greater initial and sustained participation relative to telephonic disease management programs. ¹⁰ Additionally, with PCMH clinician-based performance incentives for achieving evidence-based treatment outcomes, involved clinicians are likely to actively pursue patient engagement, with a greater likelihood of success than telephonic programs.

But if employer skepticism surrounding the return on investment of, and engagement in, population health management programs prompts some to view PCMH or ACO as possible alternatives, the lack of hard evidence surrounding the cost savings, and the lack of definition around the optimal practice and payment models remain obstacles to adoption. While the population health industry is adopting an accepted methodology for documenting and reporting outcomes, PCMH programs have not yet formulated a comparable standardized approach, particularly important in the setting of a broader scope of provided health care services. More convincing evidence of PCMH effectiveness, as evidenced by improved quality, better outcomes, and lower cost, may be necessary before employers are willing to invest in PCMH.

Despite promising early outcomes data for PCMH, limited employer understanding of PCMH program capabilities, as well as patchy access to those offerings, have dampened employer demand for PCMH. ACOs, while on the health reform horizon, have not yet been implemented, and while offering conceptual value, remain an unknown for employers.

Given these concerns, and the fact that many employers are already paying population health management vendors for services that they will expect the PCMH or ACO to provide, it is not difficult to appreciate employee reluctance to invest in these emerging models of care and the apparent service redundancy. In the meantime, employers may well maintain their interest and investment in wellness and chronic condition management services.

The Current “Two State Solution”

At its core, the decision between implementing a PCMH or ACO, or a population health management program is currently one between leveraging community health care resources versus leveraging population health management vendors. The PCMH is a provider-centric model that positions the primary care physician as the team leader and coordinator of a patient's care. While a number of staffing models for PCMH delivery exist, physicians generally leverage the resources available to them within the current fee-for-service model. While many practices have implemented electronic medical records or patient registries, and some have incorporated integrated specialized resources such as diabetes educators, most are in the early stages of building an infrastructure and developing resources and capabilities on par with the established program offerings of a population health management company.

In contrast, population health management companies have built a vast set of tools and capabilities to extend reach, expand access, provide chronic care management, deliver preventive services, and proactively manage a population. Historically, population health management companies have not effectively integrated their programs with community physicians or leveraged physician resources and relationships. Their programs have been offered “on top of,” “in addition to,” or “instead of” physician-directed care. Their programs have not generally been integrated or coordinated with the care delivered and directed by physicians. As a result, they are unable to leverage the established doctor/patient relationship struggle to create engagement, and are limited in their ability to manage significant employer health care cost drivers effectively.

Collaboration instead of Competition

With employers having limited, if any, resources to fund these initiatives, the decision to implement both offerings may seem to be a financial nonstarter. But when one considers the current lack of coordination, potential duplication, and poor engagement, it becomes conceivable that implementing an integrated approach that leverages the strengths of both offerings may be a possibility.

There can be little disagreement that each model offers value from which the other can derive benefit. A PCMH or ACO model can enhance existing population health programs with several important attributes, including:

• An established and trusted relationship with patients

At the same time, population health companies have much to offer PCMH practices and ACOs, including:

• Telephonic and web-based solutions to deliver content, extend reach, and expand access to a wide variety of health and care management services.

Strategically combined, a physician-provided population health management program can incorporate the value of face-to-face interaction between patients and ambulatory care clinicians, while leveraging the capabilities and experience of population health management vendors. Integrating these components and delivering them in a coordinated manner can increase patient engagement and improve operational efficiency. As a result, this may well result in lowered operational costs for the combined offering, and have even greater potential to generate improved health care quality and clinical outcomes, as well as lower health care costs.

Getting from Here to There

An integrated approach that combines the PCMH model of care delivery with the resources and tools of population health management companies, while perhaps conceptually simple, necessitates that a number of barriers be effectively addressed. Several infrastructure changes are required, including a revised payment model that recognizes the contribution of each stakeholder to successful treatment outcomes. Additionally, a distribution and support infrastructure will need to be developed to link physicians to population health management vendors. Further, increased adoption and use of physician health information technology systems are necessary, along with data connectivity to facilitate data sharing between physicians and vendors. At the same time, operational questions need to be addressed, including identification of program managers, determination of ultimate accountability for their success, physician practice attributes to make this partnership work effectively and identification of PCMH practices or ACOs willing to adopt this model.

Conclusion

The integration of population health management company services into PCMH practices and ACOs can effectively increase patient engagement, leverage established resources, and increase use of remote low-intensity services. Combining the unique attributes of these different health care delivery offerings has potential to improve overall health care quality and outcomes and lower health care costs more than either of these entities can achieve alone.

But a continuation of the markets' current approach, which has generated and perpetuated artificial silos between seemingly competing health care delivery models, will only hinder this integration. This approach runs the risk of confusing employers, plan sponsors, and consumers; creating duplication of efforts and redundancy of services; and limiting program success. Ultimate success is largely dependent on the health care services ecosystem working together to combine the strengths of many models. We cannot afford to separate, segment, or silo our efforts, but must instead combine our efforts to develop integrated approaches to increase quality, reduce costs, and improve outcomes.