UPMC's Population Health Management Strategy: A Road Map to High-Value Health Care

Introduction

As the US health care industry transitions from volume to value, the need for comprehensive population health management (PHM) strategies continues to grow. Although reports suggest that the PHM market is still in its infancy, ¹ for decades integrated delivery and financing systems (IDFSs) have been working to achieve the Triple Aim ² of improved health, enhanced patient experience, and reduced costs among populations for whom they share risk. At UPMC, one of the largest IDFSs in the nation, all of the critical elements for PHM are in place: capacity to bring together clinical, financial, and operational data from across the enterprise; ability to provide actionable analytics for providers to improve efficiency and patient care across the care continuum; robust care management platforms to monitor and continually assess clinical effectiveness; a wide variety of services and programs to support high-quality, low-cost care and fully engage members in their own health and health care; and long-standing community partnerships to further support individuals in the context of their everyday lives.

Today, the UPMC Insurance Services Division (ISD) is the largest payer in Western Pennsylvania, providing health insurance products for more than 3.2 million members and 60,000 employers. Together with its provider partners, the UPMC ISD now has Triple Aim accountability for a considerable portion of the region's population. To support further scaling of its PHM activities, the UPMC ISD has designed a geographically-focused PHM strategy that seeks to optimally coordinate and integrate health plan resources with clinical and community infrastructure and to accelerate learning and innovation for UPMC and the broader health care community. Our combined focus on care management, provider partnerships, and community integration offers great promise for addressing the full spectrum of issues that impact population health. In this article we describe the principles and methods that shape this strategy. This information, along with future learnings resulting from our work, can help guide other health care systems seeking to better manage the health of their populations and achieve high-value health care.

Using Geography to Align Populations with PHM Teams

UPMC ISD's PHM strategy divides our primary catchment area into distinct analytically-derived geographic regions based on density of chronic disease burden and the types of chronic diseases represented in a region. Because the health of populations and costs of care are driven largely by chronic disease and its consequences, ³ organizing geographies around comparable burdens of chronic disease allows for tailoring PHM activities to address these key outcomes in any given region. All members within these regions are then stratified across the full continuum of health-risk strata, including high-, rising-, and low-risk groups. Additional strategic analyses are used to track and predict member engagement, identify low-resource areas relative to chronic disease hot spots, and surface other opportunities to target resources to achieve maximum impact on health outcomes and contain or reduce costs over time.

Multidisciplinary PHM teams composed of UPMC ISD care management staff, including nurses, social workers, educators, and health coaches, provide consistent and exclusive support for all members in their assigned regions with top-of-license practice prioritized across the entire team. Enhanced functionality of the UPMC ISD's integrated health management platform facilitates connectivity with all members within a region, allows for monitoring and addressing migration of members between health risk groups, and promotes information sharing and communication within and among PHM teams to minimize duplication of services and increase coordination of care. Teams are further supported by other departments from across the Division, such as data analytics, pharmacy, utilization management, and member services, among others.

Individual members are assigned a single point of contact on the PHM team who can answer questions and help link them to services and supports appropriate to their level of need. High- or rising-risk members, who also represent the best opportunities for PHM intervention, are identified for one-on-one care management. Emphasis is placed on incorporating member, family, and caregiver input and goals into the care planning process and engaging members in a variety of services and programs that facilitate care transitions, provide home-based telemonitoring and support, and/or offer timely access to community-based social supports and services as needed. Health promotion and prevention among low-risk members are supported through a suite of online tools and digital health resources as well as optimal coordination of health coaching, employer-, and other community-based programs. With line of sight accountability for their assigned members, the ability to develop closer, longitudinal member relationships, and a deeper understanding of the communities they serve, PHM teams are fully empowered to support individual members to make positive health choices and achieve population-based Triple Aim goals.

Ensuring Medically Appropriate and Cost-Effective Service Delivery

A key focus of the UPMC ISD's PHM strategy is to ensure that every member has a trusted relationship with a primary care provider (PCP) or other appropriate physician as needed. Over the past decade, UPMC ISD's patient-centered medical home (PCMH) and shared savings program have facilitated enhanced practice-based care management and transparent cost and quality performance across our primary care network. PCMHs are supported through UPMC ISD-funded care managers, care coordination fees, and monthly clinical reports with member-specific quality and utilization data organized into actionable member subgroups. If a practice meets preestablished quality and cost metrics, it becomes eligible to share in any health cost savings. More recently, the UPMC IDFS has been working to promote convenient 24 hour/7 day/365 days per year access to virtual care through its telehealth platform, which is staffed by providers and integrates e-visits with UPMC's electronic health record to maintain continuity of care with the member's PCP. UPMC ISD's Prescription for Wellness program, through which physicians can prescribe the health plan's coaching programs to patients and receive feedback on their progress, also assists with addressing the root causes of chronic disease and helps patients to better manage their health.

Because enhancing access to high-quality, cost-effective clinical care and actively diverting use of inpatient services for nonemergency conditions are critical to effectively managing population health and costs, the PHM strategy divides each region into microsystems comprising individuals and families who reside in the same neighborhoods and are attributed to a common set of PCPs and affiliated inpatient facilities. Within these microsystems, we will introduce a range of comanagement models with PCPs and hospitals that incorporate close collaboration with PHM teams as well as value-based payments and incentives aligned with our Triple Aim goals. Providers benefit from enhanced panel management capabilities, including technology-supported clinical care pathways for members with one or more chronic diseases, additional resources to address care coordination and transitions across care settings, and improved care quality and workflow. To further accelerate progress from volume to value across the care continuum, UPMC ISD and its provider partners also are engaged in a number of innovative care models and shared-risk arrangements, including behavioral/specialty health homes, a pediatrics accountable care organization, and bundled payments for clinically-defined episodes of care. Increased integration with provider partners will continue as we expand our use of value-based payment models and increase the number of providers in such arrangements.

Leveraging Community Partnerships to More Fully Address the Determinants of Health

Interrelationships among a broad range of personal, social, economic, and environmental factors influence the health status of individuals and populations. ⁴ Because these determinants of health reach beyond the boundaries of traditional health care and are largely impacted through the environments in which individuals are born, live, learn, play, work, and age, ⁵ UPMC ISD works closely with employers, schools, and other community organizations to improve the health of its members. Its incentivized workplace wellness programs help companies identify health risk factors in their employee populations and then support these individuals and their families in improved disease prevention, chronic condition management, and positive health behavior change. Onsite health coaching, including mobile or telemedicine service delivery, further transforms traditional in-house occupational health centers into fully-integrated sources of health, wellness, and preventive services. Other school- and community-based initiatives supported by UPMC ISD seek to improve the health of families and children through improved nutrition and increased physical activity, integrate health care and long-term services and supports for older individuals as well as those with physical disabilities, and provide supportive housing and access to medical care for the homeless, among others.

One of the strengths of the regionally-focused PHM strategy is the increased ability of PHM team members to establish and maintain a detailed and up-to-date working knowledge of resources in their region for addressing the determinants of health and to tailor strategies for managing the chronicity of disease and health outcomes of individual members who live in those regions. Over time, we plan to advance the sophistication of our community partnerships by developing the ability to share data on member service utilization so that both PHM teams and community organizations can respond more quickly with outreach and supports. These efforts could be further strengthened by offering a care coordination-like payment to community-based agencies that serve a large proportion of UPMC membership within a given region.

Rapid-Cycle Evaluation and Shared Learning to Accelerate Innovation

To evaluate the UPMC PHM strategy, we will track both process and short-, intermediate, and long-term outcome measures. We are particularly interested in learning not only how well the PHM strategy works to achieve the Triple Aim goals but also the extent to which implementation differs by region, which elements have a greater or lesser impact on achieving goals, and how staff activities and experiences in their roles change as a result of the strategy.

Using a UPMC ISD-supported learning collaborative approach, ⁶ quality improvement teams of PHM staff representing each microsystem will convene regularly to design rapid-cycle improvement tests for achieving implementation objectives, use data captured by the analytics and informatics infrastructure to inform future actions, and share learnings to spread innovations across multiple geographies. These tests will focus on targeted areas for on-the-ground improvements, such as gaps in care, transitions in care, and engagement and retention in relevant health and care management programs. Real-time monitoring of individual and population health outcomes will provide information needed for optimizing clinical programs and achieving organizational performance goals, including quality targets and regulatory requirements specific to individual lines of business. Through these processes we will iterate our predictive analytic models to identify and prioritize members for services, including integrating data on social determinants of health through our improved community partnerships, and work to continuously refine model implementation. As new learnings emerge, the strategy can be continuously adapted to support new initiatives, link with other parts of the business, and incorporate new tools and assessment points to further guide line of business and organizational decision making.

Looking Ahead

As efforts continue to optimize health system performance, innovation, learning, and improvement will be required at multiple levels and across sectors in order to achieve the Triple Aim. UPMC ISD's PHM strategy, which seeks to understand and improve the health of populations based on local needs and conditions, broaden the role of primary care and other community-based services, and promote rapid testing and scale-up, represents an important step in this direction. Clearly, substantial iteration and adaption of this approach, as well as others that are emerging across the industry, will be needed to hasten our collective progress along the road to value-driven health care. We look forward to sharing updates on our experience at UPMC, including the evaluation results of our ongoing implementation efforts as they emerge. Hopefully, this work will provide a useful road map for effectively managing the health of populations and achieving high-value health care.