Population health management

1. Population health management Insight in the definitions and some considerations for evaluating HW Drewes, CA Baan, JN Struijs

2. Background Integrated care for diabetes is introduced in Netherlands since decades. The fragmentary funding hampered the establishment of long-term programs on a national level. In 2007 a bundled payment (BP) approach was introduced in the Netherlands to stimulate integrated care programs.

3. Background (II) Early results of Dutch BP model: Slight to modest improvements in patient outcomes (Struijs et al., 2012) Lesspatientsenrolled in a care program on the basis of BP usedhospital care (Mohnen et al, in preparation). BP resulted in anincrease of curative health care costswhich is mostlytoanincrease of hospital care costsand the initial investment costs of the BP model (Mohnen et al, in preparation). New payments reforms underway: global payment models and shared saving models Unclear what these newly introduced payment reforms aim

4. The concept of population health management (PHM) Relevant questions: What is it? PHM ≠ disease management / integrated care What are the goals/aims? What are key elements? Etc. Why important? Input for the (Dutch) discussion regarding the new payment reforms To evaluate the PHM appropriately To be able to align the (financial) incentives

5. Conducting three systematic reviews (work in progress) Three searches Definitions of PHM Conceptual models of PHM Existing evidence of PHM interventions (including methodology)

6. Systematic review definitions of PHM (work in progress) Search strategy: Search terms: Population health management or Population management or Populatiegezondheidsmanagement (dutch) Search engines: Embase/ Cinahl, Pubmed and Google scholar

7. Systematic review definitions of PHM (work in progress) Total number of hits: 228 Excluded: PM of PHM nietmentioned in title/ abstract: 164 Full-text : 64 Excluded: Duplicates: 8 PHM for animals: 7 Else: 3 Included in review: n=46 19 papers defined PHM/ PM

8. Some examples “a proactive, organized, and cost-effective approach to prevention that utilizes newer technologies to help reduce morbidity while improving health status, health service use, and personal productivity of individuals in defined populations” (Chapman and Pelletier 2004) A PHM program strives to address health needs at all points along the continuum of health and well-being through participation of, engagement with and targeted interventions for the population. The goal of a PHM program is to maintain or improve the physical and psychosocial well-being of individuals (Care Continuum Alliance, 2010) PHM programs combine interventions that focus on patients with specific chronic conditions (disease management) or very high cost irrespective of the cause (case management) with so called wellness components that are aimed at using health risk assessments (HRAs) to identify unhealthy behaviors (eg. smoking, lack of exercise) or risk factors (eg.elevated blood pressure) to prevent the development of chronic diseases

9. 8 aspects of PHM Motivation/ trigger Goals Risk stratification/ segmentation Population Involved sectors Type of prevention Components of PHM (coordination, self-management support, follow-up, focus on the patient’s role versus professional’s role) Role of financial incentives

10. Results: key aspects of PHM Motivation/ trigger All papers in which PHM is defined: the financial sustainability of the health care system So, not the ‘bad’ population health was the occassion Goals 4 goals mentioned: Improve quality of care / patient experience Improvements of population health Reduction in cost increase Improvements in productivity (US) Corresponding with the Triple Aim articulated by Berwick

11. Results: key aspects of PHM definitions Defined population Roughly defined by: Geographical region Insured population Enrolled in program or registered by care provider Subpopulations defined: Diseases; chronically ill, diabetes type 2 Care consumption (for instance hospital admission) Risk profile (for instance CVRM)

12. Results: key aspects of PHM definitions Risk stratification Most of the papers mentioned risk stratification or segmentation as one of the aspects of PHM.

13. Results: key aspects of PHM definitions Risk stratification

14. Results: key aspects of PHM definitions Defined sectors involved Health care system Public Health / prevention Social care Wellness sector Employers Variety in involved sectors: Always : health care, prevention Sometimes: social care and wellness sector Variety in initiating sector

15. Results: key aspects of PHM definitions Focus of PHM Mostly population focus (instead of patient level) Some definitions: Focus coordination and risksegmentation, Unclear in many definitions: patients role versus professionals role

16. Results: key aspects of PHM definitions The role of prevention Prevention explicitly mentioned in all definitions Variation in forms of prevention Universal Selective Indicated Care related

17. Results: role of financial incentives not as prominent as expected; clear distinction between concept and payment models Yet, ACOs mentioned in some papers as facilitators for PHM. No insight in which incentives are needed to achieve specific PHM goals.

18. Conclusions Wide variety in definitions but some ‘lessons’ possible: Motivation/ trigger and formulated goals are not truly in line Consensus about the theoretical concept on certain elements: triple aim, segmentation (and the focus on population); PHM is not radically new; it is a combination of many already studied initiatives such as prevention and disease management. Risk stratification based on patient’s need is (probably) a distinctive key element A clear distinction between concept and payment models Definitions differ from the daily care practice and the concrete interventions (and vary substantially) GOOD EVALUATIONS CRUCIAL

19. Some preliminary lessons to evaluate PHM • Interventions vary substantially:combine quantitative and qualitative methodologies to gain true insight in the mechanism and essential process and intervention chracteristics. • The expected cost reduction due to productivity gain is expected to be a three fold of the health care costs  include productivity in the evaluations (outcome measure?) • Some evaluations models are already available (for instance evaluation model of Care Continuum Alliance): so not reinvent the wheel!

20. Thank you for your attention E: jeroen.struijs@rivm.nl M: +31 6 46312583