Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Claims Management News

How Payers Could Improve Population Health Management with Tech

The insurer Healthfirst is using a health information exchange platform to improve its population health management strategy.

By Vera Gruessner

When payers transition their reimbursement structures toward a value-based care payment model, healthcare quality improvement needs to be addressed. In order to boost quality, payers could target population health management and data analytics when working with their provider networks. The New York City-based insurer Healthfirst has brought more focus to population health management by integrating new IT systems as well as a health information exchange platform.

Patient Care Management

“Healthfirst has always served New York’s most vulnerable populations, and our mission is to ensure they receive the best experience and highest-quality healthcare,” Rebecca Schwietz, Senior Vice President of Clinical Services at Healthfirst, told “Our quality ratings over the past few years show our investment in improving health outcomes for our members has paid dividends. We don’t have infinite resources, so our emphasis on analytics really helps us to deliver the right care at the right time for each member.”

Some of the difficulties that health payers and providers encounter in their health population management strategies revolve around patient outreach, care management, and coordination, Schwietz said. The problems behind care management revolve around having an excess of coordinators and patient navigators that do not have a clear form of cross-communication and may duplicate social services for their patient base, according to The New York Times.

“As a health plan founded by many of the hospitals and hospital systems in New York City, Healthfirst has had a close relationship, and a value-based payment model, with our providers for over 20 years,” Schwietz continued. “One thing that I see these days is that there is a general push by parties throughout the healthcare industry towards outreach, care coordination, and care management. Providers do care management as part of a Patient-Centered Medical Home (PCMH), there are community-based care management and navigator programs, and health plans also provide care management services.”

At some organizations, an excess of staff may be working to target coordination and patient outreach. As such, many efforts on behalf of the care managers may overlap. Health payers may need to work with their accountable care organizations or patient-centered medical homes to assign specific staff members to work with certain at-risk patients.

READ MORE: Why Value-Based Care Reimbursement Needs Risk Adjustment

“Two important questions to ask (and answer) are: ‘Which members need care management support?’ and ‘Who is best positioned to provide that care management?’ Because members and their needs can change quickly, coordinating these two answers so that you can execute on them in a timely basis can be really challenging,” Schwietz explained. “We haven’t yet found the silver bullet here, but we are constantly working to improve our coordination with the many aspects of the healthcare system that supports our members.”  

One way that Healthfirst has improved the care coordination aspect of their population health management is by implementing new technologies. The payer uses a health information exchange to share data between primary care providers, hospitals, and specialists.

Having this data allows care managers to cut down on duplicative efforts as well. Additionally, Healthfirst adopted a population health management platform earlier this month that allows the payer to address member and provider needs in a more streamlined manner, according to a company press release.

“We are focused on improving the timeliness of our interventions with members and providers,” Schwietz added. “Our investments in a Health Information Exchange have helped us in this regard - we no longer have to wait for a claim to be sent to us in order to know that a member visited one of the emergency rooms in our network.  That timely information means that we can call the member the next day—or even that afternoon—to see if they need further help.”

Payers can also use technology to assist patients during hospital discharges. Data systems can show payers which members need reminders to see their doctor for an annual check-up as well.

READ MORE: Top Three Ways Health Information Exchange Benefits Payers

“We are constantly looking for ways to improve our identification of members who need a nudge to get their annual wellness visits, or who need an extra helping hand as they transition out of the hospital,” Schwietz said. “One aspect of this is looking for better ways of predicting which members need this help – we want to make sure we are really helping, and not just nagging!”

Incorporating technology to enhance care coordination and population health management has led to significant improvements for this health insurance company. With regard to Medicaid and Child Health Plus Managed Care, Healthfirst has attained four stars for child and adolescent care and five stars for women’s preventive care, adult care, and diabetes care. Schwietz also mentioned that their provider networks have shown a reduction in preventable hospital admissions and increasing screening rates on a yearly basis.

“We are very proud of our Quality ratings: 2017 will be our third year in a row as a 4-Star Medicare plan and as a 5-star plan in the New York State’s Medicaid quality rankings. What makes me even more proud is that we are constantly improving,” she asserted.

“Every year, our members have better adherence to their medications, have fewer preventable admissions, and have a higher rate of screenings for preventable conditions. The recognition of the quality ratings is really important—for our staff as well as for our members—but I love the spirit of ‘we need to keep doing better for our members’ that permeates the Healthfirst culture.”

In order to reach similar patient outcomes, some vital advice for other payers as they attempt to boost their population health management strategies involves improving transparency and data sharing with their provider networks, said Schwietz.

READ MORE: Key Steps for Payers to Improve Population Health Management

“The most important ‘wins’ for us in both population health management and value-based care have involved being very transparent about our data and our analyses with our provider partners. It helps when everyone in the system—the plan, the provider, and the member—are all are pulling in the same direction,” she concluded. “Sharing data, as well as the accompanying back and forth debate around that data, has helped us clean up many of our processes and systems over the years, and I’d like to think that our provider partners have benefitted from this dialogue as well!”


Dig Deeper:

Key Steps for Payer Success in Accountable Care Organizations

Time, Commitment Required for ACO, Value-Based Care Success


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