A New Healthcare Era: Value-Based Care Success Rests on Automating Population Health Management

By Gary Hamilton

The Quality Payment Program (QPP) within the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 is another shift in the healthcare industry toward value-based payment and away from fee-for-service. As with the programs it is replacing – Meaningful Use of EHRs, Physician Quality Reporting System (PQRS) and Value-Based Payment Modifier – an organization’s success requires an emphasis on population health management (PHM) and patient engagement.

What’s encouraging, and perhaps surprising to some, is that most healthcare professionals believe they are prepared for MACRA requirements and the QPP’s Merit-based Incentive Payment System (MIPS), according to results from a recent survey conducted by our company. However, believing you are prepared and actually taking the necessary steps to improve financial performance are quite different concepts.

Evidence of this lack of preparation can be found in another question on our survey which shows a large portion of healthcare professionals are unsure of the payment ramifications of MIPS and lack technology to automate clinical interventions. It seems there are major gaps between perception and reality.



To maximize the payment incentives, provider organizations need to look beyond the narrow requirements of MIPS and instead at their broader patient engagement and PHM strategies. They should pursue workflows and technologies that will help high-risk groups manage their health, increase treatment plan adherence and decrease high-cost care utilization. The most helpful technologies would enable the many components of PHM, such as data aggregation, targeting patient populations, and implementing outreach and interventions, to achieve desired outcome goals.

Prepared, but unsure of payment impact

Our MACRA MIPS survey of 800 healthcare professionals found that participants were highly confident regarding the value-based payment program. For example, 90 percent of survey participants believe they are up-to-date on all MIPS and MACRA legislation as it pertains to them and nearly 90 percent believe they can meet MIPS requirements.

Despite this confidence, 40 percent of survey participants reported they do not understand or are unsure about oncoming payment adjustments that will be made by the Centers for Medicare and Medicaid Services (CMS) based on providers’ performance. In fact, 50 percent of respondents were not aware that the 2017 payment difference between maximum negative and exceptional performance is 26 percent. It is clear that providers understand what the goals are for the MIPS program, but are unsure how to get there.

At its core, superior performance on MIPS or any value-based payment program requires redesigning PHM workflows using advanced analytic technology. Such a platform needs to offer care managers and other providers with reliable data-based guidance to initiate preventive interventions. This real-time insight will allow care managers to easily identify care opportunities among their high-risk populations and take effective action.

Not only will avoiding an adverse health event among these populations improve outcomes, and likewise MIPS Quality category performance, it will have positive effects on the Cost category as well, which will account for 30 percent of the MIPS score by the 2019 performance year.

Technology implemented, but limited

Automating interventions is becoming a critical piece of PHM to reduce the significant resources required to analyze data and conduct outreach. Currently, a care manager can spend approximately 40 percent of their time just searching for patient data, with an industry average of 130 minutes per patient for care management. As demand for care continues to grow, particularly among the large, but aging Baby Boomer population, that level of time investment for one patient is simply not sustainable. And with that additional growth demand, organizations cannot be expected to maintain a low standard 50:1 to 100:1 care manager-to-patient ratios for high-risk care management programs.

Streamlining the data aggregation combined with technology that continuously analyzes data and initiates communication with the patient will eliminate the manual efforts that burden PHM today. To ensure outreach is most targeted and efficient, pre-set personas for risk groups can be created based on the organization’s clinical and financial goals. More importantly, such technology delivers consistency and predictability for patient interventions, an essential component to modify patient behavior and yield successful outcomes.

Simplifying population health complexities

Succeeding in MACRA’s MIPS program requires the next stage of PHM capabilities. Provider organizations need to advance beyond reactive care strategies for high-risk populations and begin leveraging technology to prevent patients from reaching those levels.

With the right patient engagement and PHM technology, predicting behaviors and outcomes and launching interventions can be automated, efficient and effective, reducing time and labor for the provider while also reducing costs and improving outcomes. Both the internal efficiencies and the positively trending patient outcomes will positively benefit MIPS performance and its associated incentive payment.

About the author:

Gary Hamilton is chief executive officer of InteliChart.

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