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Population-health management (PHM) is one of the most important directions in modern health care and a key driver behind the promise of value-based care. Unfortunately, many PHM programs treat populations as a homogeneous whole rather than a collection of heterogeneous individuals. It is important to remember that even when people have the same diagnosis or suffer from the same comorbidities, they are dealing with vastly different socioeconomic, cognitive, and environmental factors that influence how, when, and where they get health care.
Health care organizations are making strides with PHM by improving risk stratification and fine-tuning quality measures. Those are important first steps.
But many PHM strategies fall short because they fail to address three critical components that relate to patient-centeredness.
PHM strategies that succeed assess and account for cognitive factors that affect patients’ ability to understand their health needs, care goals, and recommended interventions. Does a patient have the cognitive ability to support his or her care plan? Does she or he have the knowledge necessary to understand not only what constitutes a care plan but also why and how it can be followed? Gaining this level of insight requires structured and timely interaction with the patient. Both must be embedded in the care management fabric of the PHM program.
Only after there is a clear picture of a patient’s cognitive skills and knowledge base is it possible to provide the patient with the appropriate level of educational information and outreach. If people truly understand their care plans, adherence improves and better outcomes are more likely.
Imagine two 60-year-old male patients who have recently been diagnosed with type 2 diabetes. One has a strong family support network, lives within walking distance of his primary care physician and pharmacy, and has a computer and high-speed internet access. The other lives alone, doesn’t have a convenient way to get to his physician or pharmacy, and does not own a computer.
Many PHM programs would put these patients in the same category based on claims data. But clearly the level of support required by the man who lives alone is far, far greater than the other man. PHM shouldn’t be used as an excuse for fuzzing over important differences like this.
Meanwhile, the boundaries of what’s considered health care are expanding. By incorporating social and environmental indicators into the PHM strategy, health care organizations can identify the supports individuals need. One-size-fits-all never was and never will be. Instead, the goal should be for everyone to have a size that fits.
Many Medicaid managed care organizations have member portals—and nearly all of them have members who rarely, if ever, use the portals. The reason is remarkably basic: Most people in Medicaid plans use smartphones rather than home computers to connect to the Internet. Smartphone apps, not web-based member portals, is the way to serve Medicaid plans and their members.
By identifying how patients are willing to engage, PHM programs can procure and configure technology that optimally support these preferred engagement channels. In turn, these expanded lines of communication between care teams and patients can ensure the timely flow of information and education.
Each of these three components is absolutely essential for population health strategies to work. If there’s an overall lesson here, it’s that health care organizations can’t just measure a few quality metrics, tinker with them, and call that population health.
The population is the patient in population health. But improving that patient’s health means working at the individual level to change the behavior of individuals.
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