In my previous blogs I have outlined the need for providers to develop customer relationship management and patient relationship management capabilities which includes understanding the consumer’s perspective on health and the healthcare system. Currently providers are focused on understanding an individual’s clinical risk profile but it is important to integrate an individual’s attitude and activation level on managing their own health. This will help providers develop the appropriate clinical care models to support an individual’s healthcare need. .
As providers take on more risks, they are developing clinical risk profiles from an individual perspective – who is at the greatest risk from a utilization and cost perspective? And from a population perspective, what are the condition- focused programs I need to develop? The goal is to lower costs through a proactive patient outreach model leveraging a care management team.
Traditionally, provider and payer risk segments focus on low, medium and high risk; or healthy, chronic and catastrophic with clinical interventions focused on the highest risk. But these segments limit a provider’s ability to allocate clinical and financial resources to manage costs over the long-term.
As part of consumer and patient relationship management, providers need to refine the population and individual risk segment allowing the appropriate investments in clinical resources and care models. These new population segments need to think across the risk continuum of care and conditions but will ultimately define the appropriate care model to support the individual. The population health segments can include:
- Healthy – No or one risk factors
- Modifiable At-Risk – Identification of two risk factors such as Obesity, Stress, Occupation
- Early Stage Onset – Below 75% of medical spend with one traditional condition – Diabetes, CHF, Asthma, CAD, COPD
- Complex Acute – Top 5-10% of medical spend without a define condition/disease
- Complex Chronic – 10-25% of medical spend with one or more conditions/disease
- Rare High Cost Conditions – Diagnosis such as AIDS, ALS, Rheumatrol Arthritis, Hemophilia, Parkinson’s
- Behavioral – Diagnosis with behavioral issue with no other condition/disease
- Poly-Chronic – Top 2-10% of medical spend with one more condition/disease
- Catastrophic – Top 2% of medical spend with one or more conditions/disease
For example: an individual with rare condition is managed by a specialist and typically has a high pharmacy spend. A care model that puts the specialist as the primary physicians can ensure the individual is supported and managed by the right team of providers. Or the individual in the modifiable at-risk segment who is best supported by the patient centered medical home model with a health advocate providing the help needed to proactively manage the risk. While individuals in the catastrophic segment, especially seniors, can benefit from an extensivist care model
As part of the analysis the segments need to evaluate from both a total population level and a market-based level (Medicaid, Commercial HMO, Commercial PPO, etc.) The percentage of the population, average per member per month cost (PMPM), average predictive risk score and percent of total spend. This ensures the provider creates the optimal balance of investments to ensure long-term and measurable quality, patient satisfaction, clinical risk and financial improvements.
In my next blog I will address how the intersection of clinical risk and an individual’s attitude towards health and healthcare can help support the right care models and outreach models.
–Cynthia Kilroy, Sr. Vice President, Provider Strategic Initiatives, Optum