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Population Health Reimbursement: What Providers Need to Know

July 17, 2018

population health reimbursement

What is Population Health (PH)?

More than 50 percent of all deaths each year are caused by stroke, cancer and heart disease.Population health became a concern for providers and payers due to the need to rein in the incidence and subsequent costs of treating chronic diseases as well as a shift from fee-for-service to value-based care models. It has been recognized by CMS and others for some time that fee-for-service (FFS) is becoming unsustainable, whether from a financial or medical view. For example:

  • Chronic diseases account for 7 out of 10 deaths yearly among Americans.
  • Diabetes, one of the most common chronic illnesses, is the main cause for kidney failure, lower-limb amputations and blindness in adults between 20 and 75.

Clearly, something needed to be done, both in terms of costs as well as improving patient wellness outcomes. Making the switch to value-based care also involves a fairly broad concept known as “population health management” and can be as varied as coaching diabetics in making dietary improvements, phoning and online communications with patients over disease-management medications, or educating parents on children’s car seat safety.

  • How PH has changed over the past 15 years: 

The healthcare industry is still defining the meaning of PH for a more updated description. Consider that since its original descriptions in 2003 as “the health outcome of a group of individuals, including the distribution of such outcomes within the group” the industry has undergone numerous changes. While outcomes are still primary to any definition, the advent of data analytics coupled with performance-based financial considerations have vastly widened the scope of the PH landscape.

  • The role of value-based care with PH in cost reduction:

Shifting care from facilities to community and home-based care settings would save as estimated $34.7 billion over a 10-year period, according to a report from the Alliance for Home Health Care Quality and Innovation concerning the Clinically Appropriate & Cost-Effective Placement Project (CACEP.)

Why Population Health Matters to Payers As Well As Providers

  • Payers look to save money in both short and long-terms with reduced pay outs with better quality of care outcomes.

An increasing amount of data suggests that chronic disease  can be reduced by good PH management, as well as avoiding incorrect usage of services, improving patient quality of life – all while helping providers meet their goals for value-based reimbursement.

  • Physicians have real concerns about the switch from FFS to value-based reimbursement:

For providers concerned about the effects of switching from FFS to value-based care on their reimbursement rates, frustrations arise when providers are unclear as to what type of data as well as the kind of metrics and reporting required by payers.

Teaming up with payers into value-based models often requires physicians to assume more financial risk, whereas payers in FFS have taken on more risk.Therefore, payers would be advised to move slowly when transferring financial risk, moving more incrementally to allow providers to refine and advance strategies for value-based care management.

  • Payers are beginning to understand that providers also have their own goals for quality improvement, so working with them to line up payers’ quality measures with provider-network goals can facilitate the transition to value-based care for everyone.

Information about Population Health reimbursement do providers need from payers?

These can be financial, clinical or a combination of both, such as reducing the number of diabetics with uncontrolled blood sugar.

  • How will they pay?

Payers are becoming more creative, coming up with various kinds of incentives, bundled payments, bonuses for reaching quality goals and payment adjustments. Upside and downside risk models are becoming the most common payment structures.

Data is critical for tracking and assessment of population health, but because it can be fragmented and difficult to piece together, especially if sourced from clinical notes, there needs to be a better definition of what is required by payers, as well as sharing between providers and payers. It’s important that “the right kind of data is provided to physicians”, says Mark Wager, Heritage Medical Systems’ President. “…They need data for whole populations of people across a hospital service area and across the population that a payer may contract for.”

  • How will payers evaluate population data?

Payers need to analyze patient PH data to determine which types of care and preventive services are needed from providers, with results forwarded to appropriate medical for patients’ needs. Some of the strategies used by payers may include risk stratification as well as population health analytics developed to identify and track patient and group data.

  • Providers should be asking:

Do we fully understand how data timeliness, quality, accuracy and completeness affect population health management activities?

Have we assessed our data integrity’s baseline as well as competencies of the analytics used?

Finally, do we have the skilled staff available to handle these data challenges? Could we be working with a consultant?

When providers and payers agree on the framework for PH outcome measurement, have data to support improvement, with a common vision of success, both groups can achieve a positive impact on costs, quality and outcomes.

The reimbursement advantages of working with a claims management and billing service

While providers don’t take any reimbursements for granted, the latest regulations and other changes have created more even urgency to keeping up with the latest developments in AI, analytics and the latest EHR.

Thanks to M-Scribe’s years of experience working with different platforms and more recently, our partnering with many of the industry’s top medical software and EHR companies, compatibility and interoperability issues that often hinder data access will be one less thing to worry about.  Regardless of which software systems you may use, our technological team can get on board without training or other delays.

Contact M-Scribe at 888-727-4234 or by email to learn how we can help you reach your value-based goals while increasing reimbursements.


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