Seeking ROI With PHM
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Plus, he says, until the healthcare system makes the full shift from fee-for-service to fee-for-value, Cornerstone's approach to population health is turning a profit in the current reimbursement environment. Walker says the advocate program, based on a financial analysis of office visits and ancillary income associated with those visits, returned $216 per kept appointment. And while Walker would not say how much the platform cost, he did note that even including the cost of the software, the medical home "would still be profitable in 2011."
Walker says the group is now talking with payers about how the advocate program and medical home can be applied to shared savings programs.
While Cornerstone launched its medical home program in tandem with a new platform, programs such as QualChoice's took longer to arrive at that conclusion. At the beginning of its PHM program, QualChoice tracked patient populations manually and provided monthly progress reports (with month-old data) to providers. While the manual process worked, Armstrong says it wasn't the best approach for catching patient problems in the early stages.
Ultimately this year to help it aggregate data for comparison and improve care-related communications between the payers and providers, QualChoice installed an integrated healthcare management system from TriZetto called Clinical CareAdvance 4.7.
"We wanted to look at those patients who are in the ambulatory [setting] all the time and understand how they become part of the ambulatory metrics," says Hopkins. "We also want to focus on those with diabetes, and to follow the patients with high blood pressure to make sure that these patients aren't developing worse problems. You need to look at all the data."
QualChoice's new platform will automate the process of managing members' chronic illnesses as well as the continuum of care including case, disease, and utilization management, and allow it to use clinical resources more effectively, explains Armstrong.
"As we pioneer our program, we have to help the practices get accurate, on-time information about the patients," says Armstrong. "Real-time information about the high-risk members can help the organization spot the gaps in care and improve collaboration," he notes.
This article appears in the June 2012 issue of HealthLeaders magazine.
Karen Minich-Pourshadi is a Senior Editor with HealthLeaders Media.
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