But the general consensus on population health management ends with that basic concept. There are so many different groups of patients to cover and multiple stakeholders bearing some kind of risk that nearly every model takes a different approach. Whether an insurer sees the greatest incentive to manage a patient or a physician pitches in on a shared savings model, each entity has its own perspective on how to best help patients navigate the complicated, often duplicitous health system.
Each group trying to take the lead on risk management has its particular strengths and weaknesses. And yes, true long-term success will likely come from a model that capitalizes on all of the strengths that different partners bring to the table. But ultimately, someone has to play lead fiddle.
To get closer to an answer as to whom is well positioned to call the shots while managing patients, we asked executives from both sides of the payer-provider aisle and beyond a simple question: Who is — and who should be — the quarterback of population health management partnerships, leading the team and making adjustments as the game develops?
Here’s how they answered:
The insurer: Onlife Health, Danny Timblin
Wellness solutions company Onlife Health is a subsidiary of BlueCross BlueShield of Tennessee and the Brentwood-based organization engages patients with a toolbox of population health management services for national health plans. Onlife President and CEO Danny Timblin says that, despite the often contradictory relationship between payers and providers, insurance companies hold the key to population health.
“I think the payer is best equipped, even though they’re often seen as a financial player,” Timblin says. “Now they’re morphing into more of an ‘air traffic controller’ role, where they can see the network, see what’s being coordinated. They’re the best person to have that holistic view of the patient and their interactions with providers.”
A traditionally contentious relationship between payers and providers could be a roadblock to health plans’ efforts to manage patient groups, but Timblin says that mistrust can be overcome.
“The payer needs to be seen as a true partner in the equation instead of a claims prevention service,” he says.
With a wide-lens view of a patient’s physician visits and prescriptions, some insurers make the argument that their data is more comprehensive and useful for care management than the info collected by physicians who may or may not be able to access records from other specialists or see which prescriptions have been filled. Not to mention, by having the final say on patients’ bills — the role that helped earn them that ‘claims prevention’ reputation — insurers carry a lot of financial risk, which could give them the greatest incentive to meaningfully impact costs in the long term.
The provider: Nashville General, Kimberly Lamar
Insurers certainly carry a lot of fiscal risk, but so do providers who face a challenging reimbursement environment. As the city’s safety net hospital, Nashville General Hospital has long had to carry a larger share of indigent care than other systems in the area.
This year, the city hospital added Kimberly Lamar to lead its population health initiatives. Lamar says the facility’s “unique” financial position and largely underinsured population might be just the incentive risk management needs to succeed at the hospital level.
“I think we’ll take the lead and be in a better position,” Lamar says. “We’re providing service to this population that is primarily indigent, and what we’re challenged with is getting high-cost patients to a lower cost and save those dollars we’re not being subsidized for. We’re finding a model with which to save ourselves.”
Nashville General sees a younger population with chronic conditions than other systems in the city, Lamar says. The demographic differences means the hospital has to be creative in its interventions, as they aren’t focused directly toward the traditional Medicare population — or even an insured population at all.
Dr. Joseph Webb, CEO of Nashville General, says population health is an “all-hands-on-deck” situation. But when it comes to the quarterback question, he feels differently than his payer counterpoints. He says that providers have more touch points with patients than insurers or other industry players.
“When you look at pre-acute, acute and post-acute care, there’s not another entity out there that does what the care delivery system does,” Webb says. “A pharmacy, a third-party payer — none of those are going to be as equipped to engage in population health management as a hospital or provider system.”
The employer: Premise Health, Stuart Clark
Brentwood-based Premise Health believes patients are the most important piece of the population health puzzle, but their approach is based on the incentives of self-insured employers. The company’s executives have built their model on changing patients’ behavior by meeting them where they are. For most of us, that’s at work.
Premise Health operates onsite health clinics for large, self-insured employers across the country, and CEO Stuart Clark says being able to tailor wellness approaches to specific company cultures and health insurance benefits allows his team to better engage patients and improve outcomes.
“A group practice might have 4,000 employers or payers, but we have one employer, one culture and one payer,” Clark says. “We can get very focused on the individual patient and determining their needs.”
In addition to providing onsite services for basic health needs for employees and their families, Premise Health also plays a role in the greater health system. Clark calls the company’s approach patient advocacy and his team assists in connecting patients to the right community resources. Given Premise’s relationship with the employer — which in this case is also the payer — navigating the system becomes less complicated.
“We don’t do MRIs, but we’re not just going to tell you where those providers are,” Clark says. “We’re going to book your appointment, make sure it’s in your network and our doctors are going to get those results.”
Large employers are seeing the benefits of taking health care costs vertical and managing them internally. But without health care expertise and infrastructure, the companies need a partner, and Premise Health is paid based on results.
“We’re not going to continue our relationships with these large, sophisticated customers unless they see the needle moving,” Clark says. “Our industry has always been held accountable for containing costs. The rest of the health care system has never really been held accountable in that fashion, but that’s where onsite health clinics have been living for the last decade.”
The community: NashvilleHealth, Caroline Young
One of the tenets of wellness is that population health interventions cannot occur solely at a physician’s office. In order to improve patient health significantly, clinicians have to find ways to serve populations outside of the walls of the health system.
By pulling in faith groups, government entities and other philanthropic organizations, community health efforts seek to serve people in and around their interactions with clinicians. By supporting patients as they navigate their day-to-day lives, these efforts seek to break down structural and social barriers to wellness.
NashvilleHealth, founded by former U.S. Senator Bill Frist, is a new community-based initiative focused on the population health and wellness of Davidson County residents. The program was launched under the umbrella of the Community Foundation of Middle Tennessee and counts the Vanderbilt University Department of Health Policy and the Metro Nashville Health Department as partners.
“It’s looking really broadly at how much of people’s health is impacted by social behavior, and that there are many things to affect that from a clinical perspective,” says Melinda Buntin, chair of VU’s Department of Health Policy.
NashvilleHealth is still in development but will feature three pilot programs focused on hypertension, smoking and child health. Another key partner in the effort is the Nashville Area Chamber of Commerce, which conducted a health study comparing Nashville to peer cities, says NashvilleHealth Executive Director Caroline Young.
“We looked to see if they found the same health issues, and they did, so we feel like we can springboard off of that and set the stage of more community-wide dialogue on these issues,” Young says.
Buntin says community population health efforts demonstrate that an increasing number of stakeholders are seeing wellness opportunities.
“When you hear insurers or systems talking about keeping populations healthy — that there are things that they can do apart from encounters between patients and clinicians — that really is a big change in thinking,” she says.
Illustration by Taylor Callery
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