TriZetto Expert: Population Health Management, Informed by Clinical Analytics, Can Bend Cost Trend and Improve Outcomes

DENVER, Oct 13, 2011 (BUSINESS WIRE) — The TriZetto Group noted with interest a Health Affairs article in July reporting that national healthcare spending was expected to increase from 17.6 percent in 2010 to 19.8 percent in 2020, as economic recovery spurs higher utilization and an estimated 30 million additional people receive health insurance coverage under the Affordable Care Act. It is also expected that this group of consumers will have a higher incidence of chronic disease and untreated conditions. Further, chronic disease rates continue to rise throughout the population, notwithstanding disease and care management programs administered by the healthcare industry.

With the influx of these high-risk participants, healthcare payer organizations are thinking about how they can positively influence the health of the larger population by improving the health of their own membership. Care management can help health plans improve population health and control medical costs, and clinical-analytics capabilities are necessary and core to managing costs in a meaningful way.

“Old” vs “New “

The ‘old’ model of care management — the way it’s traditionally been thought about — is defined by a single patient view. A health plan knows the condition of a member based on claim activity and begins disease or care management activities to mitigate future complications and the possibility of major expenses. While such individual interventions can be effective for both member and payer, they cannot improve the health of members on a larger scale, across one or multiple group cases. Typically, traditional, reactive care-management programs have been ineffective in managing medical costs for lack of early intervention and appropriate, clinical plans for improvement.

What is needed is a new, broader, more anticipatory approach to population health management. Under this approach, healthcare payers would stratify group populations by risk, identify prevalent or high-cost conditions, and approach members for participation in disease-management and care-management programs prior to clinically or financially adverse health events.

Recent advances in technology and modeling have helped vastly improve payers’ capabilities in population health management. New, proven technology — clinical analytics — can give health plans the proactive, stratified views of populations that is requisite for clinically beneficial care management and highly effective new models of care delivery, such as patient-centered medical home (PCMH), accountable care organizations (ACOs), value-based benefits and value-based reimbursement.

Raw Data is no “Field of Dreams”

The challenge has never been about insufficient data. The necessary data, and lots of it, is there. But raw data alone is no ‘Field of Dreams’; meaningful information for impactful population health management does not automatically spring from data. That’s where analytics comes in.

Payers recognize this. A TriZetto research study conducted by Gantry Group in late 2010 shows that within two years every health plan will be investing in and using some form of clinical analytics to inform population health management programs. The number one reason? To reduce incurred medical costs. The second and third reasons, respectively? “To improve clinical and financial outcomes for co-morbid conditions” and “to improve member compliance with evidence-based care protocols.”

Healthcare payers clearly understand business intelligence is the foundation for reversing the trend of medical spend. Having robust analytics capabilities can help health plans:

— Maximize their ability to identify and stratify members for incentives

— Interpret data to derive meaningful information for use in automating decision making for improved administrative efficiency (e.g., automatic enrollment into programmatic interventions)

— Demonstrate and evaluate outcomes through deep, extensive reporting capabilities

There’s the story of Henry Ford’s comment when a finished car rolled off the factory line. Ford said, “There are exactly 4,719 parts in that model.” While most on hand were impressed that the company president had this fact at his fingertips, an engineer nearby remarked, “I can’t think of a more useless piece of information.”

Useful, accurate information — in the right place and at the right time in the healthcare system — is required for effective population health management. The good news is that technology-enabled solutions, informed by meaningful clinical analytics and available today, can meet this requirement for healthcare payer organizations large and small.

A point-of-view paper by Jerry Osband, M.D., vice president of product management for The TriZetto Group, Inc., served as the basis for this issue brief.

About TriZetto

TriZetto provides world-class healthcare IT software and service solutions that drive administrative efficiency, improve the cost and quality of care, and increase payer and provider collaboration and connectivity. TriZetto solutions, many of which are patented or patent-pending, touch half the U.S. insured population and reach more than 21,000 physician practices. TriZetto’s payer offerings include enterprise and component software, application hosting and management, business process outsourcing services and consulting. Provider offerings, delivered through TriZetto’s Gateway EDI wholly owned subsidiary, include tools and services that monitor, catch and fix claims issues before they can impact a practice. TriZetto’s integrated payer-provider platform will enable deployment of promising new models of post-reform healthcare. For information, visit .

SOURCE: TriZetto


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