Population health management must transcend claims, medical records

Insurers and healthcare providers need to look deeper into data beyond claims and medical records to get to the heart of population health management, said two experts who spoke during the America's Health Insurance Plans Annual Institute & Expo in Austin, Texas, this June. 

For example, patient data on education level, the number of children in a household, commute times, ethnicity, access to care, affluence and social media use all play a big role in understanding a population, according to Jeff Margolis, CEO and chairman of Welltok in Denver, Colorado.

"All of these things are much more important as far as getting a more personalized experience," Margolis said. "The determinant of health status and genetics is only 30 percent of what drives (health). Other factors are lifestyle and environment."

Adverse changes, such as losing a job, living conditions and socialization are big determinants of health, said Rick Ingraham, director of Vertical Markets for LexisNexis Risk Solutions in Denver, Colorado. 

"We need sources of data, sub-segmented into something more personal," said Ingraham who has held leadership positions at both Cigna and Hospital Corp. of America. "It's the social determinants of health. It's almost like peeling back an onion to its core layer."

Welltok uses this often overlooked data to create a personalized health itinerary that can be used to incentivize an individual or group of employees to drink more water each day, take advantage of a wellness program, manage stress or another type of initiative, according to Margolis, who said they get engagement rates of 30 percent, and as high 60 to 70 percent. 

The company works with an estimated 90 clients who are payers, self-funded employers, provider systems, and the retail pharmacy business. 

"We have a partnership with IBM on claims data from subsidiary Truven they just bought," Margolis said, referring to the $2.6 billion acquisition of Truven Health Analytics by IBM Watson Health in April 2016. "(Another) source of data is from the consumer themselves."

Much of the social and economic data, such as on housing and education, is public. 

So far, insurers have been the ones to show the appetite and receptiveness to keeping track of patient data that alerts for an adverse change, such as a job loss, that can increase risk, Ingraham said.

But, he continued, physicians and providers are increasingly interested in taking a proactive approach to seeing patients who have experienced a point-of-time change that could trigger a health issue.

"If you're a physician who's going to have to live in a world of payment and quality, it's perhaps not wise to wait until patients present themselves with symptoms," he said. "You don't want to have to wait for claims to appear. Reach out and say, 'We'd like to see you.'"

Ingraham admits he gets some eye-rolling from physicians on the subject.

"I talk to physicians, they cross their arms and look at me with skepticism. They're trained to look at evidence."

Because hiring additional staff isn't always practical, the answer could be for a receptionist or nurse to contact patients who have experienced a change, or who haven't come in for a checkup for over a year.

"There are some people who just don't go the doctor," Ingraham said. "There is an art to reaching out to someone to come in. There's a success rate."

New payment models such as the Medicare Access and Chip Reauthorization Act, or MACRA, are turning providers in this direction, Ingraham said.

"The plans are highly interesting because of the incentives on physicians and hospitals for better patient engagement," Ingraham said. "They're now recognizing they have to do more than treat patients who come through the door. As health providers have to act more like a plan, the incentive is there to attack these problems."

Twitter: @SusanJMorse