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POPULATION
to their practice immediately. Some of the Medicare Advantage plans
are sharing in the savings to the extent that the IPA and their physi-
cians achieve a medical loss ratio (MLR) less than the contracted tar-
get of the health plan’s MLR. And since the physician receives a fee
for service (FFS) amount for each office visit of the Medicare Ad-
vantage patient on the front-end, there is simply upside income po-
tential for the physicians on the split savings on the back-end, when
the doctor is participating in an experienced IPA. Thus, when the
front-end payment is added to back-end split in savings, some physi-
cians have collected over 200 percent FFS in reimbursement for their
population of interest. Now that is a compelling reason to begin un-
derstanding “Population Health Management.”
Of course, for physician’s that have a full booking of patients,
adding more patient visits to their busy schedule can seem daunting.
The key is to prioritize the patients from those with the most severe
and acute disease, which may need treatment sooner than later and
the less severe that can be fit into the doctor’s schedule over time.
Unfortunately, most practices are not that proactive in managing
their patient population. Many practices are filled by the patient de-
mand. A patient has a symptom and calls their doctor to be seen.
Seldom does a practice data-mine their own patient population to
determine who might be at risk for some particular disease and reach
out to these patients in an effort to slow down the progression of
the disease or, in some cases, stop it altogether.
Population health management involves many aspects of manag-
ing a patient. The goal is to assure that for a given disease, the patient physicians, that can demonstrate high STAR ratings. Those physi-
is contacted, treated, followed-up and the outcome is improved.
There have been some early elementary attempts of trying to get
physicians to adopt components of population health management.
The Healthcare Effectiveness Data and Information (HEDIS) is one
such attempt.
HEDIS is a tool used by more than 90 percent of America’s
health plans to measure performance on important dimensions of
care and service. Many health plans use the HEDIS measurements
to highlight their scores to prospective employers. HEDIS meas-
ures address a broad range of important health issues. Among them
are the following:
Asthma Medication Use
Persistence of Beta-Blocker Treatment after a Heart Attack
Controlling High Blood Pressure
Comprehensive Diabetes Care
Breast Cancer Screening
Antidepressant Medication Management
Childhood and Adolescent Immunization Status
Childhood and Adult Weight/BMI Assessment
For the Medicare Advantage population, CMS has used another
tracking program called STAR. One of the differences between
HEALTH
HEDIS and STAR is that HEDIS is responsible for making sure
that providers at least perform the activities of measurement as
required by HEDIS, whereas STAR requires both the performance
of the measurement activity with the additional requirement of
demonstrating improved outcomes. Thus, it is not good enough
that the doctor saw the patient, they also need to make sure that
the prescribed treatment is heading in the right directions in terms
of outcomes.
Star Ratings are driving improvements in Medicare quality. The
Star Ratings measures span five broad categories:
Outcomes
Intermediate Outcomes
Patient Experience
Access
Process
Not every domain is weighted equally however. For 2017 Star Rat-
ings, outcomes and intermediate outcomes continue to be weighted
three times as much as process measures, and patient experience and
access measures are weighted 1.5 times as much as process measures.
CMS assigns a weight of 1 to all new measures. Of the 364 health
plan contracts that participate in Medicare Advantage, there were
only 81 with a STAR rating of 4.5 or higher.
The implications for physicians is that health plans want to con-
tract with physicians, or IPAs that contract with high performing
cians that have lower STAR ratings may find cancelation notices
from the managed care companies. The private Medicare Advantage
companies will not, in the long run, keep physicians that are doing
a poor job managing their population of patients. Thus, if you are a
physician that is looking to participate in population health man-
agement, you might want to first look at high performing Independ-
ent Practice Associations (IPAs) to assist you with your practice
before you receive a cancelation notice from a managed care com-
pany that is measuring every doctor on their plan.
Alan Preston, MHA, Sc.D., is the Executive Director of
IntegraNet Health San Antonio, an IPA that helps physi-
cians navigate through the difficult regulatory framework
and helps them achieve higher reimbursements from insur-
ance companies; skilled with a tremendous background in managed care
and Population Health Management, epidemiology, team building, and
biostatistics; strong healthcare professional with a Doctor of Science
(Sc.D.) focused in Public Health, Health Services Research from Tulane
University School of Public Health and Tropical Medicine. Dr. Preston
is involved in risk sharing contracts, ACOs, Medicare Advantage in-
cluding RAP scores, HEDIS, and STAR ratings which helps physicians
and health plans alike in reducing MLR.
visit us at www.bcms.org 23