Live Webinar | Legal and Regulatory Compliance
Live Webinar | Health Plan Payment and Reimbursement
Live Webinar | hfma:content/topic/behavioral_ethics
Blog | Analytics

Population Health Management’s Revenue Cycle Impact

Blog | Analytics

Population Health Management’s Revenue Cycle Impact

Access to applicable data can help physicians overcome financial and clinical challenges.

As healthcare providers acclimate to new value-based payment models, they face the two-pronged challenge of achieving better outcomes while reining in costs. Providers face increasing pressure to shore up funds to support new quality payment program initiatives and offset potential revenue losses and are looking toward data analytics solutions to identify savings and clinical improvement opportunities with the biggest potential to improve the revenue cycle.

The benefits that can be gleaned from such an approach are exemplified by the experience of Allegiance ACO, an accountable care organization affiliated with Allegiance Health Group in New Jersey and Pennsylvania. Allegiance turned to data integration and analytics to uncover patient care delivery and utilization trends as it worked to build an effective population health management strategy.

The physician-led ACO, which provides services to economically disadvantaged patients in and around Trenton, N.J., used analytics to stratify patient risk, identify opportunities for resource reallocation, and empower data-driven patient care intervention to reduce non-acute emergency department (ED) utilization and inpatient admissions among its patient population.

Patient Risk Stratification: Predicting Threats

Allegiance’s first step in addressing network inefficiencies was to identify those of its patients who were at highest risk of negative health outcomes or episodes. Risk stratification was based on a scoring model that weighed patient expenses against diagnosis, comorbidities, and demographics. Once at-risk patients were identified, the ACO set out to better manage their clinical care. Physicians began using dashboards to track and manage high-risk members. The technology continually analyzed new data to prioritize patients that required focused attention, thereby reducing the cognitive burden on physicians and nurses.

Using populationwide data, predictive analytics enable Allegiance’s providers to understand the potential needs and risks of their patients. Such data provide a means for healthcare organizations to forecast costs and introduce new interventions that are designed to reduce the risk of costly acute care encounters. For example, if laboratory, clinical, electronic health record, and claims data show that a patient with diabetes has HBA1c values greater than 9 percent, blood pressure higher than 130/80, and goes more than three months between physician visits that patient may be eligible for interventions, such as  proactive scheduling of more frequent office visits, greater emphasis on education programs, involvement of pharmacists in medication management and counseling, and others. Assessments on the social determinants of health (e.g., socioeconomic status, physical environment, social support networks) constitute another realm of heath factors influencing patient outcomes. By putting such information into the hands of its care teams, Allegiance enabled its teams to work with patients to identify and remove barriers to primary care engagement.

Resource Utilization: Identifying Costs and Opportunities

Through such financial and operational data analytics, providers can identify care expenditures and patients who fall into a high resource-utilization category. These patient populations provide opportunities for clinicians to implement targeted care intervention programs that reallocate resources and promote more cost-effective preventive care. By identifying gaps in care, providers and care managers can augment workflows to close those gaps and prevent exacerbation of illness.

By analyzing resource utilization in this way, Allegiance detected instances where patients were undergoing duplicate and unnecessary tests in the hospital care setting. This finding prompted the ACO to take steps to improve laboratory service delivery in the office setting, leading to a 9 percent reduction testing costs. The data also made it clear that Allegiance could reduce ED visits by offering early evening office appointments, and on making this change, the ACO also saw a 32 percent concurrent decrease in ambulance services.

Data-Driven Care Coordination: Adapting Care Delivery

The transition from patient data insight to informed care delivery is one of the biggest obstacles in population health management. To effectively execute on outcome improvement initiatives, providers must be able to tether analytics to the point of care. Patient-specific workflow prompts can help physicians and care coordinators boost patient engagement and appointment follow-through.

With a shared view of patient health records and activities, Allegiance care teams were able to streamline transitions of care episodes and settings. The ACO used care coordinators to help patients navigate the health system by addressing challenges in access to care, such as arranging transportation for patients to dialysis appointments. Through such population health management efforts, Allegiance reduced overall ED visits by 8 percent and ED visits leading to hospitalizations by 10 percent in 2016.

To most easily and effectively identify the biggest opportunities for care enhancement, process improvement, and cost savings, providers require ready access to applicable data that can support informed actions. Scalable population health management solutions offer physicians the opportunity to wade into the waters of value-based care, driving effective patient intervention and smarter utilization, one targeted initiative at a time. 

Sanjay Seth, MD, is executive vice president at HealthEC, Piscataway, N.J.

About the Author

Sanjay Seth

Sign up for a free guest account and get access to five free articles every month.


Related Articles | Analytics

How To | Cost Effectiveness of Health

Cost Effectiveness of Health Report, July 2022

The July 2022 issue of HFMA’s Cost Effectiveness of Health Report, sponsored by Kaufman Hall, includes insights from an industry thought leader into how hospitals and health systems can make better use of data to address the challenges posed by health inequity and social determinants of health. Also included is a discussion of ways healthcare organizations can take the lead in promoting health equity.

Executive Roundtable | Billing and Collections

Navigating the changes to revenue and billing practices in the No Surprises Act

In this roundtable, revenue cycle leaders discuss the anticipated challenges and strategies for approaching these challenges arising from the No Surprises Act, which went into effect Jan. 1, 2022.

Q&A | Cost Effectiveness of Health

Information is key to improving health of Americans while reducing healthcare costs

U.S. hospitals, and the healthcare industry overall, must learn to apply data more proactively if we are to begin to make meaningfully progress toward addressing the financial and social challenges besetting our healthcare system, says Daniel Marino, managing partner of Lumina Health Partners.

Column | Revenue Cycle

4 proven strategies for optimizing revenue cycle performance

Hospitals revenue cycles can all too often experience denied claims and delayed payment due to outdated manual processes and workflow inefficiencies. Hospital revenue cycle leaders can address these problems with a sharper strategic focus on submitting clean claims, managing denials, applying analytics and outsourcing.