How Population Health, Risk Stratification Support Value-Based Care


To excel in value-based care, providers must lean on strategies for managing population health and skillful risk stratification.

Amid the COVID-19 pandemic, organizations observed the ramifications of fee-for-service, leading to communication and revenue challenges for both providers and patients.

While value-based care is not a novel idea, the pandemic greatly accelerated the adoption of this approach to care delivery and reimbursement. As patients increasingly embraced virtual care alternatives, prominent healthcare institutions directed investments toward digital technology to remotely address manageable conditions.

Within the framework of value-based care models, providers secured fixed payments to offset the expenses of patient care. Furthermore, providers were granted incentives for effectively mitigating patient health risks and cutting costs. Throughout the pandemic, value-based care models extended financial stability to healthcare organizations, empowering them to offer tailored care management.

Embarking on the Journey to Value-Based Care

The objective of value-based care is to establish a standardized healthcare process by enhancing the patient experience, promoting the health of patient populations, and optimizing the cost of care. By utilizing data mining, healthcare providers can identify the most efficacious procedures. Emphasizing strategies for wellness and prevention takes precedence within value-based care models.

As outlined by the Cleveland Clinic, “Promoting health (through actions like quitting smoking, dietary and lifestyle adjustments, exercise, etc.) reduces the necessity for costly tests, procedures, and medications. Maintaining wellness leads to reduced healthcare expenses for everyone.”

To provide optimal value-based care, healthcare providers can introduce strategies for managing population health, shifting away from a “one size fits all” approach. Through population health management, organizations can factor in physical and social determinants of health that might impact individuals, focusing on proactive “well care” instead of waiting for patients to fall ill.

The Significance of Population Health Management

As per the American Hospital Association’s definition, population health management pertains to the “process of enhancing clinical health outcomes within a specified group of individuals through improved coordination of care and active patient engagement, facilitated by appropriate financial and care models.”

The term “population” can encompass a more limited subset of individuals or a considerably larger one. What holds paramount importance is that all members of the group share a common characteristic or issue. Ultimately, the focal point of medical professionals in population health management lies in enhancing care within the particular patient group.

The process of population health management commonly commences with the collection of crucial demographic and clinical data from patients associated with the provider, frequently derived from electronic health records. Attribution of patients might hinge on factors like the geographical service region, their health insurance provider, or their existing diagnoses.

Subsequently, these patients are categorized based on their clinical backgrounds and levels of risk.

Researchers and healthcare practitioners then leverage aggregated clinical and claims data for the purpose of risk stratification. This data could encompass metrics such as the count and types of chronic illnesses, a history of extensive utilization or frequent hospital stays, diagnoses of mental health issues or substance abuse, advanced age, or residence in a low-income or underserved locality.

Understanding Risk Stratification

Risk stratification is identified as the ongoing process of assigning all patients a particular risk status. Risk statuses are based on data that reflects vital health indicators, lifestyle, and medical history. Researchers and clinicians can match risk with levels of care, individualized treatment plans, pursue value-based care approaches, and address population health management challenges.

The overall goal of risk stratification is to identify patients who are most likely to benefit from care management to improve patient outcomes and decrease costs.

Using analytics tools, the provider then assigns each patient a risk score.

Patients with higher risk scores may receive extra attention, including more frequent follow-up, social and community support, enhanced care coordination services, medication adherence advice, or an invitation to enroll in an educational patient support program.

Those with lower risk scores might still benefit from services like automated screening reminders or telehealth options.

These preventive care strategies are intended to help maintain each patient’s highest possible health status while avoiding crisis events, decreasing preventable hospitalizations, and improving the overall quality of life.

As a result, providers may be able to lower expensive services, avoid duplication of efforts, raise patient satisfaction, and enhance the overall health of their patients.

Risk stratification plays an important in population health management by understanding the needs of patients in different risk categories, improving health outcomes.

Strategies for Implementing Population Health Management

The primary objective of population health management is to employ preventive care in order to reduce the need for patients to visit doctors. Moreover, this concept benefits healthcare providers by lowering program expenses. To implement strategies for managing population health, organizations should begin by establishing a robust population health team and maximizing the use of analytical technology.

Once the organization gains insights into its patient demographics and available technological tools, it can devise a strategic plan by considering the following inquiries:

• Are we intending to engage in formal value-based reimbursement initiatives, such as the Medicare Shared Savings Program (MSSP) or a private payer accountable care organization (ACO)? Are we aiming for recognition as a patient-centered medical home by accrediting bodies like the NCQA? 

 • Do we comprehend how these arrangements and recognitions will impact our future compliance within the MACRA framework? 

 • Do we possess a comprehensive understanding of the socioeconomic challenges faced by our patients? What is the average health literacy level? How will we communicate with them? Do the majority have access to home internet, or should we explore a platform based on text messaging?

• Have we comprehended our geographical region and the healthcare resources accessible to our patients? Can we collaborate with public health departments, school districts, and community leadership organizations to gain a better grasp of the specific area’s challenges? 

 • Have we conducted a thorough assessment of our foundational data integrity and analytical capabilities? Do we grasp how data accuracy, quality, completeness, and timeliness will impact our insights into population health management? 

 • Do we have competent staff available to address these data-related challenges? Are we open to working with consultants? Should we contemplate outsourcing any technological or business processes? 

 • Is there a local health information exchange entity offering access to population health insights? Is there a nearby regional extension center that can provide advice on technology adoption and planning? 

 • What will be the inaugural project we undertake? What is its timeframe, participation requisites, and anticipated outcomes? How will we report on its results, and what actions will we take based on that information?

Subsequently, the organization will gather feedback on workflows and patient satisfaction, actively seeking methods for further enhancing the program.

Through the practice of population health management and risk stratification, organizations can adopt strategies rooted in value-based care and participate in alternative payment models to enhance patient outcomes and reduce costs.

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