CalAIM Corner: What is Population Health Management?
One of the key elements of California Advancing and Innovating Medi-Cal (CalAIM) is the Population Health Management program. Many Medi-Cal managed care plans already offer some components of Population Health Management, but under CalAIM starting in 2023, managed care plans will be required to implement Population Health Management.
What is Population Health Management? Dr. Palav Babaria, Chief Quality Officer and Deputy Director of Quality and Population Health Management at DHCS, says it’s about proactively helping people stay well by identifying illnesses before they worsen and anticipating member needs before they increase.
“It’s about moving from a reactive health care system that cares for individuals when they are sick or hospitalized, to a proactive statewide system that understands member needs, even when they don’t feel sick or don’t need to see a doctor. Population Health Management helps members access resources and preventive services and ensures that Medi-Cal members and communities have longer, healthier, and happier lives with improved health outcomes and a reduction in health disparities.”
Q: Why does Medi-Cal need Population Health Management?
A: Currently, the lack of a comprehensive Population Health Management program across all managed care plans contributes to poor health outcomes in several ways. For example, many members are missing basic preventive and wellness services. This results in often more severe disease when diagnosed, such as more advanced cancers and uncontrollable diabetes. Medi-Cal members often also experience higher rates of unnecessary emergency room visits and hospital readmissions. These visits contribute to unnecessary health care spending and often do not actually address the health needs of members. There are also significant disparities in outcomes by race and ethnicity.
In order to address these pervasive inequities, Medi-Cal needs a system that does not solely rely on people having to seek out their own care, which is often challenging for members who may lack transportation, child care, or paid sick leave from work.
Q: How will the CalAIM Population Health Management program improve health and reduce disparities?
A: DHCS will set standards to assess and meet the needs and preferences of Medi-Cal members. We will use data, analytics, and member assessments to meet member needs in a comprehensive way, tailored to each person. The Population Health Management program will identify the health risk of each member, based on claims data, electronic health records, and a standardized assessment process, to determine who would benefit from additional support via care management programs and proactively identify and address gaps in care.
This may mean that a generally healthy member may receive a reminder if they missed their flu shot or were due for their colon cancer screening. And for an older member managing multiple chronic conditions with a recent hospitalization may need more comprehensive services including a care manager who helps monitor symptoms at home and helps the patient manage their new medications. In addition to member screenings and care management, the CalAIM Population Health Management program will also set standards for wellness and prevention programs, care coordination, and better supporting members with transitions in care (e.g., going home from the hospital or transferring to a long-term-care facility) to prioritize member safety and clinical outcomes.
Q: Why are Population Health Management strategies, like wellness and prevention programs and services, important?
A: CalAIM’s Population Health Management program identifies members’ health care needs early which supports improved health outcomes for these individuals. The Population Health Management program requires plans to have a broader range of programs and services that support all members, including those with social needs, members who may not have visited a provider recently or need help connecting to a provider, and members that have certain conditions like diabetes.
For example, robust Population Health Management programs will alert parents that a 6-year-old has missed her annual well-child visit and directly notify them of the importance of the visit and offer to help with transportation, if needed. A comprehensive chronic care program might realize that a senior with a history of stroke hasn’t picked up aspirin in the last three months and might call to find out why and to offer support with follow up, education, and coordination with a provider, if needed. Population Health Management programs identify these gaps proactively and do not wait until that child gets sick or the senior has another stroke.
Q: How will a Population Health Management approach reduce health disparities?
A: CalAIM’s Population Health Management approach will reduce health disparities through improved community partnerships, member engagement, and a broader focus on identifying and addressing unmet health and health-related social needs. Furthermore, managed care plans will be evaluated against quality measures, some of which will be stratified by race and ethnicity, to gauge the reduction in disparities as a result of Population Health Management efforts.
We also know that certain members may not have easy access to transportation, services, or providers that can meet their needs in culturally and linguistically appropriate ways. Population Health Management strategies help identify these gaps using data and continuous assessments of all members so that the health care system can better meet the needs of communities.
Q: What comes next to advance Population Health Management in Medi-Cal?
A: Throughout 2022, DHCS will continue developing the Population Health Management strategy and roadmap for managed care plans, procure a vendor to support data exchange, and deploy select components of the service, with the goal of launching the full Population Health Management program at the beginning of 2023.