Rethinking population health management: Why successful risk-based contracting requires provider empowerment

As the healthcare industry shifts from fee-for-service to value-based care, antiquated revenue models continue to stifle progress. Hospitals enter risk-based contracts with the intention of providing high-quality patient care, yet the bulk of their revenue still comes from treating sick patients.

“Healthcare still functions by waiting until our bodies are broken,” said Richard Queen, co-founder and CEO of DignifiHealth. “We’re working retrospectively. Everything becomes more expensive and less efficient. It’s no wonder why providers feel burned out and patients feel as though they don’t matter.”

There are also additional challenges with providing value-based care, namely an inability to risk stratify patients based on their unique health and social circumstances as well as an absence of digital tools and data integration to provide point-of-care insights.

DignifiHealth hopes to solve these challenges by reversing the long-standing narrative that population health management isn’t possible or profitable. The company does this through its flagship product, DignifiEngage, that empowers healthcare providers to deliver first-class patient care. It provides actionable clinical intelligence and analytics designed to inspire healthcare professionals, patients and payers to achieve high-quality, cost-efficient care, resulting in improved population health.

“When you lead with quality, profitability follows,” said Queen. “But you must be willing to make that leap. You need the right people, processes and technology as well as the knowledge that you’re not making a blind leap of faith.”

How it works

“We sit on top of the EHR,” said Queen. “We take that data and use cutting edge technology to develop clinical insights, then serve up those insights in a way that doesn’t disrupt workflow.”

DignifiEngage combines EHR data with data from a variety of external sources (e.g., the FDA, U.S. Census Bureau, CDC, American Heart Association, American Diabetes Association and others) to assign individual risk scores to each patient, identify care gaps, and help providers and staff address those care gaps in real time at the point-of-service through multiple, timely, user-friendly channels.

“We’ve had a lot of technological innovation over the last few decades,” said Queen. “But we still have incredibly high rates of diabetes, COPD and other chronic conditions. We need solutions that will move the needle on value-based care — solutions that marry the data and present it in an actionable way at the point-of-care to not just measure performance improvement, but also drive it.”

Promoting staff empowerment

These insights are what empower clinical and non-clinical staff to move the needle on value-based care.

With DignifiEngage, physicians, nurses, front desk staff and others become patient champions. Physicians connect patients with resources and referrals right at the point-of-care with no additional time or effort required.

“DignifiEngage allows me to effortlessly maximize my patient encounters while also improving health, all without adding additional time to the visit,” said Renee Caslow, DO, executive director of primary care at Memorial Health System, an Ohio-based health system that employs more than 300 providers.

Since partnering with DignifiHealth, providers at Memorial Health System report greater scheduling flexibility, some choosing to see two additional patients per day due to increased efficiency.

“Physician burnout is a significant problem in healthcare,” said Queen. “Physicians need tools that reduce the workload while also helping them be more efficient and feel as though they can make a difference in their patients’ lives.”

Likewise, nurses using DignifiEngage move away from retrospective care gap closures toward chronic care management, a service that properly aligns financial incentives while promoting preventive care, health and well-being.

DignifiEngage also empowers front desk staff, providing them with streamlined workflows to easily identify patients in need of care, including those who recently canceled an appointment but didn’t reschedule it in the last month. Front desk or call center staff can contact these patients directly to ensure gaps in care don’t cause adverse health outcomes.

“Empowerment requires access to data,” said Queen. “We give full transparency to the data, operationalizing a much bigger workforce for that goal.”

 “Extending throughout the organization, Memorial Health System uses DignifiEngage to revolutionize the care it provides,” said Luke Smith, MBA, vice president of clinic operations at Memorial Health System. “DignifiEngage is accomplishing the quadruple aim, and we’ve seen the direct results of that. We’ve lowered costs, increased outcomes, enhanced patient experiences and increased access.”

Doing more with the same amount of resources

“Some health systems wrongly assume they need to hire dozens of care coordinators to implement new workflows,” said Queen. “Those that have taken this approach might have already lost millions of dollars through unnecessary labor costs and failed value-based contracts. They may be reticent to try again. What I want to emphasize is that population health management doesn’t require more people — it’s about working smarter by taking advantage of the data and making that data work for the patient in front of you.”

Identifying risk and closing care gaps

“Hospitals that find success in value-based care arrangements are those that treat patients as individuals,” said Queen. “This requires an ability to leverage the right data at the right time along with actionable steps to promote positive patient outcomes.”

Health systems that partner with DignifiHealth are already seeing results. Using a data-driven team approach to value-based care, Memorial Health System increased Anthem A1C gap closure rates from 7% to more than 75% of its diabetic population. It also increased Humana overall gap closure by 44%.

“DignifiHealth has transformed the way we practice,” said Dan Breece, DO, chief medical officer at Memorial Health System. “We have seen marked increases in both our quality scores and indicators as well as compliments from our payers.”

Improving patient engagement

DignifiHealth also partners with external third parties to further promote population health management and value-based care. For example, it shares data with patient engagement companies to surface care gaps to patients directly at the point-of-service.

“Our workflow informs the provider, but we can work through these partners to inform the patient, empowering both just minutes before they go face-to-face for an appointment,” said Queen.

Addressing care deserts

Population health management is often most challenging for rural providers where access to care is limited, and financial resources are scarce. DignifiHealth wants to change that.

 “In rural areas, a patient may have access to primary care but need to drive several hours to get to a specialist,” said Queen. “Being able to deploy resources to serve patients, where they are, makes a huge difference.”

For example, a 15-provider rural health clinic uses DignifiEngage to overlay clinical information on a mapping interface to geolocate patients.

“It pinpoints their exact address by location so the clinic can look for clusters of patients and identify neighborhood’s driving risk,” said Queen. “The clinic can then send community-based care workers — boots on the ground — to  reach these patients.”

With the help of DignifiEngage, the clinic also revamped its population health program that relied heavily on manual spreadsheets and processes to track patient outcomes.

“They can now go into our platform and pull up a single dashboard that trends all lab values, vital signs and success factors of their patients,” said Queen.

Looking ahead

DignifiHealth recently partnered with a managed service organization to promote direct contracting with Medicare through the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model.

“We can now facilitate the direct alignment of Medicare financial incentives to providers for delivering this outcomes-based healthcare,” said Queen. “Then we drive provider success by giving them everything they need to perform under that contract and achieve those shared savings.”

DignifiHealth is passionate about helping healthcare organizations approach value-based care with confidence.

“Value-based care is first-class patient care and more convenient care,” said Queen. “You’re giving patients what they need and managing risk while also decreasing costs and ED utilization. That’s the kind of thing that becomes possible with our platform.” 

About DignifiHealth

As a technology-enabled platform, DignifiHealth partners with health systems on value-based healthcare, chronic disease management, care gap closure, and more to create exceptional patient and health system results. While many providers find themselves overburdened, understaffed, and under-tooled to drive outcomes-based healthcare, DignifiHealth is proving there is a formula for successfully delivering value-based healthcare. Purpose-built for healthcare professionals by healthcare professionals, DignifiEngage, provides actionable clinical intelligence at the point of service to achieve high-quality, cost-efficient care by identifying the right care for the right patient at the right time.

This published piece is provided solely for informational purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions by participants are those of the participants and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear do not constitute endorsements by HFMA.