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The Name of the Game in PHM Is Variability: Part 1 - Introduction

by Scott MacStravic

Population Health Management (PHM) has become a major market for insurers, governments, and employers to invest in – and for a wide range of organizations, from traditional healthcare providers to specialized PHM suppliers to insurers to deliver to that market.  The numbers of suppliers keeps growing as the number of payer clients does also. The market is beginning to look like the early stages of many new markets, from automobiles to radios to TV sets, cell phones, and electronic gadgets in general – it offers a vast number of options to purchasers, including the “do-it-yourself” (DIY) alternative to purchasing PHM.

Many traditional healthcare organizations (HCOs), from physician practices to hospitals to integrated health systems (IHSs) have entered this market, as DIY providers to their own workforces, or as competitors in marketing PHM services to payers, mainly to employers.  They may do so in order to support their sickness care services marketing strategy by creating and sustaining stronger and more lasting relationships with employers as influencers of both insurance plan decisions on provider networks, and employees’ choices of providers.  Or they may see the PHM market as one they would rather join than merely suffer its sought-after effects in reducing sickness care use and expenditures and thereby their sickness care revenue.

Employers have been involved in a “toe-in-the-water” approach to PHM since the 1970s at least.  Many began with some kind of DIY “worksite wellness” program for their employees, and a growing number are offering onsite medical clinics that engage in PHM along with traditional sickness care.  But most appear to be outsourcing the PHM function to specialized suppliers or HCOs, since there are so many complications in their knowing about their individual employees’ health problems — and most have no great competence in PHM.

Insurers have often been influenced by their own interests or their employer clients’ demands to become PHM DIY suppliers, as well as insurers, to employers, at least.  Both Aetna and CIGNA, for example, offer PHM services to employers other than those to which they provide health insurance plans.  Since insurers can gain substantial experience, and with large populations, by delivering PHM services to their own insured populations, they can gain both the competence and track record needed to become viable suppliers in the overall market, as well as capable DIY providers for their own health plan members.

Specialized PHM suppliers have been in the PHM market, as operators of worksite medical care clinics for employers, or suppliers of PHM services for commercial and government insurers, for a few decades.  There has been a significant movement toward merger and acquisition among such suppliers, resulting in consolidation of their numbers, but many new ones keep entering the market, so the overall numbers of suppliers is still huge.  And while some have captured large market shares, there appears to be no single supplier who could be called dominant.

One of the reasons for this is the vast degree of variability among PHM suppliers, due to both their large numbers and the fact that there is nothing close to agreement on what are the “best practices”, the most cost-effective approaches to PHM in any one of its essential elements.  These elements include:

  1. Determination of what dimensions of economic impact will be included in the PHM planning, management, and evaluation
  2. Assessment of the PHM current state of these dimensions in whatever population (insured plan members, employees, dependents, retirees) is to be involved
  3. Targeting of which individuals shall be sought as participants in either standardized or differentiated PHM approaches to particular problems, risks, or potential gains are to be addressed
  4. Recruiting targeted individuals and segments to become active, engaged, and enthusiastic participants
  5. Sustaining participants throughout the PHM intervention program, at least long enough to achieve some desired effects, if not to the end of a limited intervention, or on a continuous basis if there is no intended end.
  6. Carrying out the intervention process on those participating, using a wide range of interaction and communications technologies and methods
  7. Evaluating the effects of interventions over whichever time frame(s) clients wish

Not only are there vastly different approaches to each of these elements being used by different PHM suppliers, but clients may engage different suppliers for two or more of such elements, including doing one or more themselves, or at least sharing the responsibility with outsource suppliers.  As a consequence of the numbers of and variations among suppliers, the overall PHM market contains far more variation than is true for almost any other example in the business-to-business (B2B) or business to consumer (B2C) markets.

In subsequent postings, I will describe and discuss the seven separable elements in PHM that are subject to such variations.  The combination of this number of basic elements, and the variability in how they are carried out by different suppliers, even within the same supplier for different clients, is what makes the PHM market so replete with variability.


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