case study 69

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William Paterson University *

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6062

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Health Science

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May 3, 2024

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docx

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Case Study Q1. What is Population health management, and how is it different from traditional health care? Population Health Management (PHM) addresses health needs and broader social, environmental, cultural, and physical elements affecting health. On the other hand, traditional healthcare primarily focuses on individual medical services. In the case study of a midsized private payer, PHM involves developing strategies and programs to influence the health of special populations (Langabeer, 2018). These special populations have unique health needs and challenges, such as multiple chronic diseases. PHM is proactive, emphasizing prevention, early intervention, and health promotion, while traditional healthcare is reactive, responding to health issues as they arise. PHM considers broader determinants (social, economic, environmental) that impact health outcomes for entire populations, while traditional healthcare addresses the immediate health concerns of individual patients. PHM segments patients into distinct risk categories, like high-risk, medium-risk, and low- risk, and tailors interventions accordingly, while traditional healthcare treats patients regardless of their risk level. PHM focuses on care coordination, collaboration among providers, and community resources to address patients’ needs comprehensively, while traditional healthcare often lacks coordinated efforts across providers and settings. PHM collects and analyzes data from various sources, such as claims, clinical records, and social determinants, to inform decision-making and program development. At the same time, traditional healthcare may not fully leverage available data beyond individual patient encounters. Q2. How does an ACO change the way FFS is delivered? An Accountable Care Organization (ACO) fundamentally alters how Fee-for-Service (FFS) healthcare is delivered. Firstly, FFS reimburses healthcare providers based on the number of services rendered, such as tests, procedures, and visits. ACOs emphasize value-based care, where healthcare practitioners are motivated to prioritize quality outcomes and cost-effectiveness. Instead of sheer volume, ACOs reward providers for achieving better patient health and reducing unnecessary services (Freed et al., 2022). Secondly, FFS often needs more coordination among different providers and settings. Patients may receive fragmented care. ACOs promote care coordination by integrating services across the continuum. In ACOs, providers collaborate, share information, and work together to manage patients’ health holistically. In the case of the midsized private payer organization working with various providers and health systems, establishing a PHI program aligned with an ACO model would involve a shift towards value-based reimbursement structures. Lastly, wellness programs may be underemphasized in FFS. ACOs prioritize wellness, preventive services, and health promotion. They save money in the long run by ensuring people stay healthy. Q3. What are the incentives for a hospital or health system to pursue population health management?
There are several incentives for a hospital or health system to pursue PHM. Firstly, pursuing PHM can lead to improved financial outcomes for healthcare organizations. Hospitals can save money by controlling the occurrence of expensive chronic diseases, avoiding readmissions, and reducing needless trips to the emergency room through proactive population health management. This focus on preventive care and early intervention can contribute to cost savings and operational efficiencies, a significant incentive for healthcare organizations, especially those operating within an ACO framework (van Vooren et al., 2020). Secondly, hospitals that proactively invest in PHM are leaders in healthcare innovation. Collaborating with other providers, payers, and public health entities strengthens partnerships and expands the organization’s reach (Langabeer, 2018). For instance, forming alliances with academic medical centers or research institutions can yield valuable insights. Lastly, many regulatory bodies and accrediting agencies recognize the importance of PHM. Hospitals favorably position themselves with regulators and policymakers pushing for a healthcare system that prioritizes population health outcomes; this can lead to regulatory advantages and potentially secure funding or support for PHM initiatives. Q4. How does PHM support the definition of quality from a value perspective? PHM takes a broader view of quality beyond individual medical services. It recognizes that various factors, like social determinants, lifestyle, and community context, influence health outcomes. PHM seeks to enhance total well-being by addressing these issues, which aligns with the value-based definition of quality. Quality in PHM involves preventing health issues before they escalate (Langabeer, 2018). Early intervention improves outcomes and reduces long-term costs, aligning with the definition of quality from a value perspective. Value-based quality considers efficiency and cost-effectiveness. PHM strategies, such as care coordination, risk stratification, and data analytics, optimize resource utilization. Hospitals can allocate resources efficiently and provide high-quality care without unnecessary expenses. The case study's focus on building partnerships, gathering information, and creating a Population Health Improvement program underscores the commitment to efficient and targeted healthcare interventions. PHM evaluates success based on population-level health improvements (Zio, 2022). It utilizes metrics like reduced hospital readmissions, better chronic disease management, and improved preventive care. These outcomes directly impact the value delivered to the community. Q5. Should PMH focus on populations with the greatest disparities and health inequity or areas with the greatest financial opportunities? Why? PHM should prioritize populations with the greatest disparities and health inequities. Prioritizing populations with significant inequality and health inequities aligns with the core principles of public health. These populations often face barriers related to social determinants, such as poverty, education, and care access, impacting their health outcomes. The case study mentions a particular population of interest. If this population experiences significant disparities, for example, higher rates of chronic
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