CalAIM’s population health management program requires managed care plans to proactively assess each of their member’s health risks and health-related social needs and implement a comprehensive tailored set of services based on their needs and preferences across the continuum of care.
CalAIM Basic population health management (BPHM) model is based on the simple principle of providing the right programs and services to each member – no matter where they are in the spectrum of need.
BPHM requires health plans and systems to understand the needs of their population, at any point in time and based on their needs, proactively provide them access to services such as primary care, care coordination, navigation, and referrals for medical, behavioral, and social supports.
Traditional population health management is built around risk stratification and segmentation where the risk models are used to group members into high, medium-rising, and low risks. Often care teams spend a significant amount of their time and resources addressing the needs of high-risk members. This creates a considerable gap for members in other categories who are left on their own to navigate our complex healthcare system. Population health managers know the concept of regression to the mean, whereby the majority of the members in the previous year’s high-risk category are not likely to be in the next year’s high-risk category. Various research studies have shown that approximately 30% of members move out of the very complex risk band (0.5% of the population) within one month; 50% after five months and 80% after one year. Thus risk stratification based on past year results quickly become outdated. If members’ needs in other categories are not addressed in time, some of them will likely experience costly and avoidable health events in the future.
BPHM is designed to address this problem. It is about creating a systematized approach to whole-person care where all members are provided convenient access to primary care, wellness and prevention, and chronic disease management programs. Whie some of these services can be provided by managed care plans (MCPs), the effective implementation of BPHM is enabled via providers in the community where members live. In general, members who are already getting their care from primary care providers have gained some level of trust, however, what they are lacking is holistic whole-person care that is proactive, comprehensive, and coordinated. This is where managed care plans (MCPs) can assist the providers, by providing access to tools for care coordination, and health education and connecting them to community supports (such as arranging transportation, etc.), where necessary.
Outcomes-based payment models are critical for providers to achieve goals such as ensuring that all of their assigned members (irrespective of race and ethnicity) have adequate access to primary care and that members with more complex needs can have coordinated access to behavioral, SUD, oral, vision, pharmacy, LTSS, and other resources.
Without a solid data-sharing backbone, the basic PHM will not work. Managed care plans (MCPs) need to invest in infrastructure that enables sharing of information on evolving members’ needs, services, and interventions provided to address those needs and the outcomes achieved.
Built on CalAIM’s PHM guidelines, our whole-person care platform provides the technology infrastructure to implement comprehensive population health management for all Medi-Cal members. Connect with us to learn how our end-to-end unified solution can help you achieve better and more equitable outcomes for your members.