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Population Health

Management

July 21, 2014

Dr Mark Davies European Medical Director

Paul Molyneux Head of Analytics

Kings Fund 24th November

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Population Health Management

Population health management is an approach to managing health and well-being

that incorporates total care costs and outcomes. It provides insight and improvement

opportunities for both populations and individual citizens.

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Mede/Analytics Population Health Platform

Individual Level Stratification

Population Modelling

Improvement Opportunities

Predictive Analytics Platform

Delivery Assurance

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5www.outcomesbasedhealthcare.com

Types of Outcomes

Source: Outcomes Based Healthcare

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Population Health

• Population Health enables shared risk arrangements between all stakeholders

Clinical Scorecards

External ReportingInternal Analysis

Gaps in Care Workflow

Care Management Support

Health Economy Scorecards

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Risk modelling involves statistical analysis of historic events, in order to

derive a probability for every member of a population of experiencing a

specific outcome in the future

Risk models should ideally always present not only the risk score, but also

make available the risk attributes that form that score (e.g. age, medical

history, hospital activity etc.) so we know why they’re at a certain risk level

Risk modelling

28% 28% 55% 40% 29% 97% 56% 57% 35% 70% 29% 77% 99% 70%68% 21% 88% 95% 35% 63% 9% 21% 93% 8% 73% 9% 41% 14% 63% 41% 19% 25%

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PARR30 & Mr. Jones

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Stratification partitions the distribution of risk scores in any population

This is crucial in determining thresholds of risk at which specific actions

should (or shouldn’t) be taken, and which resources should be targeted

Stratification will only ever consider one outcome at a time

Risk Stratification

High High High High High High High

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Example 1 – Risk Pyramid

The distribution of risk scores in a population are normally formed into a ‘risk pyramid’ (though we note that the distribution looks more like a spinning top) with highest risk at the top, and lowest risk at the bottom, where attention is largely focused on the top tier: our ‘very high risk’ group.

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Correct Approach?

• We should question this for a number of reasons:

– Where should the line be drawn to identify our top tier?

– Are those cases at the top even preventable?

– Does this present sufficient opportunity for improvement across the health economy?

– Which strata of risk groups should we focus on?

– Which resources do we target them with?

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You should always ask three fundamental questions ahead of

embarking upon any new program of risk stratification:

1. Is the outcome you’re predicting for negative and actually predictable?

2. Can you do anything to prevent it in a timely manner?

3. Is it making the best use of valuable resources when considering the

incidence of the problem and the likelihood of a successful intervention?

Mede/Analytics Recommendations

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The Benefits…