Health Plan VP Shares the Secret for Success in Value-Based Care

A population health model focused on health and wellness is the key to success in value-based care, Cary B. Shames, DO, CHCQM, ABQAURP, vice president and chief medical officer at Sharp Health Plan explained at NAMCP.

Population health management involves analyzing big data for a population to ultimately best manage the individual patients within that population, Dr Shames explained. Population health management has allowed Sharp Health Plan, through its providers, to proactively manage patient health and earn top ratings in the process. 

Sharp is an integrated delivery system in San Diego that consists of a health plan, medical groups, outpatient clinics, urgent cares, and numerous hospitals.

“Currently, 15% of members account for 70% of healthcare costs,” Dr Shames explained. But by taking a holistic population health view of the remaining 85% of members who are currently healthy or whose risk is just beginning to emerge, “we can bend the healthcare cost curve,” he added.

Sharp combines clinical, administrative, and program data with predictive algorithms to assign all plan members a status: (1) healthy members; (2) members with emerging risks; (3) members with acute care illness; (4) members with chronic illnesses; and (5) end-of-life care. The healthcare team uses that information to address patient needs, Dr Shames said.

Members considered healthy are encouraged to stay that way through the plan’s health and wellness promotion activities and interactive phone-based coaching, he explained. Those with emerging risks or chronic conditions also have access to health coaching as well as to diabetes and hypertension disease management programs to reduce risk.

Meanwhile, members with acute care illness receive inpatient case management focused on appropriateness, timeliness, care continuity and coordination, effectiveness in delivering services, and discharge planning. Those with chronic illness receive comprehensive case management that includes care coordination, resource management, referral authorization management, health insurance benefits, and health education. 

Finally, members at end of life are supported by home-based palliative care, which includes in-home medical consults, ongoing evidence-based prognostication, caregiver support, and advance health care planning, according to the presentation. 

“Sharp maintains its status as a top organization for quality and value by continually measuring the effectiveness of our interventions,” Dr Shames said, adding that the plan is at the highest level of maturity in the value-based care journey.

Reimbursement for providers is directly tied to their ability to meet the system’s high standards. Value-based reimbursement has led to top-decile Healthcare Effectiveness Data and Information Set results in areas such as preventive care, wellness, disease management, medication management, and behavioral health. —Jolynn Tumolo