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Top 5 videos from HIMSS17

The human factor of population health

In the new world of shared-risk, some situations call for creative ways to treat patients that hospitals cannot code for but still yield cost-savings.
By Susan Morse
01:47 PM
population health shared risk

Rowena Bergmans deals in risk every day.

As vice president of clinical integration and population health for the Western Connecticut Health Network, that risk spans multiple hospitals in the health system.

Yet when Bergmans talks about what she hopes to gain, she turns to the human element.

“We have to look at a patient holistically,” Bergmans said.

This involves psychosocial issues and the integration of behavioral health into primary care services. So it’s essential for the codes to be correct, both for reimbursement and for population health.

But sometimes the best treatment means a creative solution that has no code.

“We had a patient who ended up the ER because of COPD or congestive heart failure,” she said. “We went out and bought that person an air conditioner for their home. That person stopped going to the ER. There’s no code for an A.C. We have to find revenue in a way that we don’t code.”

Another service for which there is no reimbursement is when a physician or provider makes a phone call to a patient at night. Unless this is done as telehealth in a rural area, there is no mechanism for a hospital to get paid for doing the right thing.

“We’ve had great success implementing psychiatric telehealth,” Bergmans said. “Our northern hospital doesn’t have a crisis team. Patients must go to a southern hospital. We implemented telehealth so they could be screened up north to determine the appropriate care level.”

Western Connecticut Health Network embedded social workers into primary care practices to allow for co-occurring visits.

Accurate population health data is needed to determine what medications patients are taking, and whether their home health and clinical needs are being met.

Bergmans said the payer-provider partnership is essential to getting this data, and to getting reimbursed for services geared to the needs of an individual patient.

“Historically providers and payers have been adversarial,” she said. “The joke is every provider is trying to become a payer and every payer is trying to figure out how to become a provider. We’re taking on risk that’s complicated. When we think about our ability to manage a population and we think about the ability to capture an accurate representation of the health of the population, and trying to deliver the care appropriately, it’s accurately assessing the risk of the population.”

Some payers are paid a per member per month management fee.

“You have to have the right clinical programs in place to manage the population, you have to have right programs in place,” Bergmans said. “How are you partnering with payers in a way to keep them motivated to care for populations and help them transition volume to value?”

Bergmans will speak on “Clinically Enhanced Risk: A Payer-Provider Partnership,” at HIMSS17 on Wednesday, Feb. 22, from 11:30 to 12:30 p.m. in Room 304A. 

HIMSS17 runs from Feb. 19-23, 2017 at the Orange County Convention Center.


This article is part of our ongoing coverage of HIMSS17. Visit Destination HIMSS17 for previews, reporting live from the show floor and after the conference.


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