Population management for preventing the 80–20 rule

Chronic conditions require longer and more frequent visits, as well as more care coordination. Learn how to anticipate, plan for, and even prevent intensive resource use.


Consider the following 80-20 rule as applied to your patient population: 20% of your patients consume 80% of your time. Most patients have one or two minor conditions resulting in a couple of visits per year. Those who have chronic conditions such as diabetes, hypertension, arthritis, or lung disease require longer and more frequent visits, more phone calls, and more care coordination. Add to that all the relevant quality measures for various entities and payers, and that is a recipe for inefficiency. So how do you anticipate, plan for, and even prevent some of that intensive resource use?

Population management, whether for addressing patients with chronic conditions or coordinating preventive care services, is a proactive use of data that are easily available in the practice. It is a team-based approach that focuses on prevention, care coordination, and partnerships with patients to manage chronic conditions. The term “population management” is one of the common buzzwords heard in discussions of value-based payment and quality improvement, and if done well it can reduce some office burdens.

Population management is nothing new. Physicians by their very nature already perform population management with every patient that walks through the door. What's new is the systematic, evidence-based approach practices can use to take care of certain categories of patients.

Data generated by office systems and used by staff are key to successful population management. Reports, chart reminders, reminder letters, and standing orders can be set up in your electronic health record (EHR) or practice management system. Reminder letters can be used to contact patients who have missed important screenings. In addition to helping physicians provide high-quality care to patients, population management can also serve to even out schedules by arranging visits during slower periods.

Technology is the first place to start. For example, diabetic patients can easily be identified based on diagnosis codes. Staff can run a report of patients who have not been seen in a year or six months and then query the EHR to identify those patients with diabetes whose last HbA1c levels were above a certain number. A member of the clinical staff can call the patients to discuss possible testing, counseling, and medication review; to answer questions about lifestyle changes; or to schedule a visit with a clinician. A plan can be created, and follow-up can be continued with these patients over time.

This process, if documented appropriately, would offer additional benefits. First, the practice can bill Medicare for a chronic care management code for the ongoing care provided between visits, which represents some additional reimbursement to cover some of the additional staff time required. The proactive management of chronic and preventive care for specific conditions also counts as a medium-weighted improvement activity in CMS's Quality Payment Program (MIPS Improvement Activity IA_PM_13). This could also satisfy requirements for becoming a patient-centered medical home (PCMH). For the National Committee for Quality Assurance (NCQA), for instance, “identifying patients for care management” is a core requirement.

Glycemic management services (MIPS Improvement Activity IA_PM_4) for patients with diabetes who are prescribed antidiabetic agents, receive an individualized glycemic goal that takes into account personal factors, and are reassessed at least annually count as a high-weighted improvement activity. Physicians who perform such services also qualify for 10% bonus points if a certified EHR was used in the process. Recording the HbA1c level at each visit can count as an “intermediate outcome” measure in the Quality category (National Quality Forum [NQF]: 0059, CMS Quality ID: 001). (It should be noted that small practices with 15 or fewer clinicians get double points for improvement activities and that such activities only need to be performed for 90 days during 2018.)

ACP's website and Practice Advisor® quality improvement tool have sample policies, procedures, forms, and letters that can help staff implement recall and reminder systems for patients needing condition-specific, timed services. For more information and resources on how to implement population management in a more systematic and effective way in your practice, see the “Manage Populations” module in ACP's Practice Advisor®. For help in implementing chronic care management for specific patients with two or more chronic conditions, see ACP's Chronic Care Management Toolkit.