A New, Unique Frame for Population Health Management

WOONSOCKET, R.I., — CVS Health's Chief Medical Officer Troyen A. Brennan, MD, delivered a keynote address outlining CVS Health's unique potential to help change current paradigms for addressing population health, during HLTH 2018, a health care innovation conference, recently held in Las Vegas, NV. Brennan outlined how the combination of data-driven insights, and the convenience of community-based retail health care can provide a highly personalized health care experience that supports the primary care medical home, and can improve patient outcomes and lower costs.

"Chronic disease in America is growing, and our ability to pay for it is shrinking," said Brennan. "At CVS Health, our goal is to make care more accessible, affordable, and convenient to help create a healthier population. Our unique enterprise-wide capabilities, including our vast physical retail footprint, and digital and analytic capabilities, put us within reach of nearly every American, which allows us to help create a new standard for health care engagement."

Today, just 5% of the United States population is driving approximately 50% of total health care spending, at more than $50,000 per patient annually. Many of these patients have common chronic diseases which, when unmanaged, can result in costly, and sometimes debilitating medical complications. In addition, when patients experience transitions in care, from the hospital to a home setting, more than 40% of resulting hospital readmissions are preventable, totaling more than $17 billion in avoidable costs in Medicare.

Brennan discussed the potential for CVS Health to "create a new, unique chassis for population health management" by complementing the traditional use of telephonic case management with digitally-gathered information and real medical intelligence, combined with in-person visits to conveniently located health care hubs based at MinuteClinic and CVS Pharmacy. "We are looking to narrow the distance between patients in their everyday lives, and the caregiving facility by leveraging digital data, and making health care accessible in convenient community locations," Brennan said.

Brennan noted that initial pilots exploring retail-based population health management will focus on 3 target groups of patients: those with 5 common chronic diseases (diabetes, hypertension, hyperlipidemia, asthma, and depression); fragile patients who disproportionately drive a large percentage of total health care costs; and patients transitioning from a hospital setting, who require focused care to prevent readmissions, and avoidable costs.

To support interventions with these patient populations, the company will be exploring innovations in 4 major categories, including new ways to coordinate health care interventions at CVS Pharmacy and MinuteClinic; improved health monitoring, and data collection in patients' homes; enhanced outreach to patients using a variety of disruptive digital tools; and embedded connectivity with patients' primary care providers to complement, and enhance preventive care. "Without true innovation, more people will simply be without health care in the future," Brennan said. "At CVS Health, we share in the responsibility to create a healthier population, and a better, more sustainable health care system, and our goal is to do this by removing unnecessary costs through high qualit,y and coordinated care."

Brennan also discussed how the company is using advanced analytics, and enhancing its digital capabilities in areas such as telemedicine, and home-based biometric monitoring for certain conditions. Between regular doctor visits, a patient with a chronic condition, such as diabetes or hypertension, could see a MinuteClinic provider for a series of tests to help understand how their medications are working, make adjustments to their therapeutic regimen, and receive tailored counseling on adherence and lifestyle management.

In addition, telemedicine can also help fill the gaps between in-person visits to a local CVS Pharmacy or primary care provider. All information gathered during these visits could be captured and shared via the patient's electronic health record with their primary care provider ,and other members of the patient's care team to help ensure connected care. This high-touch, integrated model could also be used to help patients transition from a hospital stay back to their home in order to help prevent unnecessary ER visits or hospital readmissions.