Managing high-risk patients within a population health management framework

Lumeris worked with this client, from the top down, to determine the appropriate opportunities, and then implement population-level interventions and care management opportunities. A major opportunity was the ability to reduce high-cost and over-utilizing members by holding monthly meetings to review high-risk patients. Lumeris used a three-year approach with the client that achieved the Triple Aim Plus One: increased quality of care, reduced costs, and patient plus physician satisfaction.

Client Profile

  • Upside-only contract
  • Capitation then internal PCP compensation based on profit and loss


  • Improve a poorly performing group lacking strong leadership using data to enable best practices and high-risk patient management

Specific Solutions

  • Adjusted compensation to pool risk for high-cost cases and required monthly meetings to review care of high-risk patients
  • Identified and trained new Medical Director and leaders
  • Conducted opportunity analysis that identified needed population-level interventions and care management opportunities
  • Established processes to share comparative data, best practices and identify opportunities
  • Payer implemented advanced imaging, social work, complex care management, and medication management
  • Used the Nine C’s® Playbook with strategies and tactics to support provider behavior change
  • Deployed Enhanced Encounter®, a prospective health assessment program that supports effective management of chronic and high-risk populations for revenue management


      • 30% reduction in acute admits
      • 4% reduction in ER visits
      • 27% reduction in acute days
      • 10% reduction in SNF days
        *Results per 1000 from years 2010 to 2013


            • Higher-than-market percentage on four HEDIS® measures

Patient Satisfaction

            • 94% of patients seen annually

Physician Satisfaction

        • 63.2% MCR (2013 before surplus distribution)