Top 7 Benefits of Population Health Management Software

Healthcare organizations managing large patient populations require systems that centralize medical information. Population Health Management Software aggregates data from physician practices, insurance carriers, laboratories, and pharmacies. Organizations implementing these systems experience reduced hospital readmissions, improved quality performance, and decreased healthcare expenditures.

1. Reduces Hospital Readmissions and Emergency Visits

Population Health Management Software identifies patients at elevated risk for hospitalization. The system analyzes patients with deteriorating chronic conditions, medication non-compliance, and recent emergency department utilization. Clinical staff contact these individuals with preventive interventions before acute care becomes necessary.

2. Improves Quality Measure Performance

Quality scores determine how much insurers pay under value-based contracts. Software tracks HEDIS, MIPS, ACO, and STAR rating measures for all patients. The platform shows which patients need screenings, disease monitoring, or medications. Staff get lists of who to contact before reporting deadlines arrive.

3. Streamlines Care Coordination Across Settings

Patients receive care from primary physicians, specialists, hospitals, and post-acute facilities. Population Health Management Solution platforms enable information sharing across these care settings. Primary care physicians access hospital discharge summaries. Care managers review specialist treatment recommendations. Post-acute providers receive current medication lists. Coordinated information exchange prevents duplicate diagnostic testing and contradictory treatment plans.

4. Automates Regulatory Reporting Requirements

Federal and commercial payers require distinct quality reports with specified formats and submission deadlines. Software generates these reports using aggregated patient data. Organizations export formatted files for MIPS attestation, HEDIS reporting, ACO quality submission, and Medicare Advantage STAR calculations. Automated generation reduces manual data compilation time and minimizes reporting errors.

5. Identifies Social Determinants Affecting Health

Clinical records provide incomplete pictures of patient health challenges. A Population Health Management Solution incorporates social determinant data, including housing stability, food security, transportation access, and financial constraints. Care teams identify patients requiring social services alongside medical treatment. 

Social Factors Analyzed

• No stable place to live
• Not enough food to eat
• No way to get to doctor appointments
• Cannot afford medications

6. Provides Real-Time Performance Dashboards

Hospital bosses want to know if their programs work. Computer screens show quality numbers, how much money is spent, hospital usage, and what staff accomplished. Hospitals see if their efforts cut readmissions, help diabetics, or reduce emergency visits. Having fresh information means hospitals can change things right away instead of waiting for quarterly reports.

7. Supports Multiple Value-Based Contract Types

Organizations have several different payment contracts at once, including Medicare Shared Savings, BPCI Advanced, Medicare Advantage, Medicaid managed care, and commercial ACO agreements. Software tracks what each contract requires and shows expected savings or losses. This information helps organizations focus their work where it matters most financially.

Bottom Line

Persivia's software handles over a million patient files and gets information from thousands of doctor offices and insurance companies. Hospitals using Persivia’s solutions spot very sick patients, fix quality problems, and share information between hospitals, clinics, and rehab centers. Learn more.

Practical ACO Success Strategies For Health Systems

Accountable Care Organizations link payments to patient outcomes and cost savings rather than service volume. Health systems in ACO programs need ACO Success Strategies for clinical quality, financial performance, and care coordination. Medicare Shared Savings Program ACOs earned $4.1 billion in shared savings in 2024. ACOs that perform well focus on primary care, data analytics, team-based care, and patient engagement. These organizations invest in infrastructure for population health management.

1. Building Primary Care Foundations

Primary care drives ACO performance. ACOs with more primary care physicians save more money than those with fewer primary care doctors.

Primary care requirements:

• Hours during evenings and weekends
• Teams with nurses, pharmacists, and social workers
• Behavioral health in primary care offices
• Care managers for high-risk patients
• Same-day appointments when needed

2. Integrating Data and Analytics

Data runs every ACO operation. Organizations must see clinical patterns, cost drivers, and quality measure performance.

Multi-Source Data Integration

ACOs pull data from EHRs, claims systems, lab results, and pharmacy records. This makes complete patient profiles showing all care across settings. EHR data gives diagnoses, medications, and vital signs for chronic disease tracking. Claims data shows utilization and costs by service. Lab results show test outcomes and screening rates. Pharmacy data tracks medication adherence and drug interactions.

Analytics platforms must show performance against benchmarks continuously. Monthly reports arrive too late.

3. Managing Care Transitions

Hospital-to-home transitions create high risks for readmissions. Poor transitions waste money through penalties and repeated hospital stays.

ACOs run formal transition programs. These programs collect hospital discharge information, check medications, and screen for complications after discharge. Care managers call patients within 48 hours of leaving the hospital.

Health information exchange alerts tell primary care providers when patients visit hospitals or emergency departments. This starts an immediate follow-up.

4. Quality Measure Performance

Quality scores directly affect ACO shared savings eligibility. Medicare requires ACOs to meet quality thresholds before paying any shared savings.

ACOs track HEDIS measures, patient satisfaction scores, and preventive care completion continuously. Staff see which patients have open care gaps and call them.

Methods include:

• Quality measure tracking in EHR workflows
• Patient registries for chronic conditions
• Staff assigned to close care gaps
• Same-day services for overdue screenings
• Automated reminders for preventive care

5. Provider Engagement and Culture Change

Physician leadership drives ACO success. Providers must understand why clinical changes matter and see how changes affect outcomes and finances.

Culture change needs:

• Regular performance feedback to providers
• Transparent data on costs and quality by physician
• Financial incentives tied to quality and cost

Take Action Now!

Persivia's platform supports health systems with ACO Success Strategies. The system pulls clinical and claims data from multiple sources into complete patient profiles. Risk tools find high-risk patients who need intensive management. Quality tracking monitors HEDIS, MIPS, and other metrics continuously with automatic care gap identification. 

Visit Persivia to see how population health platforms support ACO operations.

How To Evaluate A Digital Health Platform For Long-Term Growth?

Healthcare organizations invest in technology, expecting it to scale with their needs over the years. A Digital Health Platform must handle more patients, new payment models, and changing regulatory requirements without complete replacement. Organizations using scalable platforms manage 160 million patient records while adding new data sources and programs. The right platform grows from supporting 5,000 patients to 50,000 patients without performance issues or major upgrades.

Evaluating A Digital Health Platform For Long-Term Growth

1. Check If Architecture Grows With Your Organization

Digital Health Platforms need a modular design where organizations add capabilities without rebuilding core systems. A platform might start with care management and later add risk adjustment, quality reporting, or analytics modules. Each addition integrates with existing functions rather than requiring separate installations.

Check whether the vendor offers all the needed modules or limits options. Organizations often start with one program and expand to multiple value-based contracts over time.

Architecture Components to Verify

• Modular design allowing capability additions
• API access for custom integrations
• Database capacity for growing patient volumes
• Processing speed that maintains performance under load

2. Verify Data Capacity Handles Future Volume

Organizations start with data from their own EHR and gradually connect claims feeds, lab systems, health information exchanges, and specialty vendors. A Digital Health Platform must ingest and process increasing data volumes without slowing down.

Ask about current data limits and what happens when organizations exceed them. Some platforms charge more for additional data sources. Others include unlimited connections in base pricing.

3. Assess Vendor Stability for Long-Term Partnership

New software companies may not survive long enough to support your investment. Check how long the vendor has operated in healthcare and how many organizations use their platform. Companies serving hundreds of clients for over a decade are more stable than startups.

Request client references from organizations that implemented the platform three or more years ago. Ask whether the vendor delivered promised updates and maintained system performance as usage grew.

4. Evaluate Implementation Speed and Adaptability

Platforms requiring 12-18 months to deploy often have rigid configurations that don't adapt well to changing needs. Digital Health Platforms that are implemented in 8-10 weeks typically offer more flexible architectures that adjust as organizations grow.

Fast implementation also means organizations can launch new programs quickly when opportunities arise. A health system joining a new ACO needs its platform ready within months, not years.

5. Confirm Updates Support Continuous Growth

Software that requires downtime for updates creates operational problems. Modern platforms update continuously without interrupting users. Check the vendor's update schedule and whether updates require system outages.

Organizations need platforms that adopt new regulatory requirements automatically. When CMS changes quality measure specifications, the platform should update calculations without custom programming.

Update Requirements to Check

• Frequency of platform releases
• Downtime needed for updates
• Automatic vs manual update processes
• Regulatory change incorporation timeline

6. Test Integration Flexibility for Future Systems

Organizations use different EHRs, billing systems, and specialty applications. A CareSpace® Digital Health Platform must connect bidirectionally with all these systems. Single-vendor lock-in limits flexibility as organizations acquire new practices or change technology partners.

Verify the vendor maintains current integrations with major EHR systems and can add new connections as needed. Ask about interface development timelines and costs.

7. Review Reporting Capabilities for Evolving Needs

Value-based contracts change frequently. Medicare launches new programs. Commercial payers modify quality metrics. The platform must generate reports for new requirements without extensive reprogramming.

Look for platforms with report builders that let staff create custom reports. Pre-built reports for HEDIS, MIPS, ACO, and STAR ratings should update automatically when specifications change.

8. Calculate Pricing Model for Sustainable Expansion

Some vendors charge per patient or per transaction, making costs unpredictable as volumes increase. Others offer flat rates or tier-based pricing that scales more predictably. Understand the total cost of ownership, including licenses, interfaces, support, and future expansion.

Hidden costs appear when organizations need additional modules, data connections, or user licenses. Get detailed pricing for projected five-year growth.

Final Call

Persivia has supported healthcare organizations for over 20 years as they grew from regional practices to major health systems. The CareSpace® Digital Health Platform processes data from thousands of sources while serving organizations with millions of patients. Health systems add new value-based contracts, quality programs, and care management services without replacing their core platform. Implementation happens in weeks, and the platform updates continuously to meet new CMS requirements and payer specifications.

What Does The CMS TEAM Model Signal About The Future of CMS Payment Models?

The CMS TEAM Model (Transforming Episode Accountability Model) starts in 2026 and runs through 2030. CMS mandates participation for selected hospitals. Hospitals become financially responsible for surgical episodes like joint replacements, spinal fusions, and major bowel surgeries. The model spans 30 days after surgery, measuring both costs and quality. Early participants achieve 4% better pricing compared to national benchmarks while maintaining quality standards.

Mandatory Participation Shows CMS Moving Away from Voluntary Programs

The CMS TEAM Model requires hospital participation, rather than making it optional. Earlier payment models let organizations choose whether to join. CMS picks hospitals by location and how many surgeries they perform. This signals future payment reforms will likely be mandatory rather than voluntary.

Surgical Focus Shows CMS Testing Before Broader Rollout

The TEAM Model CMS focuses on surgeries with known costs and clear outcomes. Joint replacements, spinal fusions, and bowel surgeries follow standard treatment steps. CMS tests episode payments on these procedures first before adding harder-to-predict conditions. This suggests CMS will expand episode payments gradually to other medical areas once surgical episodes prove successful.

Financial Risk Elements

• Spending above episode target prices reduces payments
• Quality score penalties for missed benchmarks
• Readmission costs come from episode budgets
• Post-acute care expenses count toward episode totals

30-Day Windows Indicate Shorter Accountability Periods Ahead

Hospitals are responsible for patient care during the 30 days after surgery. Older bundled payment programs used 90-day windows. The shorter period covers immediate recovery and complications. CMS appears to be checking if shorter episodes work as well with less paperwork. Future payment models may use these condensed timeframes instead of longer periods.

Five Years Shows CMS Commitment to Episode-Based Models

CMS built the TEAM Model to last until 2030. Hospitals operate under these payment rules for five years. This extended timeline means CMS plans serious testing rather than short pilots. Organizations can expect episode-based payments to become a permanent part of Medicare rather than a temporary experiment. This extended timeline indicates CMS plans sustained testing rather than short pilot programs. The duration also gives organizations time to develop care coordination systems and see measurable results.

Dual Metrics Point to Quality-Cost Balance in Future Models

The model measures both spending and clinical outcomes. Hospitals can't succeed by cutting costs alone if quality declines. This dual accountability suggests future CMS models will continue linking financial performance to patient outcomes rather than rewarding cost reduction independently. Expect all future payment reforms to include quality requirements alongside spending targets.

Signals About Future Medicare Policies

The TEAM Model reveals CMS priorities for future payment reforms. Episode-based approaches may expand to additional procedures and conditions. More payment models will likely include downside risk, where providers lose money for poor performance.

CMS appears committed to moving away from pure fee-for-service toward models that reward outcomes and cost management. Organizations unprepared for these payment structures will face financial challenges as Medicare expands alternative payment models.

What Future Payment Models Will Likely Include

• Mandatory participation replacing voluntary programs
• Episode-based payments expanding to medical conditions beyond surgery
• Shorter accountability windows under 90 days
• Combined cost and quality metrics determining payments
• Multi-year implementation periods for system development

Hospital Preparation Needs Start Now

The model starts in 2026, but hospitals need their systems ready earlier. They need software that tracks costs for 30 days after surgery, connects with rehab facilities and home health agencies, and watches quality numbers. Implementation planning should begin well before mandatory participation dates.

About Persivia

Persivia's platforms support healthcare organizations managing episode-based payment models, including the CMS TEAM Model. This technology tracks episode costs, monitors quality performance, and coordinates care across multiple providers. Health systems using Persivia’s solutions achieve better pricing than national averages while meeting quality standards. 

What Actually Changes When Organizations Shift to Value-Based Care?

Hospitals and medical groups traditionally bill insurance for every visit and procedure. Value-Based Care pays based on patient outcomes and overall costs instead. Organizations sign contracts that put them at financial risk if their patients need expensive care. They also earn bonuses when they improve health outcomes while spending less. This shift demands different technology, workflows, and staff than most healthcare organizations currently have.

Payments Depend on Quality Metrics

Value-Based Care contracts pay providers based on their quality scores and total spending. A hospital gets bonuses when diabetic patients maintain good A1C levels. That same hospital loses money if too many patients get readmitted within 30 days.

Medicare ACOs that met quality targets earned bonuses averaging $67 million in recent years. Groups that exceed spending benchmarks or miss quality goals see reduced payments even when they treat more patients.

Common Payment Models

• Shared savings, where organizations keep a portion of the cost reductions
• Capitation payments that give providers a set amount per patient, monthly
• Bundled payments covering all services for procedures like hip replacement
• Quality bonuses added to base payments

Care Teams Reach Out Before Problems Happen

Doctors' offices used to wait for sick patients to call for appointments. Now, care teams contact patients before health issues get worse. Staff call diabetics when their blood sugar trends upward. They schedule cancer screenings before patients miss their eligibility window.

McLaren Health saved $34 million by stopping hospitalizations before they happened. Their teams found high-risk patients and helped them early instead of treating them in emergency rooms later.

Organizations Need Much More Patient Data

Traditional practices track billing codes and schedules. Value-based care needs claims records, lab results, pharmacy data, and information about patients' living situations.

Health systems need software that pulls data from different EHRs, health information exchanges, and insurance companies. Prime Healthcare gathers information from thousands of places to find missed screenings and monitor quality across all their patients.

Hospitals Hire Different Types of Staff

Traditional hospitals employ doctors, nurses, and billing staff. A Value-Based Care Solution needs care managers, data analysts, quality specialists, and population health coordinators.

Care managers contact patients and help them manage chronic diseases. Analysts watch quality numbers and costs. These positions cost money upfront before the organization sees any savings from value-based contracts.

New Team Members

• Care coordinators who manage chronic disease patients
• Population health nurses focused on preventive services
• Data analysts tracking quality and cost metrics
• Social workers addressing non-medical barriers to health

Technology Infrastructure Needs A Complete Overhaul

EHR systems designed for fee-for-service billing lack population health management capabilities. Organizations invest in Value-Based Care Solutions that stratify patient risk, identify care gaps, and measure outcomes across thousands of patients.

Implementation timelines vary widely. Some organizations spend 12-18 months deploying new systems. Others complete installations in 8-10 weeks, depending on vendor capabilities and organizational readiness.

Financial Risk Transfers to Providers

Fee-for-service healthcare carries minimal financial risk. Providers bill for services and collect payments regardless of patient outcomes. Value-based contracts make organizations responsible for their patients' total healthcare costs.

An ACO managing 10,000 Medicare beneficiaries faces potential losses if those patients' combined medical expenses exceed benchmarks. This risk exposure requires reserves, insurance products, and financial management expertise that most healthcare organizations developed for fee-for-service operations.

About Persivia

Persivia supports healthcare organizations through value-based care transitions with technoloy developed over 20 years in population health management. Health systems using Persivia's platforms manage over 160 million patient records while connecting to thousands of data sources. Organizations report measurable improvements in quality scores and cost performance after deployment. The company's implementation approach completes system setup in weeks rather than months, allowing care teams to start managing populations quickly.