Population health management is a proactive, comprehensive approach to patient care combining new reimbursement models, innovative workflows, and data-driven insights to help primary care providers stay ahead of clinical risks.
As healthcare stakeholders work together to improve the efficiency and quality of care, primary care providers are finding themselves face to face with a number of new challenges and opportunities.
Value-based care is expanding rapidly, providing financial support for a different approach to working with patients known as population health management.
In 2003, healthcare researchers David Kindig, MD, PhD and Greg Stoddart, PhD proposed one of the first definitions for population health management.
Kindig and Stoddart described the emerging concept as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group," adding that the academic field of population health also includes health outcomes, the patterns of health determinants, and all of the policies and interventions that link the two together.
More than 15 years later, that definition still holds true. However, the intervening decade-and-a-half has added new complexities, urgencies, and strategies to the population health management process.
The widespread adoption of electronic health records (EHRs) and advancements in information sharing have drastically expanded providers’ capabilities to identify high-risk individuals and analyze patient patterns at scale, while the advent of quality reporting programs and outcomes-based incentives have created a framework for gauging results and putting population health into action.
For primary care physicians, this combination creates an ideal environment in which to practice patient-centered medicine with a strong focus on holistic, preventive, and comprehensive care.
The goals of value-based care are to improve patient outcomes while reducing avoidable spending. In order to achieve these objectives, providers will need to deploy a population health management plan that incorporates new reimbursement models, innovative workflows, and data-driven insights to help them stay ahead of clinical risks.
There is no getting around the fact that providers must generate enough revenue to keep their lights on, which is why population health management is often supported by value-based care contracts that do a better job of offering aligned incentives than traditional fee-for-service payment structures.
Joining an accountable care organization (ACO) and participating in the Medicare Shared Savings Program (MSSP) or a commercial value-based care contract reduces the need to rely on the volume of patients or services for maintaining a steady practice income. Instead, providers can focus on maximizing the delivery of preventive, clinically appropriate care for their attributed patients.
Providers often begin their ACO journey in an upside-only risk model, which allows the ACO to earn shared savings for meeting quality and spending targets without being responsible for paying back any losses if the ACO spends more than expected.
However, two-sided risk models offer even greater potential rewards in exchange for accepting a degree of financial accountability if ACOs exceed their spending targets. These models are becoming more popular and effective as practices gain experience with population health and value-based incentives.
Population health management is built around the concept that a practice can optimize outcomes for an entire population of patients by providing services customized to patients’ unique needs, whether they habitually present to the office for care or not.
Prevention and access are critical components for healthy and chronically ill patients. Evidence-based preventive care, such as cancer screenings, chronic disease management programs, and regular wellness assessments, can catch rising risks early enough to forestall the need for many hospitalizations, ED visits, and other high-cost interventions.
Payers and regulators use quality measures to ensure that providers are conducting key processes and working with patients towards favorable outcomes. These may include regular blood sugar testing for patients with diabetes or blood pressure control for patients with hypertension. Quality measures also collect data on how well providers can successfully reduce unwanted outcomes, including avoidable hospital readmissions or preventable falls.
Quality measures define objectives that providers have to meet, but primary care practices are responsible for designing and executing the interventions that drive results.
These strategies may include:
- Developing comprehensive, physician-led care teams that include physician assistants, nurse practitioners, nurses, and medical assistants as well as other staff members such as nutritionists, social workers, and care coordinators
- Creating educational chronic disease management programs to improve self-care skills and encourage positive lifestyle choices
- Following up with patients after a hospitalization, skilled nursing facility (SNF) stay, or ED visit to manage transitions of care, answer questions, reconcile medications, and reinforce adherence to discharge instructions
- Expanding access to care by offering additional office hours, after-hours help lines, texting or online messaging, and same-day appointments for urgent needs
- Partnering with community organizations and other providers to connect patients with services that can help address socioeconomic issues
These offerings and services can provide comprehensive support for patients struggling to cope with chronic conditions or those who might otherwise turn to high-cost emergency departments as their primary mode of accessing care.
Success with population health management relies entirely on being able to identify needs and categorize patients by their health risks and existing conditions.
After all, providers will not be able to ensure that all their attributed hypertension patients have their blood pressure under control if they do not know who these patients are and what services are already being performed to help meet the objective.
Health IT tools and data analytics are critical for stratifying patients by risk, closing gaps in care, and identifying potential areas for performance improvement.
In order to accurately assess patients for risk, primary care providers need complete visibility into activities across the care continuum, including ED and hospital events, specialist utilization, laboratory work, and pharmacy use.
These insights allow providers to engage the right patients at the right time and personalize their care accordingly. As a result, providers can reduce unnecessary spending and create opportunities to see rewards for their work.
As with any transition, there are rough patches and frustrations that may induce skepticism about its long-term value.
Population health management is no exception. This approach represents a significant departure from the world of fee-for-service healthcare. However, the results so far are extremely encouraging.
When backed by value-based care contracts, the population health approach is having a positive impact at every level, from moving the needle on national spending to improving the everyday health of individuals and their families.
ACOs have become particularly powerful vehicles for change. As the MSSP continues to grow and evolve, ACOs are saving hundreds of millions of dollars for Medicare and taxpayers while performing extremely well on quality measures.
In 2018, more than 540 ACOs generated $739.4 million in total net savings for Medicare, according to CMS data, while securing average quality scores of 93 percent.
With a coordinated, data-driven approach to population health management, Aledade’s physician-led ACOs beat the national average with a 96 percent average quality score while saving Medicare $69 million in 2018.
Aledade partners reduced hospitalizations by an average of 6 percent, with some ACOs achieving reductions of more than 15 percent for their attributed patient groups.
These statistics are an important barometer for how well population health management is working to raise quality and reduce costs at the national and regional levels.
Yet the impact on individual health and wellness is even more immediate and profound.
People like “George,” a patient of Dr. James Zini in Mountain View, Arkansas, often need the structure and support of population health management programs to help them regain control of their health and avoid long-term complications and high-cost healthcare utilization.
After George ended up in the emergency room with dangerously high blood sugar and blood pressure, Dr. Zini used Aledade’s population health tool to receive an alert and schedule a speedy follow-up appointment. He prescribed appropriate medications and referred George to a diabetic educator, who encouraged dietary changes and exercise to help control George’s chronic conditions.
George’s job in a fast food restaurant made it difficult for him to make healthy choices consistently. But with regular follow-up and support from his care manager, family members, and physician, he was able to reduce his A1C from 10.5 to 5.0 in just three months. George has lost 100 pounds and is tapering off his blood pressure and blood sugar medications, since they are no longer necessary to keep his conditions under control.
Improving his self-management skills is likely to lead to fewer expensive encounters with the emergency department and may improve his prospects for better long-term health.
This real-life example of population health management in action is replicated thousands of times a day across the primary care environment as more and more providers embrace a coordinated, proactive approach to patient care.
When supported by aligned incentives and actionable, data-driven insights into patient activities, the population health approach has the potential to drastically improve the health outcomes of individuals, communities, and the nation as a whole.