The Keys to “True” Population Health Management

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David Kindig and Greg Stoddart first defined population health management in their 2003 paper for the American Journal of Public Health as “the health outcome of a group of individuals, including the distribution of such outcomes within the group.” Although for some this simple definition represents the “true” form of population health management, what we understand by population health management has morphed over time in line with the healthcare industry’s own evolution.

As an online MHA student and future healthcare leader, true population health managemement is a vital concept to grasp. In her 2016 article “How To Get Started With A Population Health Management Program” for Health IT Analytics, Jennifer Bresnick proposed a more modern and detailed definition of population health management as “the process of using big data analytics to define patient cohorts, stratify members by their risk of experiencing certain events, deliver care targeted to the individual needs of those members, and report on individual and group outcomes to ensure quality and accountability.” The following elements are key to the population health management process and its best outcomes.

Identifying and Understanding the Population

To accurately manage a population’s health, it’s vital to identify and understand exactly who is considered part of the population. This may seem simple, but identifying a population has become increasingly complex under modern health systems, explained Jennifer Bresnick in her Health IT Analytics article “Top 10 Challenges of Population Health Management.”

Bresnick explained that identifying the population a health provider is responsible for is now a complex matter because health insurance companies typically ask their beneficiaries to nominate a primary care provider (PCP) on enrollment. Any beneficiary who doesn’t name a PCP gets the nearest one assigned to them. This means health providers may be financially responsible for patients they have never treated.

Providers should take a broader view of their populations to balance the ratio of high-needs patients and healthy ones and create a more accurate picture of the population’s health. Healthcare providers should liaise with their partner payers to understand patient attribution methodologies and the impact of changing populations on incentive payments and quality metrics, according to Bresnick.

Identifying and Addressing Social Determinants of Health

Barry H. Ostrowsky, the president and chief executive officer of RWJBarnabas Health, told Tamara Rosin of Becker’s Hospital Review that true population health management must identify and address the social determinants of health. The World Health Organization defines social determinants of health as the conditions under which people are born and those that influence their lives as they age and grow. Employment, housing, education, and food and financial security are all social determinants of health.

The World Health Organization states that social determinants of health play the largest part in health inequities. By identifying and then addressing the social determinants of health within any population, Ostrowsky believes inequities can be reduced and individuals are more likely to achieve and sustain positive health results.

Ostrowsky’s organization, New Jersey’s most comprehensive health delivery system and the state’s largest employer, has taken steps to address social determinants of health in the communities in which it operates by training chronically unemployed members of the community and helping them find work. Ostrowsky believes this initiative is important because employment can improve several other social determinants of health, like financial stability, housing, and access to nutritious food.

Identifying and Targeting High-Risk Individuals

Identifying and addressing social determinants of health involves taking a holistic approach to improve population health. However, it can fail to improve the health outcomes of some high-risk individuals, such as people with good social determinants for health who still suffer from chronic illnesses. That’s why Bresnick suggests identifying and targeting high-risk individuals is also key for true population health management. She suggests assigning risk scores to members of the population based on social determinants for health, psychological risk factors, and chronic diseases. Patients with the highest scores should be targeted for intervention before presenting with serious health complaints.

The Association of American Medical Colleges and National Association of Accountable Care Organizations agrees with the importance of focusing on high-risk patients for sound population health management, commenting in a September 2016 white paper that “Across all [reimbursement] models, the identification, stratification, and management of high-risk patients is central to improving quality and cost outcomes. The use of predictive modeling to proactively identify patients who are at highest risk of poor health outcomes and will benefit most from intervention is one solution believed to improve risk management for providers transitioning to value-based payment.”

Engaging Patients in Population Health Management

While health providers must lead population health management efforts, Brenick states that patients must become involved in population health management programs to ensure their success.

While health providers are responsible for educating patients about chronic disease management, for example, patients are responsible for ensuring they understand the information their physicians impart. They should ask questions and clarify any information they receive. Patients are then responsible for following the recommended treatment plan and maintaining contact with their health providers to ensure any changes in their condition can be diagnosed and addressed. They should also connect with any friends, family members, and community resources that will help them better manage their health.

Lisa Roome-Rago, Advocate Health Care’s director of enterprise outpatient care management, speaking to Bresnick, claims that most patients want to meet their health responsibilities, but some face barriers that can impair their efforts. Healthcare providers and patients should also work closely to identify and address any barriers to health management. Common barriers include a lack of transport, childcare, or time to attend medical appointments, confusion about the treatment plan, or financial pressure that reduces the ability to access medications and treatment services. Patients should be transparent about the barriers they face so their health providers can offer solutions to better manage their health. Only when individual patients engage with their health can the health outcomes of the entire population improve.

Learning how to manage and improve a population’s health outcomes is a core component of the University of Southern California Executive Master of Health Administration online degree program. If you want to deepen your understanding of population health management and other health administration topics, visit the USC website to learn more about this online MHA program.