Population Health: Expanding the View and Value of Health Care

Posted: December 1, 2023 | Category: News

By Mark Wendling, MD, Executive Director, Valley Preferred, Primary Care Physician

Through data and significant analysis and research, we know that the U.S. health care system falls behind that of other countries in life expectancy and prevention of chronic disease. Yet we spend a larger portion of our gross domestic product on health care than almost any other nation.(1) These factors prompted a reason for experts to consider the underlying structure of care in this country and how to improve it. The concept of population health was the result: it’s a way to try to mitigate some of the deficiencies in our health care system, as well as improve how care is provided to patients as a whole.

Now following a value-based vs. fee-for-service reimbursement model, insurers have adopted the concept of population health with metrics and measures that hold providers accountable for panels of patients rather than each one individually. Pursuit of these universal outcomes has brought the concept to the forefront and has made it a necessary consideration for all providers, health systems, and communities.

Defining population health

Population health aims to keep people healthy rather than treating them after they are sick, resulting in larger groups of people with improved health. To do that requires a system-wide approach, leading to transformation of all areas of clinical practice and public health. David Nash, MD, MBA, a board-certified internist, the founding dean of the Jefferson College of Population Health, and the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy at Thomas Jefferson University in Philadelphia, outlined the mechanics of population health in an article published in Pharmacy and Therapeutics (P&T).

Population health:

  • Connects prevention, wellness, and behavioral health science with health care delivery, quality and safety, disease prevention/management, and economic issues of value and risk—all in the service of a specific population, be it a city, provider’s practice, hospital’s primary service area, or preschool children.
  • Identifies socioeconomic and cultural factors that determine the health of populations and develops policies that address the impact of these determinants.
  • Applies epidemiology and biostatistics in new ways to model disease states, map their incidence, and predict their impact.
  • Uses data analysis to design social and community interventions and to develop new models of health care delivery that stress care coordination and ease of accessibility.
  • Emphasizes value rather than volume of services rendered.

Focusing on improving health and lowering cost at the population level has become recognized as the most viable tactic for sustaining health care nationwide. It continues to grow in significance as providers and health systems strive to transition their operations to the new paradigm. Much like trying to steer an ocean liner on a whole new course, it takes understanding, cooperation, and thought-out action.

For a detailed view of some parts of the process, watch this video interview with Dr. Nash.

Moving fast in a broader direction

From a population health perspective, we are part way through what could be considered the biggest challenge of all: a pandemic. Such an event clearly illustrates why the time for viewing health population-wide has arrived. This disease has affected people of all ages, it requires both physical and behavioral health assistance, it brings together clinicians from all disciplines, and it had to be attacked on a world-wide population basis. It led to timely discoveries in the need for unprecedented information sharing, proactive outreach, and increasing delivery of alternative visit models. Trying to eradicate the virus patient-by-patient would not have worked.

As we look to the future, the broader population health point of view is a given as the cost of providing health care continues to rise. Noted one health care executive: “It’s been known for a long time that the cost of providing medical services has escalated to the point where it can no longer be perpetuated into the future.” He goes on to note, “This means … providers must coordinate health care in ways that allow populations and individual patients to participate in their own care and aid decisions about medical resources, so we can manage the whole population at large.” (2)

What do providers need to do?

For providers, a population health focus takes the view away from a single patient in the waiting room to a panel of patients in the EMR. It’s a major shift and requires flexibility as well as organization. The following tips originate from a chief nursing officer versed in population health (3) and can help with setting a new course that’s aligned with the direction of health care in general.

Get used to working with data. Managing the health of a given population requires data to identify who’s in need of care, measure the care provided to those populations, and deliver care to the correct people. Applying analytics to the data lets providers enhance care management and address social determinants of health along with identifying rising- and high-risk patients and the care they need. Working with a population health management firm gives providers this ability and renders them capable of using data to their benefit and that of their patients. Ideally, data is gathered from both medical records and insurance claims for a broader overview of the patient, with the idea being that outreach can be specifically targeted.

Create small groups and target certain metrics. Considering a practice’s entire patient population all at once can be overwhelming. Instead, break the population into small groups for evaluation. Start by working with a low-risk group that’s easier to manage, then move onto those that require more care. You can also focus on certain metrics, such as reducing the number of patients that use the emergency department for non-urgent care. Once that metric has been tackled, you can move onto to another taking with you what you learned.

Become comfortable with risk. Physicians have become crucial players in supporting integrated care, promoting best practices, and achieving the clinical efficiencies required for value-based arrangements. That entails accepting greater risk and accountability for both cost and quality of care, with insurers tracking performance and outcomes. Therefore, it behooves physicians to work closely with administrators and financial leaders, carefully considering how all the aspects of an organization’s care and services fit together from the patient’s perspective. Those with systems in place that can take on more risk to care for populations will position themselves to be successful in this value-based world.(2)

Leverage clinical and community relationships. When practices are part of a larger health system they have the advantages of the system’s resources. Those resources may include care coordination*, which can be valuable in coordinating services and after-discharge care. If a provider works independently, he or she is probably versed in what’s offered in the community and can reach out to those service providers to assist patients. Either way, including these relationships in the delivery of care serves to delegate care activities across an entire team and preserve the provider’s time for attending directly to patients.

Communicate for better engagement. It’s the consensus of many that the health of a population can’t be improved without patient engagement. The responsibility for much of that comes down to the provider. There must be good communication, understanding, and honesty. In today’s world that is enabled through emailing with patients, texting with patients, telemedicine with patients, participating in mobile health with patients, getting back to patients in a reasonable time, sharing all the information with them, and sharing decision-making with them.(4)

*Organizing the activities of participants in a patient’s health care to facilitate the appropriate delivery of services. Marshalling the personnel and other resources needed to carry out all required patient care activities relies in part on the exchange of information among participants responsible for different aspects of care.