Healthcare Analytics, Population Health Management, Healthcare Big Data

Population Health News

Is There a True Definition of Population Health Management?

By Jennifer Bresnick

- “Population health management” is one of the healthcare industry’s most darling terms, used by everyone from CMS to payers to EHR vendors hoping to capture the spirit of care delivery transformation in rapidly changing, aging, and sickening patient landscape.  Just like health information exchange, population health management is both a noun and a verb – it is both the means and the ends of raising the overall quality of life and health status of a given patient group.

Population health management

The term first rose to prominence around 2003, when David Kindig and Greg Stoddart first tried to answer the question “what is population health” by defining it as “the health outcome of a group of individuals, including the distribution of such outcomes within the group.” 

Since that time, with the sharp rise of chronic diseases, innovative clinical analytics technologies that make risk stratification a routine task, and new financial incentives to invest in proactive, preventative healthcare, the theory of population health management has moved into practice without much thought devoted to the standardization of the term.

But providers who are actively seeking ways to deploy the principles and strategies of population health management in their own organizations need more than vague generalities to implement the right technologies and make the best possible use of their human and financial resources.

As a tool or a strategy, a goal or an action, the definition of population health management remains so elusive that researchers at The George Washington University’s Executive Master of Health Administration program ([email protected]) decided to ask a group of industry movers and shakers about their own opinions on population health management in an attempt to illuminate how providers, payers, and other stakeholders are putting the principles of large-scale patient management into action.

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What were the most common definitions of population health management in the industry, and how can these attempts at codifying a movement help healthcare providers achieve their patient care goals?

A strategic vision for improvement

In a broad sense, population health management is an aspiration.  It forces healthcare providers to ask themselves how they can use health IT and patient-centered care strategies to promote better lifestyle choices, seek evidence-based care at recommended intervals, manage their chronic diseases most effectively, and keep unnecessary costs for the healthcare system low. 

True population health management helps to develop a partnership between providers and the patient community built on mutual trust and effort to generate better outcomes for everyone involved in the process of care.

“Population health is a visionary statement that gives a sense of what we want for our population,” said Tammie Jones Senior Health Policy Officer, US Army Office of The Surgeon General. “[It’s] a health status that allows individuals in our communities to serve one another to their greatest ability.”

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For patients, population health requires a higher level of engagement, education, and participation than has been expected in the past.  For the healthcare system, that means an overhaul to the way it perceives itself, starting with payment reform.   

“Population health involves transitioning care delivery to a model that is value based which includes focusing on better case management of those patients with multiple co-morbidities, partnering in care delivery with other providers, including previous competitors, better managing overall utilization and caring for patients in the most appropriate setting, not necessarily acute care,” added Barry Ronan, President and CEO of Western Maryland Health System.

A big data analytics project

The term can also be used to describe the workflows, technologies, and strategies involved in improving the overall health status of a given subset of patients.   Clinical analytics and patient risk stratification, developed from EHR data, claims data, health information exchange information, or patient-generated health data, can give providers a better way to prevent vulnerable patients from falling away from the continuum of care. 

“Population health means taking an analytical approach to understanding the health needs, disparities and outcomes of the community and to align improvement initiatives,” said Kathryn Ruscitto, CEO of Joseph’s Hospital Health Center.

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Janet Porter, Principal at Stroudwater Associates, agreed that population health management is a data-driven project requiring advanced planning and forethought. “Population health is the analysis and design of interventions and management of large groups of citizens focused on improving their health status,” she said.

In this sense of the term, population health management is a set of actions, backed and dictated by the flow of information, that guide providers to the best way to providing optimal services to a group of patients with specific healthcare needs.  Since the rise of big data analytics and a slew of dedicated health IT tools to make workflows easier and reporting more meaningful, implementing these strategies has become a major objective for most healthcare providers.

A balance of quality and cost

For payers and revenue cycle managers, population health management is all about cutting the most possible costs while producing the highest possible quality.  The Triple Aim captures this sentiment well, several [email protected] respondents said, by helping providers focus on the individual, the community, and the opportunities for savings.

“Population health is the acknowledgement that the goal of all health system stakeholders is to do the most good for the most people at the least amount of cost,” said Providence Health Plan CEO Jack Friedman. “It requires a primary care centered model that incentivizes all providers to measure their clinical performance at the population level, and it requires interface between public and private institutions along with local community engagement. Population longevity and broad values around quality of life are the ultimate measures of success and performance.”

“Population health is keeping people healthy in a coordinated fashion for better clinical outcomes at a lower cost,” added Jay Higgins, Senior Director of Network Strategy and Surgical Program Development at Brigham and Women’s Hospital. “It is a ‘proactive’ solution in an industry that has thrived on being ‘reactive’” in situations that may end up generating more costs than they save, he said, like sending a patient to the emergency room when access to primary care is unavailable.

Cost-cutting, quality-boosting delivery models like the patient-centered medical home try to preempt these expensive and dissatisfactory situations by expanding care access, ensuring that patients have the right resources at hand to manage their health, and connecting primary care with other services that create a safety net for high risk, high utilization patients.

An overarching responsibility

At its core, population health management is the responsibility of healthcare providers to do the most good for the most number of patients.  Whether by improving chronic disease management programs, ensuring that community resources are available when patients need social support, or using data analytics to help patients catch up on missed screenings or complete necessary tests, population health management is about the need to do more than treat the disease the patient comes in with.

It’s about “assuming total health and health care responsibility for a group of individuals and empowering them with health information and tools with an emphasis on personalized prevention and self-management programs,” said Marie Savard, MD, Managing Director of Health Care Practice at Diversified Search. “From my experience, it is managing care for the right reasons and improved health of the patient versus for economic reasons alone, which was the primary motivation of past attempts in population health.”

Bahaa Wanly, Administrator at UW Medicine, said that population health is “effectively taking responsibility for the health care of populations of patients to ensure high-quality, efficient health care at the lowest possible cost for the population.”

“Responsibility” is the name of the game in a healthcare industry that is preparing for the seismic shift of accountable care and value-based reimbursement.  Providers who will be getting paid based on their patients’ outcomes will need to expand their preventative care capabilities, take advantage of new data analytics technologies that will give them actionable insights into the tasks at hand, and embrace the idea that healthcare now runs more deeply into the community than ever before.


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