Introducing a four part series on the integration of population health management, as the healthcare delivery ecosystem focuses on providing higher value care and reducing ballooning costs.

Like many fields, the healthcare industry is undergoing rapid changes on a seemingly daily basis. One of these has been around integrating a long-standing pillar of public health—the development of population-centric healthcare. Our system has been developing care approach from what happens to a patient who is sitting on the exam table to include preventing the patient from sitting on the exam table in the first place. The scope of factors being examined across the ecosystem has broadened, as we deepen our understanding of the correlation between access, adherence, transparency, regulation and outcomes.

Social & Environmental: Indicators of Health Status Beyond the Point of Care
The social determinants of health effectively bridge the gap between communities and health status. When studied and implemented, we see increased resource alignment for longitudinal improvement of health and decreased variation in care pathways to achieve health equity. Environments that differ in economic and social policies, political systems, or social norms can lead to patients thriving or suffering, and the World Health Organization says, “we need to create a complex set of variables that healthcare providers must address for effective care.” This includes considerations for: safe and secure housing, local language and culture proficiency, education level, transportation access, health food availability, public safety, and social support, to name a few.

Regulatory: State & Federal Push for Universal Buy-In
Population health and achieving health equity has been promoted to date through Medicaid-specific and multi-payer federal & state initiatives. In 2017, a number of state-led Medicaid managed care plans required screening for and/or providing referrals to identify social needs for patients in combination with traditional screening and referrals to increase patient access to beneficial services.

As with other initiatives in healthcare to improve value, making institution wide change requires complete organizational transformation. The birth of Accountable Care Organizations (ACOs) has catalyzed tracking of specific quality measures tied to an organization’s reimbursement in order to incentivize addressing need using risk-sharing models – but for a lot of organizations jumping into two-sided risk sharing agreements have taken time and reform.  

Adherence: Transparency & Awareness Across Clinical Pathways
The ability to connect patients and providers outside the doctor’s office has created a transparent relationship between the two parties and enabled patients to take a more active role in their own health care journey. With more than 90 million people struggling to understand and act on the vast and often confusing clinical information they are provided, treatment adherence tracking has increased insight into the effectiveness of clinical pathways. Payers and providers are investing in digital programs, as a means to optimize efficiency and monitor adherence. This collective data can be utilized to reform current healthcare policies and practices with an upstream, population health lens.

Data & Analytics: A Collaborative Approach to Drive Insight
2018 has seen billions of dollars in healthcare mergers in the ultimate quest for data acquisition. These days, personal health data is being collected not just by payers and providers in the form of pharmaceutical records, EHRs, and claims data, but patients themselves through increasingly advanced device and wearable technologies.

Digital health and data analytics systems have been playing prominent roles in the healthcare space, by allowing organizations to track quality data, implement outreach programs, and manage meeting quality goals. Rather than just looking at clinical and financial information, these systems are being increasingly used to look at sociodemographic and geographic data throughout a population–and with advancements in artificial intelligence (AI) are getting smarter over time. Such information can provide valuable insight on how to successfully implement processes that will have an impact across a community and consumers are better understanding the benefit sharing their personal health data can have on their health.

A pillar that has traditionally been a focus of public health is now being integrated across healthcare delivery to create a collaborative partnership between healthcare organizations, communities, and patients. Population health management is more important than ever as controlling health costs is largely dependent on these drivers. To continue to see meaningful impact on outcomes, quality, and cost we must embrace this upstream, population-based approach, shifting the focus to look more at what should be invested in health, versus what should be spent on healthcare.
Each week we’ll dive deeper into each segment as it relates to the advancement of population health management.