Picture a town where an unusually large number of residents have diabetes. The disease is often poorly managed, so patients frequently end up in the emergency room. Each time, the patients are stabilized and sent home – yet return to the hospital just weeks later with similar concerns.
Many communities today are stuck in this expensive cycle. Why? Health systems today have little incentive to address the root causes of chronic diseases. More often than not, our costly and reactive system waits to treat people until after they get sick.
There is an alternative approach, however: population health. Instead of focusing solely on individual patients who are already sick, population health takes a wider view to examine health trends within communities. Once patterns are found, solutions can be designed to address the root causes of disease, promoting a healthier population overall.
The benefits of population health are clear: It leads to healthier people and more affordable care since preventing disease is a lot cheaper than treating it once it becomes full-blown. Plus, population health promotes health equity by striving to create a system where everyone has an equal shot at good health.
Value-based care is the engine that drives many population health initiatives. By shifting from paying providers for the volume of services to rewarding them for keeping people healthy, value-based care creates a powerful incentive. Providers are motivated to identify and target broader community health needs, addressing the social factors that impact health, and ultimately promoting greater health equity. It's a shift from simply reacting to illness to proactively shaping the overall health of an entire population.
This shift is crucial for population health because it incentivizes healthcare systems to think about their community as a whole and target the environment that contributes to the problem, not just the individual cases. For a neighborhood with high diabetes rates, for example, a clinic might partner with local grocery stores to make healthy food more accessible, sponsor educational sessions on nutrition, or create walking groups.
The momentum behind population health is gaining even more traction with the backing of the Center for Medicare and Medicaid (CMS) Innovation Center, whose 2021 Strategy Refresh report lays out a clear vision for the next decade: achieving equitable health outcomes through high-quality, affordable, and patient-centered care. The CMS report emphasizes the need for future healthcare models to address social determinants of health — like housing, transportation, and access to healthy food — the precise areas population health focuses on.
The report also emphasizes the need for tighter coordination between different healthcare providers so patients don't get lost in the system. It highlights the importance of actively involving communities in designing solutions that genuinely meet their needs. Most importantly, the report calls for tracking health equity outcomes alongside traditional measures like cost and quality to ensure progress in creating a more just healthcare system.
The shift towards population health and value-based care presents an incredible opportunity for healthcare providers and systems to lead transformative change and create measurable impact on the health of the populations they serve. Stay tuned for our next blog post in this series, where we'll dive deeper into how value-based care models are paving the way for a more equitable and effective health system.