Why population health

As the nation continues to work out the details of making health care services more widely available to all, issues of population health become all the more important. This is of particular concern as we marshal resources to respond to crisis situations, such as a global pandemic like the novel coronavirus that causes COVID infections.

Population health consists of the incidence of diseases in a variety of groups of people, such as when comparing outbreaks among individuals in different age categories or races or who reside in a range of ZIP codes. This contrasts with public health, which examines the health condition of a whole population of individuals. When you are moving a population toward complete healthcare coverage for every individual, such as through exchanges or a single-payer system, population health details will inform financial decisions as well as how we approach logistics, policy, and surveillance matters.

Health outcomes can vary between different groups in a population for a number of reasons, including socioeconomic differences treatment and outcomes compared in low-income neighborhoods and the most wealthy cities can be quite different, for example. Society can come to terms addressing these inequities more readily when we have the hard facts and statistics of these differences in health outcomes.

Any discussion of population health will need to account for its differences with public health. We already know that population health looks at comparisons of disease incidence in groups according to criteria such as age, gender, or location while public health examines everyone in a population.

The distinction is useful because you might want to see what the average outcomes are for people who work in different professions, such as respiratory illness comparisons for coal miners versus office workers, or the prevalence of diseases among vaccinated populations versus groups where parents withhold vaccinations because of feared side effects.

This is an example of population health that most people are familiar with. Public health by definition affects all members of the public. One of the most important aspects of population health that will impact the future of the field is understanding populations in specific health care systems.

It is important for health care organizations to gain insights about their own patient populations to gather data and better serve them. The following trends demonstrate why population health is so important and how its future will likely be shaped. The purpose of payment models such as these are to form a correlation between service quality and provider reimbursements. In total, these programs work to promote improved quality of services and population health.

The integration of behavioral health treatment into mainstream practice has challenged care providers for some time. As a result, the CMS has introduced a new collaborative care model. Along with the addition of four behavioral health reimbursement codes, this approach will assist providers in making great improvements in the health outcomes of U. The agency has confidence that facilitating the treatment of physical and behavioral conditions in the primary care setting will greatly enhance the overall well-being of patients.

To facilitate the integration of behavioral health treatment into primary care, the CMS finalized what is known as the Physician Fee Schedule. The CMS believes this value-based reimbursement will improve care across the continuum of services, reduce financial expenses, and result in a healthier population. Value-based care rewards providers for working together to coordinate treatments, administer the correct services, and improve overall population health.

As time goes on, insurers will continue to base their reimbursements to care providers on treatment quality rather than quantity. The positive outcomes that have resulted due to value-based programs have caused the model to ignite one of the largest changes in the history of the health care marketplace.

By linking reimbursements to service quality, insurers such as the Centers for Medicare and Medicaid Services have facilitated a massive leap forward in the performance of U. S health care providers.

This achievement is a considerable change for an industry that has received insurer reimbursements via a fee-for-service model for some seventy-five years. Soon, valued-based payment models will represent the norm, as more insurers support initiatives such as shared savings programs, integrated clinical care, and accountable care payment models. In this article, we describe how mature population health programs in a learning health system have been rapidly leveraged to address the challenges of the pandemic.

Population-level data and care management have facilitated identification of demographic-based disparities and community outreach. Telemedicine and integrated behavioral health have ensured critical primary care and specialty access, and mobile health and postacute interventions have shifted site of care and optimized hospital utilization.

Beyond the pandemic, population health can lead as a cornerstone of a resilient health system, better prepared to improve public health and mitigate risk in a value-based paradigm. Am J Manag Care. Robust population health management integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises.

Prior to the coronavirus disease COVID pandemic, the US health care system was in the midst of major transformation—shifting away from the inefficiencies of fee-for-service toward value and patient-centeredness. The pandemic has highlighted the fragility of a volume-driven health care industry and illustrated how mature population health infrastructure can promote public health, strengthen health system resiliency, and support financial recovery.

Historically, large health care systems focused their population health efforts on optimizing performance in risk-based insurance contracts. With a dramatic decrease in procedures and in-person visits, population health stands to become increasingly vital in health care delivery to improve outcomes and reduce costs.

In this article, we examine how strategic population-based efforts can combat COVID, highlighting our experience within Partners Healthcare System PHS , a large integrated health system based in Massachusetts summarized in the Table.

We detail the programs that have had the highest impact at PHS and other health systems in potentially stemming the impact of COVID, and we explore the fundamental role of population health in revitalizing health systems beyond the pandemic. During COVID, PHS utilized established population health information systems to identify high-risk patients, including data from clinical sources, claims reports, and risk capture efforts.

Other population health programs have similarly adapted existing data and analytics infrastructure to support pandemic response efforts. After the pandemic, these dashboards will be able to identify ongoing health inequities and monitor for COVID recurrence Table. For example, registries for hypertension, diabetes, and chronic kidney disease identified the highest-risk patients to receive laboratory monitoring or medical procedures, prioritizing those who were likely to need dialysis in the near future.

For the last decade, the integrated care management program iCMP has been an essential component of PHS population health to coordinate care, improve outcomes, and reduce cost for high-risk patients by leveraging a dedicated nurse, social worker, or community health worker. They performed wellness checks, provided COVID education, and conducted serious illness conversations clarifying goals of care before patients presented to a hospital.

The PHS ED Navigator program, which serves as an emergency department ED resource to link patients to primary care and social services, adapted its work to be telephonic and to identify isolation resources for patients who are homeless, housing insecure, or living in crowded conditions.

ED navigators increased their work from to encounters monthly across the network to connect high-risk patients with critical resources. Population health teams from other organizations, such as the Public Health Institute PHI , have similarly adapted operations to meet public health needs exacerbated by the pandemic.

Such care management programs will be critical after the pandemic to follow patients affected by COVID and to identify those at risk of poor outcomes due to deferred care Table. By proactively addressing chronic health conditions and the social determinants underlying them, care management can stem the impacts of a future pandemic.

The Home Hospital program provides inpatient level of care to low-acuity patients in their homes, and the Mobile Integrated Health MIH program uses paramedics to further support home-based care delivery. Postacute care is critical to identify safe locations for patients with and without COVID to recover and to maintain inpatient hospital capacity. The University of Washington also collaborated with postacute partners to develop a comprehensive strategy for COVID, which included establishing clear criteria for facility admission, providing PPE training, equipping testing supplies, and developing isolation plans.

COVID has brought numerous mental health challenges due to elevated stress, financial insecurity, and exposure to traumatic events. We identified patients at high risk of mental health complications and used primary care—based resources to intervene on acute anxiety and stress.

We also adapted substance use disorder programs to include virtual recovery coaching, resulting in 10 virtual recovery groups weekly, and supported medication-assisted treatment when new regulations allowed prescribing without an initial face-to-face visit. Fitterman says. Listen to more of our interview with Dr. As better nutrition is suggested, we must understand that the cost of a meal at a fast food chain is likely cheaper than one at a health food store.

And, when arranging for a follow-up appointment, we must account for the bus schedule if a patient depends on that mode of transportation, as well as the potential to be released from work if employed. Failure to [consider them in the discharge plan] will inevitably result in worsened health outcomes for the patient, and possibly hospital readmission.

Hospitalists should be aware of the community-based organizations and services that exist, maintaining a working knowledge of who can provide volunteers, aid, food, and clothing to patients in need. A team-based approach is key to improving patient outcomes upon discharge, Dr. Lenchus says. Hospitalists should interact with social workers and case managers in anticipation of discharge; include the pharmacist in discharge medication counseling sessions. Are there relevant pharmaceutical industry-sponsored programs that can help the patient obtain prescription medications?

Does the patient already qualify for some assistance? If the patient is insured, is the medication being prescribed on the formulary, or can it be modified so that it is covered? Could a generic version be prescribed? Does the patient understand the reason for hospitalization, have a follow-up appointment, and know how to take his medications?

Nash sees physicians as the team captains; physicians know how the system works, because they see it up close every day. The team includes key personnel, such as nurse practitioners, physician assistants, pharmacists, patient navigators, social workers, and patient educators. Nash says. He also encourages hospitalists to become patient advocates and educators, even though this is not their traditional role.

For hospitalists who already feel overstretched with demands and overwhelmed with taking on the task of managing population health, Dr. McPherson suggests they learn more about the trend by studying it as part of their continuing education requirements.