Population Health

Blog post by Fred Goldstein MS, Alexis Skoufalos EdD, Gregg Masters MPH

Ah, Population Health…it’s everywhere! Hospitals, health plans, clinics, IT companies, care management companies – is there any sector where people are not talking about it?

But is Population Health for real?  Or will it go down as just another fad that cycles around every 20 to 30 years?

Let’s talk about where population health came from, and share a definition. It seems everyone says they practice population health…but do they really?

According to Dr.David Kindig, a pioneer in the field, Population Health (the noun) is:

The health outcomes of a group of individuals, including the distribution of such outcomes within the group

That’s it. To me that sounds like it’s a reporting and analytics function. If that were all of it I’d be a bit disappointed, because there is no action that statement.  We’ve measured the health outcomes of a group and determined their distribution, but so what? Perhaps this is why most every IT company at HIMSS says they do “population health”.

Over the years, though, our understanding of population health has developed and expanded into a much broader endeavor.  In fact, I would argue that a fully functioning population health program is all inclusive of everything within the healthcare system, operational, clinical and financial and expands well beyond the healthcare system into the broader community, integrating those assets as well, and includes public policy.

The broader field of population health now includes the impact of social determinants (education, income, employment, housing, nutrition), policy and interventions (including medical care, disease management, health behaviors) on those outcomes.

Population health management looks at how you put all of those things together to have a positive impact on outcomes.

So, when you “do” population health, it has to be specific to the needs of the community, taking into account all of the things that make them unique. Rural/urban, high or low income, high tech or rust belt jobs, ethnic / gender / age distribution, education level…and oh yeah, how much health care is available.

To provide greater clarity of a population health program, let’s look at a Framework that was developed by the Population Health Alliance (PHA). Population health requires data, but it does not necessarily require a lot to get started.

The image below slide shows the steps that the PHA believes are involved in doing population health. So, let’s review them.

Monitoring/Identification – The first step in the framework is identify your population. Is it persons with asthma in a solo practice, all patients in a practice, employees in a company, a capitated group of patients, a community, city or state?

Health Assessment – the assessment step has become very interesting.  This used to be done with claims or claims and clinical data.  After a while, health risk appraisals were added, along with screenings for depression and other Quality of Life measures, health literacy measures, etc.  Now we are also examining social data and even precision medicine and genomics. The addition of each of these assessment tools allows one to better define the person, perhaps getting to an N of 1.

Risk Stratification –  The assessment data is then used to organize the populations into groupings (distribute them). Depending upon the assessment tools used, this can be a very simple methodology, or very complex.

A simple example that I recently saw at a HIMSS booth and has been used for years is: If the persons had two or more ER visits or 1 hospitalization in the past 12 months, they are labeled high risk.

A more complex model would take in all of the data from a wide range of sources and perhaps even inject some machine learning predictive algorithms to stratify the population.  Most current stratifications will place individuals into a low, moderate or high-risk category.  This is important because this risk level allows you to focus your efforts and provide an appropriate level of resources based upon the individuals’ needs.

It’s also important to understand that some risk measures are not so relevant, or maybe are not actionable.  Here is an example. Genomics can be used to identify individuals who are at a higher risk for many conditions; one is Parkinson’s. While this is nice to know, it is not really actionable since as of today there are no programs that have been shown to reduce that risk. Right now, assessing for the risk of Parkinson’s may not be worth doing.

Engage – This is perhaps the most critical step. How does one engage the person in interventions and programs? How do you get them to complete the necessary assessments to determine who would benefit? There has been a lot of great work in behavioral economics and I believe that companies like Amazon, Google, eBay and others will help us take the expertise that they use to get us to “buy” things and apply the same or similar algorithms to get us to “do” things to improve our health.

Intervene – There are clinical interventions, community interventions, lifestyle interventions, education, care coordination, reminders, all bundled up here.  These interventions need to flow from the Assessment. They include closing gaps in care, but are much broader: Does the person need a health coach? Can one identify a place and time for them to exercise?  Do we need to solve a hunger issue? Can they afford their meds and do they fill their prescriptions?

And, finally, measure the program. This includes operational measures (such as the number enrolled, number of contacts, type of contacts) as well as outcome measures as shown in the image.  It’s important when measuring to understand that there are leading and lagging indicators.  Process measures are often leading indicators of how the program is doing, while outcome measures such as clinical improvement or changes in utilization of services or costs may take many years to appear. This information is then fed back into the system, the population is re-stratified, and the distribution is looked at again.  Did the program create a movement of the overall population to a healthier status?

This is a very quick introduction to Population Health and represents my perspective.  If you want to really dive in, attending a conference like the Population Health Colloquium @PopHealthConf March 19-21 in Philadelphia (conference hashtag #PHC18) will let you hear from experts in all of these areas.

Join us on the next #hcldr chat, Tuesday March 13th at 8:30pm ET (for your local time click here) where we will be discussing these four population health related questions:

  • T1 What does it mean to be “engaged” in your health? Thinking of yourself in a population health program, how would you define engagement? And, based on that, how would you measure it?
  • T2 Who should be responsible for overseeing a population health program?
  • T3 What can IT and other technologies do to better assist population health programs?
  • T4 What interventions would work for you or those you know to improve their health?

About Fred Goldsteitn

Fred Goldstein is the founder and president of Accountable Health, LLC, a healthcare consulting firm focused on population health. He has over 30 years of experience in population health, disease management, HMO and hospital operations. He is an expert in population health, care management, risk management, HIT and health system design and development.

During his career, he founded a disease management company that provided services to 11 State Medicaid programs and numerous employer groups, operated an HMO that was ranked the highest quality Medicaid Health Plan in Florida, developed an award winning mobile health app and worked with health systems and vendors to develop population health programs and platforms. He was also directly responsible for the inclusion of the Medicare Annual Wellness Visit in the Affordable Care Act. Fred serves on the editorial Board of the journal Population Health Management, the founding Advisory Board of Population Health News, the Best Practices Review Panel for the Institute for Medicaid Innovation at Medicaid Health Plans of America, is a judge for the Health Value Awards and is Past Chair of the Board of Directors of the Population Health Alliance.

About Alexis Skoufalos, EdD

As Associate Dean for Strategic Development and Executive Director of the Center for Population Health Innovation at the Jefferson College of Population Health @JeffersonJCPH (JCPH), Dr. Skoufalos is responsible for facilitating strategic external partnerships and collaborative initiatives for JCPH. In her role as Executive Director of the College’s Center for Population Health Innovation, she leads the team that implements the college’s professional development activities, including expert panel roundtables, specialized training programs, conferences and symposia. Dr. Skoufalos also oversees JCPH’s external communications, including the college’s affiliated peer-reviewed journals and newsletters, website, blog and social media.  She has been the primary author of articles and editorials related to medical education, quality improvement, patient education and engagement, and staff recruitment and retention. She is an Associate Editor for American Journal of Medical Quality, and serves on the editorial board of Population Health Management.

About Gregg Masters

Recognized by his peers as a thought leader and key influencer in healthcare social media via @2healthguru, and included in several industry publications such as the Top 100 Voices in Health Information Technology by Health Data Management, Healthcare IT news ‘HealthIT 100 2012, and Fiercehealth IT ’8 More Faces to Follow in Healthcare Social Media, Masters mentor’s clients in strategic and tactical applications of interactive digital media technologies. He specializes in visioning, design and development of client branded online identities, messaging and engagement strategies, deploying a portfolio of tools and/or platforms suitable to budgets from ‘lean’ to turnkey private labeling.

Masters’ publishes ACOwatch.com & JustOncology.com, and hosts several Internet radio programs including ‘This Week in Oncology’ and ‘This Week in Accountable Care’ all ‘go to’ resources for trends, developments and insights into the healthcare transformation theater. Recently tapped by CMS Center for Medicare and Medicaid Innovation to review grant applications for the ‘Healthcare Innovation Challenge‘ program, and a frequent new media journalist at major healthcare conferences from the Digital Health Summit at CES to the likes of HiMSS, Health 2.0, Healthcare Unbound, and the HDI Forum, Masters strong domain experience and ‘social media street smarts’ credibly engages a wide spectrum of voices in the healthcare innovation conversation.

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