Simplifying Healthcare: Population Health?

You might hear the term “Population Health” mentioned in healthcare today and often used in relation to health equity and addressing disparities, having officially entered the everyday healthcare vernacular around 2003 . But what exactly does it mean???

Standard definitions like the one from the American Hospital Association define population health as “the process of improving clinical health outcomes of a defined group of individuals through improved care coordination and patient engagement supported by appropriate financial and care models.” Population health is often defined differently based on things like geography, job function or healthcare environment – many think about it through a public health lens without the context of cost and how healthcare is paid for.?

I believe an understandable definition of population health is the provision of “the right care, at the right place and time, for the right person –?improving the health of the community in the context of improving care quality and reducing cost”– noting “right” should encompass coordinated, holistic care, wellness and prevention. The definition of care should be expanded beyond the traditional provision of medical services and medications; it should also engage a person’s physical, mental, environmental and social needs.??

A few elements need to be in alignment for this to happen. “PPTC”—or People, Process, Technology, and Culture—all need to be engaged to improve the health of a population. Historically, we haven’t had alignment across these 4 focus areas.??

In order to improve the health of a population, you need to know who you’re targeting, what they need, and why they need it – and that’s where the use of data comes in.??

How did we get here?

It is well known by now that the pandemic had far-reaching effects on our society and the healthcare system that we are still unpacking to this day. In the context of population health, the pandemic quickly brought to light the disparate access and outcomes across various groups of people, making those already high-risk even more vulnerable.?

But the pandemic didn’t create these disparities –?it simply surfaced the inequity already present across our population’s health. What is currently helping us better understand these disparities before, during, and after the pandemic is data.??

However, continued access to increasing amounts of data has its pros and cons. Gathering and analyzing data can be complex and expensive, but it does provide the means and opportunity to measure and monitor whether interventions have a positive outcome across and within populations. This access to data and a greater understanding of disparities post-pandemic (and their underlying causes) have better positioned us to address health through a population lens and in the context of delivering value to the communities we serve.?

How Population Health fits in Value-Based Care?

It’s important to note population health is different from value-based models (VBM) of care in definition. The population health framework centers around how we operate coordinated care for patients, while VBM provides the framework for how we measure the outcomes for populations and how care is paid for.?

We can’t be successful long term with value-based models (and the eventual transition to value-based care from the fee-for-service model) if we don’t think about how diverse groups engage with and have access to care. Traditionally, the finance side of healthcare thinks about how care is paid for, while the clinical side thinks about how care is provided. We miss the value of their intersection when we are focused on how these two frameworks work together.??

The success of the population health approach within our system depends on the alignment of care, both in how it is delivered and paid for.?

Things to watch??

When thinking about population health and the inequities often seen, one of the greatest drivers of disparity is access to care. Access to care is closely aligned with access to health insurance coverage.?With the continued Medicaid Unwinding process and the projected loss of Medicaid coverage for millions of Medicaid recipients through the end of the year, it’s more important than ever for providers to look at the coverage issue at the population-level and leverage data to assess which groups will be most affected and use this information to inform ongoing outreach and engagement activities. You can follow the tracker below:?

https://www.kff.org/medicaid/issue-brief/medicaid-enrollment-and-unwinding-tracker/ ??

On the clinical side, many providers and health systems like Providence are leaning on data to innovate within their population health programming. For example, Ayin Health Solutions has been assisting the state of Oregon in support of a Health-Related Social Needs program focused on the social and economic needs individuals experience that affect their ability to maintain their health and well-being. The program will provide coverage for climate, housing and nutrition support services to improve the health of those covered by Medicaid.???

Looking Ahead + Final Thoughts??

As with most things in healthcare, implementing a population health approach is a marathon. One of the biggest challenges for population health and value-based care is to harness all the data we have and make it actionable for patients and providers to improve interventions in real time. We need to have the ability to ensure the care we are providing is having an impact, and that the impact is positive across all subsets of the population. And as we learn, we should use the information to continually do better.??

It’s hard to believe this year is already coming to a close (and this newsletter is nearing its 1-year anniversary!). I have my healthcare predictions locked in for 2024, but first, I’ll revisit and recap our industry's most notable moments this year in my final newsletter of 2023. See you next for the December issue of Simplifying Healthcare!??

Until next month.???

- Ruth ????

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Have an idea for a future topic or questions in the world of healthcare? I’d love to hear from you!?