Population health: What is it and what does it take?

Population health has become a real buzz phrase since the Institute for Healthcare Improvement first defined the Triple Aim as a strategy for healthcare transformation in the US (and beyond). However, the definition of population health and the tactics for successful population health interventions, remain key topics of discussion.

In response to a number of inquiries, below are a set of general guidelines that we believe are key to delivering high value care (better quality at lower costs) that improves the health of a given population. Our aim here, is to provide some guideposts for organizations to design their own/ tailored population health improvement strategies, as it is becoming increasingly clear that what works for asthma or diabetes patients in New York City for example, will likely fail to produce the same results in the suburban sprawl that characterizes Phoenix, AZ.

Since there is some confusion about what constitutes population health, let’s start with a few definitions. Kindig and Stoddart define population health as, “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Population health efforts are also often muddled with public health interventions, in part due to the lack of clarity around what constitutes prevention/ preventive care. So, we (and others) define 4 levels of prevention as follows:

• Primary prevention aims to prevent disease from occurring by addressing its causes. Smoking cessation programs to reduce the incidence of lung cancer are examples of primary prevention.
• Secondary prevention involves the detection and treatment of asymptomatic disease to prevent it from progressing into a chronic condition (or worse). Routine Pap smears and colposcopies are examples of secondary prevention.
• Tertiary prevention is used to prevent individuals with chronic conditions from gaining additional impairments and disabilities. ACE inhibitor therapy to prevent renal failure in diabetic patients is an example of tertiary prevention.
• Quaternary prevention ensures that the care a patient receives in the acute care setting is the right care, at the right time, and is performed safely to avoid complications.

While there is a degree of overlap between public health and healthcare delivery in the realms of primary and secondary prevention, tertiary and quaternary prevention are largely the purview of clinical care providers. Given that most of our healthcare dollars are currently spent on acute and chronic care interventions, focused tertiary and quaternary prevention efforts carry the advantage of simultaneously improving population health outcomes and reducing costs (thus also freeing up resources and setting the stage for effective primary and secondary prevention efforts).

Now that the definitions are out of the way, what could an effective population health improvement strategy look like, particularly at the tertiary and quaternary levels of prevention?

Step 1: Define and characterize the population

The population of interest could be defined geographically (e.g., Maricopa county), clinically (e.g., patients with asthma), demographically (e.g., <18 years of age), at enterprise level (e.g., employees of a business or patients covered by a specific health plan) or a prioritized combination of these factors (e.g., 2-17 years old kids with asthma, residing in Maricopa county, and covered by Medicaid insurance).

Step 2: Characterize the population

Specifically, who are the people, what is their full medical status, where are they currently getting their medical care, what are their socio-economic (SE) and behavioral characteristics. Understanding the latter is vital to designing successful population health interventions, since SE and behavioral factors have a much bigger impact on the health of a population than healthcare delivery alone.

Step 3: Identify and prioritize issues to address

Here the adage, “Think big, start small, learn fast, scale quickly,” seems pertinent.

Step 4: Define a clear and specific set of value measures to track progress

Relevant measures should focus on patient outcomes, safety, service, and cost over time. To succeed, the organization may need to invest in IT redesign to ensure that it is a) able to collect timely, accurate and reliable data, and b) that these data can be reviewed and acted upon on an ongoing basis to support population health improvement activities.

Step 5: Design the clinical intervention(s)

Since population health is determined by much more than clinical care, devising successful strategies and tactics for population health improvement will require a multi-prong approach. Specifically, organizations will need to

• Implement a tailored approach to patient treatment, focused on the needs and best interests of the individual. Designing individual and specific plans for each member of a given population is often necessary to improve the health of said population. As alluded to above, this will frequently require addressing relevant socio-economic and behavioral factors and engaging the patient as a partner in care decisions.
• Integrate and coordinate services around the needs of the patient, with provider teams (including generalists, specialists, nurses, pharmacists, public health and community workers) and payers working together seamlessly.
• Focus efforts, at least initially, on tertiary and quaternary prevention.

Step 6: Establish a sustainable business model

In the current primarily fee-for-service system, reimbursement for preventive care (at all levels) is either limited or non-existent, thus often penalizing the providers trying to do the right thing for their patients. Thus, scaling population health interventions effectively will require new payment models, either through formation of new partnerships between payers and providers or the establishment of provider-owned insurance plans. In turn, these payment models should be structured in ways that

• Link payments to value (outcomes, safety, service and cost over time)
• Allow providers the freedom and flexibility to implement new care management models and leverage non-traditional healthcare providers
• Create a realistic business case for providers making investments to improve the value of patient care