Population Health Management eBook

Population Health Management

The Start-to-Finish Population Health Management Guide

Use the toggle below to navigate between chapters.


Value-based Care Changing The Industry

Healthcare organizations across the nation are in the midst of transition. For decades, physicians, hospitals and health systems have sustained and grown their operations through fee-for-service (FFS) reimbursement. Now we are in the era of value-based care (VBC). FFS is slowly being replaced by reimbursement based on patient outcomes and cost control, among other factors.

This paradigm shift alone is challenging for healthcare organizations. However, these organizations also face continually changing regulations, electronic health record (EHR) optimization, increasing consumerist demands from patients, and a growing number of complex patients with multiple chronic conditions. In this environment, healthcare organizations must operate more efficiently while continuing to deliver optimal care.

Enter Population Health Management

Population health management (PHM), supported by sophisticated, integrated and automated data analytics technology, helps organizations more efficiently track and intervene with high-risk and potentially high-cost patients. Proactive, preventive intervention can keep patients out of the emergency room and hospital, which further controls costs. Modern PHM strategies also help increase engagement to support patients in managing their conditions to drive better outcomes.

This eBook offers a start-to-finish guide for organizations to design their own technology-enabled PHM strategy. But first, we need to understand how we arrived at this paradigm shift.

Patient Complexity Driving Increased Spending

The United States spends $10,348 per person per year on healthcare. This is highest in the world and 31 percent more than the next wealthy country in this ranking, and chronic illness is driving much of these costs. The medical treatment spending and lost productivity attributed to chronic conditions is expected to reach $42 trillion by 2030. Reducing these costs is the heart of value-based care payment models that government and commercial healthcare payers are introducing at a rapid pace.

However, high-quality care inside the four walls of a healthcare organization is only a portion of what delivers better patient outcomes. Rather, driving stronger Population Health Management and helping patients stay adherent to their personalized care plans is the essence of effective PHM. In many cases, improving engagement and adherence involves overcoming patients' behavioral, economic and physical environment, in addition to other social obstacles. One study estimates that more than 80 percent of outcomes are influenced by these social determinants of health.

InteliChart $10,348 Per Person The United States spends $10,348 per person per year on healthcare.

“Population health management (PHM)… helps organizations more efficiently track and intervene with high-risk and potentially high-cost patients.”

Data Analytics Technology Leveling The Playing Field

In past decades, managing complex patient populations with both chronic conditions and challenging social determinants of health was labor-intensive, if not impossible, due to lack of available data and tools for providers. Despite these challenging historical issues, newly available PHM data-analytic technology platforms and enterprise-wide integrations of data systems have leveled the playing field.

Centralized databases combined with intelligent, automated tools help care managers monitor high-risk patients in ways that were inconceivable 20 years ago. Thanks to access to numerous other commercial and consumer databases, care managers within integrated healthcare organizations can now track patient behaviors in near real-time both throughout the care continuum and between visits.

This comprehensive care perspective enables timely interventions, which is crucial particularly among the five percent of the population that account for an estimated 50 percent of healthcare spending. Preventive interventions can divert patients from high-cost emergency department visits that may lead to an even costlier, and potentially unnecessary, hospital admission and associated inpatient care.

Automation And Real-time Data And Is Essential

Even with automated patient data capture and analytics, PHM can still be highly labor-intensive with manual report creation, data searching and patient outreach. Sophisticated PHM platforms, however, are taking automation a step further by instantly generating dashboards showing performance on key metrics. Platforms are also automatically initiating patient outreach through text messages, phone or secure patient-portal messages based on pre-determined criteria and patient preference from the care manager or healthcare organization.

Automated communication from the healthcare organization is designed to remind, notify or encourage patients to adhere to their care plan and take positive action. The goal is the same: to modify behaviors and overcome social determinants of health that are driving them away from optimal outcomes. Real-time data ensures automated interventions and communication are more relevant, effective and focused on prevention.

Chapter 2 InteliChart

How PHM is changing clinical roles to produce better outcomes.