Three Priorities Driving Population Health Management Toward Better Data Capture

Population health management continues to pivot and change post-COVID-19 in the United States. Factors such as the growing need for chronic disease management, financial uncertainties, and increasing patient numbers contribute to challenges and successes in addressing broader determinants that affect the health of communities. 

Many health systems, accountable care organizations, and clinically integrated networks have expanded or introduced programs for managing population health to make the most of resources and enhance the efficiency of delivering patient care.

Technology has played a vital role in this transformation. Hospitals and healthcare organizations have focused on broadening their offerings for managing population health and promoting health equity using advanced analytics. These organizations have better met their patients’ needs by using data to identify at-risk populations and tailoring intervention programs to specific groups.

The priorities for health systems that have intensified these efforts have included:

1. Expanding programs for managing population health and promoting health equity.
2. Incorporating data-driven analytics and technological solutions.
3. Conducting thorough analyses of the cost and quality of programs.

Population Health Management Focus Spurs Transformative Action

Hospitals have shifted their focus from fee-for-service models to prioritizing outcomes, promoting preventive care, and building collaborative care networks to provide more comprehensive patient care and manage diseases. 

In 2023, several population health management entities worked to improve care and outcomes, including Accountable Health Partners, a clinically integrated network with nearly 3,000 physicians, advanced practice providers, and twelve leading hospitals in the region. This partnership aims to improve care coordination between physicians and hospitals by implementing advanced interoperability and reporting systems. 

Additionally, Bryan Health, a health system based in Nebraska, revealed plans to utilize a new population health analytics platform to enhance care coordination, cost-effectiveness, and quality across its extensive network of 23 Critical Access Hospitals (CAH), three Prospective Payment System (PPS) hospitals, 265 clinics, and 1,885 providers. The Bryan Health Connect program will leverage robust data and analytics tools that seamlessly integrate with any EMR system as part of its Population Health Services network strategy.

Federal Population Health Management Initiatives Reviewed

In 2023, the Centers for Medicare & Medicaid Services (CMS) introduced new initiatives to improve population health management and promote health equity across the Medicare and Medicaid provider and patient communities.

The Medicare Physician Fee Schedule (MPFS) Final Rule outlined policies to support primary care, advance health equity, assist family caregivers, and expand access to behavioral and specific oral healthcare. Additionally, these policies included provisions for payment of principal illness navigation services to aid patients and their families in navigating cancer treatment and other serious illnesses.

Furthermore, CMS unveiled the States Advancing All-Payer Health Equity Approaches and Development Model (AHEAD Model), a program designed to address chronic disease, behavioral health, and other medical conditions in a transformative way.

States participating in AHEAD will be responsible for ensuring quality care and improving population health outcomes while simultaneously reducing avoidable healthcare spending across all payers as part of broader efforts to transform healthcare on a statewide and regional level.

Population Health Analytics Key to Outcomes Improvement

Hospitals and health systems rely on efficient tools to pinpoint areas for improving population health management and analyzing performance. Fortunately, technological advancements in 2023 have continued to support cost-reduction efforts and enhance the quality of patient care. 

Notable outcomes in 2023 included WakeMed Health & Hospitals achieving a $10M variable cost reduction by reducing unnecessary care variation while enhancing care quality. This was made possible through an innovative population health management platform and a suite of analytics applications, enabling access to valuable data needed for performance improvement.

Additionally, WakeMed implemented data governance, prioritization processes, and a program focusing on data quality and performance, leading to improved care processes for 23 distinct patient populations.

Similarly, Carle Health leveraged a robust population health analytics platform to gain access to high-value data necessary for effective operations management. As a result, the organization could assess population health services utilization and demand while identifying sources of variation and opportunities for improvement.

This led to two full-time equivalent (FTE) reductions in maintenance time required, access to over a dozen key performance indicators (KPIs) for thousands of patients and providers, and the ability to identify high-demand service offerings for improved strategic planning.

Sea Mar Community Health Centers, a national health and social services provider, launched an extensive, multi-year initiative to enhance the delivery of high-quality, integrated care for marginalized communities. Sea Mar will deploy an innovative data platform and population health analytics to improve visibility into patient data, gain deeper insights into its patient population outcomes, and improve reporting capabilities.

This proactive approach to population health management will enable its teams to make informed decisions based on data and align its network of over 90 medical, dental, and behavioral health clinics and various nutritional, social, and educational services.

Population Health Investments to Persist Into 2024 and Beyond

In 2023, healthcare organizations made significant strides in addressing health equity by embracing population health management tools to drive quantifiable improvement.

By leveraging these tools, healthcare organizations have demonstrated their dedication to creating more equitable access to quality care and improving health outcomes for underserved populations.

Indeed, the enthusiasm for initiating a health equity strategy reflects a commitment to prioritizing the well-being of all individuals, regardless of background or circumstances. 

Healthcare organizations can continue this momentum in 2024 and ensure their efforts lead to tangible and sustainable progress in achieving health equity, creating a future with equal access to high-quality healthcare.

Additional Reading

Would you like to learn more about this topic? Here are three articles we suggest:

Three Ways HIEs Empower Population Health Management

Population Health Success: Three Ways to Leverage Data

Advancing Health Equity – Data-Driven Strategies Reduce Health Inequities