The Implications of Population Health Management

bindman 1It has long been recognized that a small percentage of patients with complex needs tend to use a disproportionately high percentage of health care resources. These individuals are referred to by a variety of terms including “super-utilizers”, “high-risk patients” and “beneficiaries with complex needs.” These patients tend to over use acute care services and often have a combination of physical health, mental health, behavioral health and social needs. While many of these individuals require a higher level of service to address their needs, there is also the potential for them to use resources inefficiently because their care is being delivered by multiple providers with little ongoing coordination.

Population management has recently emerged as a strategy to address this inefficient use of health care resources by trying to provide coordination for these patients across all of the settings where they currently get care. Population health management relies upon the automated routine aggregation of patient data from across different settings such as primacy care visits and hospitalizations. This aggregation leads to a single set of actionable patient records that can be screened to assess which patients use the most health care services. The growing availability of health information technology is making it increasingly possible for providers in real-time to develop a shared understanding of who the patients are who have complex needs and to develop a shared care plan to improve the quality and lower the cost of caring for high-risk patients. The goal of population health management is to increase the value of health care by attempting to keep patients as healthy as possible while minimizing the use of unnecessary care and testing. The key to this approach is to identify beneficiaries with complex needs and to then target them with care management interventions to prevent disease complications. When successful, these care management approaches shift the site of care from high cost centers such as the emergency department (ED) and the hospital to lower cost delivery sites such as primary care.

One difference between the traditional approach to delivering care and population management is the utilization of a multi-disciplinary care management team to coordinate services. The care team works with patients to develop a care plan to address the complex issues, clinical and social, that many patients face [1]. Sharing the care plan with the patient and with all of a patient’s caregivers, ideally through an electronic health record, helps to ensure that ongoing care will be coordinated for the purpose of maintaining and improving health, while limiting the need for avoidable high cost care.

Across the country, a number of sites have begun to utilize population health management techniques and they are achieving some impressive results. In Camden, New Jersey there is a model program targeting those who make 6 or more visits to emergency rooms within one year. The program assigns patients an outreach team made up of a nurse practitioner, a social worker, an outreach worker, and a family medicine doctor. This team routinely visits their patients in their homes, the hospital, or wherever they happen to be [2]. Through these visits, the care team can help coordinate health care needs as well as address other needs like inadequate access to housing or food. One year after implementing the program, Camden saw a 57% reduction in hospital admissions, a 33% decrease in ED visits, and a 56% decrease in cost of care [3].

Although the evaluations of model sites like Camden are suggestive of the benefits of population management, the evidence for the value of these sorts of programs is still emerging. In general, these programs have not been rigorously evaluated in a randomized control trial and the lack of good control groups leaves open the possibility that what appears to be a benefit is merely the natural history of what would have occurred even without the intervention. Consistent with an epidemiological principle known as regression to the mean, individuals who are identifiable by having a very high use of services will naturally over time reduce their use of services, without interventions. Without a control group of similarly high use patients who do not receive population management, it is impossible to identify the degree of impact that population management is having on the natural history of high users of care.

bindman 2It’s clear why health systems and those concerned with managing health care costs would be interested to pursue population health management, but what are the implications of these changes for patients? One aspect of population management that may be unfamiliar and therefore lead to some resistance among patients is the extension of care beyond the traditional doctor-patient relationship to include the involvement of non-physicians in the provision of care [4]. Patients may be unaccustomed and therefore uncomfortable to accept advice from behavioral health or social workers when they are historically used to a private one-on-one interaction with their regular physician. Patients may not be prepared or comfortable with someone other than their personal physician directly advising them and they may consequently ignore or challenge this advice. The degree to which the care management team is integrated into a patient’s primary care practice may have an impact on how members of that care team are perceived by the patient. A successful care management program in Oregon published preliminary data on the responses to their program and patients reported a strong feeling of connection between themselves and the staff [5].

There is also the concern that if population health management initiatives are seen by patients as primarily for the purpose of saving money for a health insurer rather than for improving their health, there could be a major backlash. Patients’ resistance to population management related to financial interests may be compounded if they are asked to contribute to the cost of the service. For example, Medicare implemented a billing code for chronic care management this past year for non-face-to-face management of patients with multiple chronic conditions. As is the case with all Medicare billing codes, patients are expected to contribute 20% toward the costs. It may be confusing for patients to receive a bill for a health care service without their receiving a face-to-face visit and for a service which patients may have assumed their physician was already doing.

One way to perhaps get patients more engaged in the process of population management is to consider providing them with the potential for shared savings. Health care providers are increasingly forming shared savings arrangements with payers when they demonstrate that they have avoided costs while maintaining quality. Perhaps by involving patients in these financial opportunities the shared interests of payers, providers and patients can be brought into alignment in a way which will help to get everyone focused on not just more care by higher value care.

Despite preliminary studies and speculations on its future, population health management remains an emerging process with much to be learned. In adopting these practices, there is a large potential for both health systems and patients to experience positive financial and health outcomes. However, in order for population management strategies to be accepted by patients, physicians need to develop a way to communicate to their patients the changes they can anticipate and engage them in a way that feels comfortable and familiar. With cooperation from all parties, population health management stands the greatest chance of successful integration into the health system.


  1. Hong, Clemens, “Caring for High-Need, High-Cost Patients” The Commonwealth Fund, August 2014.
  2. Huget, Jennier, “‘Super-utilizers’ place huge burden on health-care system,” The Washington Post, November 2012.
  3. Green S.R., Singh V., and O’Byrne W., “Hope for New Jersey’s City Hospitals: The Camden Initiative,” Perspectives in Health Information Management, April, 2010.
  4. Markiewitz, Andrew, “Identifying the high risk patient”. American Academy of Orthopaedic Surgeons. October, 2013.
  5. L. Lockert, “The Health Resilience Program” CareOregon, 2013.

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Julia Bindman is an undergraduate student at Johns Hopkins. She is a pre-med majoring in Computer Science and Biology.

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