Editor’s note: This is the fifth part of an eight-part series that previously appeared in an abridged form in Becker’s Hospital Review.
We will not succeed in reducing healthcare costs until we can promote the health of people who are not yet patients, better care for people who are patients, and better coordinate the care of those who consume the highest proportion of the healthcare spending – the chronically ill.
There is no one-size-fits-all approach to population health management, but we must first identify all who are in that population. If, for example, the population is the participants in your employee health plan, it is critical to realize that spouses and children are likely in that population. After passage of the Patient Protection and Affordable Care Act, now adult children are likely beneficiaries of your plan. So, it would be very possible that employees are the minority of people covered under your employee health plan.
Once you identify those in the population for which you are accountable for the quality of outcomes and cost of care, you will want to segment this population into subpopulations.
Here are the minimum sets of subpopulations I believe you would want to identify:
Those who are currently healthy and apt to stay that way, i.e., they have healthy behaviors and they have no identified family or genetic risk factors. This population needs the fewest resources from your organization. They need access to health information; a point of contact for healthcare, nutritional, and exercise questions; periodic health screenings and health maintenance; and reminders as to when they need to obtain these screenings and preventive services. Since a lot of this population will be children and young adults, you would want to consider mobile applications and other fun ways, that are convenient for them, to keep in touch with this group.
Those who are currently healthy and have risk factors that place them at risk of becoming patients. This is a population with significant opportunity – keeping people from becoming patients. Risk factors may include, among other things, obesity, smoking, e-cigarette use, illicit drug use, prescription medication abuse, alcohol abuse, risky behaviors (e.g., not using seatbelts, keeping guns in the home that are not secured, or having unprotected sex with multiple partners), family history and genetic risks, and depression. In this population, it is important that you identify the risks and discuss them with the person; identify the person’s readiness for change, willingness to change, and establish their personal goals; and then offer resources for risk mitigation.
- The acute care subpopulation. People will move into and out of this subpopulation. The keys here are to make access to care timely, provide the patient with evidence-based care (in those cases for which we have evidence to guide our treatment), and ensure our programs and services are designed to deliver the highest possible outcomes, in the safest manner possible, at the lowest possible cost.
- The chronically ill subpopulation. This group provides us with the greatest immediate opportunity. The ability to effectively coordinate care and manage care transitions can reduce emergency room visits, increase medication compliance, reduce avoidable hospital readmissions, and decrease duplication of tests and risks of medication interactions. Further, there are additional cost savings if population health managers focus not just on the acute care settings, but create post-acute care management programs.
In the weeks to come, I will illustrate the segmentation and care of subpopulations.