Healthcare in the United States is in crisis, with costs growing to almost $ 4 trillion in 2017, alongside some of the worst health outcomes relative to other wealthy countries. With the goal of  delivering better care outcomes while reducing care costs, healthcare providers and professionals are pursuing population health management initiatives, and seeing promising results.

While the term “population health” is defined in various ways, it’s commonly understood to refer to the health status and outcomes of a defined population, for instance all the patients served by a particular health plan or provider organization, patients with a particular diagnosis, or all the residents of a community, city or country.  

Population health management is the means by which providers use data to assess population health and health disparities, and to develop interventions to improve them, cost-effectively, over time.

Population health management initiatives take many different forms, but they all require defining the population to be managed, and gathering as much health-related information on individuals within that population as possible. Information gathered includes the impact of healthcare interventions, social context, and other factors on physical and mental health; and impact measures often include mortality rates, rates of hospital admission and readmission, rates of unnecessary medical care, as well as the overall cost of care provided. Once data becomes available about the disease burden on both individuals and communities, and the social and environmental factors affecting that burden, providers are better able to identify risk amongst individuals and groups within the defined population. This information then enables professionals to craft targeted interventions and reduce health disparities.

Population health management in action: A powerful tool for cracking chronic

So why are people talking about population health management? To highlight its importance, let’s explore how it can be leveraged to reduce the burden of one of our nation’s most challenging healthcare problems: chronic disease.

A RAND study found that the 12% of the adult population have five or more chronic diseases, which account for a whopping 40% of US healthcare spending. Population health management can help curtail these costs, while also improving outcomes for those diagnosed with chronic illnesses, by revealing the wide-ranging factors driving the chronic disease epidemic in the US. Take the following example of how professionals might tackle diabetes, a chronic condition that affects over 30 million Americans.

Imagine some researchers want to better address diabetes within an urban area. They might start by looking at the rates of diabetes in the given area compared to the state and country as a whole, and observe the circumstances in which diabetes patients live. This would be done with data collected from payer and provider networks, electronic health records, and analyses of the community at large.

Now, say the researchers find that over half of the diabetes patients in the area don’t adhere to their medication plans; this contributes to poorly controlled diabetes and related complications, and as a result, overuse of hospital services for avoidable care needs. The researchers might establish a plan to address medication adherence by bringing health coaches and pharmacists to highly-frequented community spaces where they can fill prescriptions for diabetes patients, and explain how and when the medication should be taken. Solutions to other barriers could also be explored—for instance, reliable transportation to and from pharmacies. An intervention like this would hopefully increase medication adherence, cut down on the overuse of hospital services, and ultimately improve the health of the afflicted population.  

Given their potential to zero in on the unique health-related challenges and barriers facing Americans today, more and more innovative healthcare providers are building their delivery models to enable population health management. As these models expand across the country and become more effective in addressing the numerous problems facing US healthcare, our health system will be better equipped to handle the evolving needs and rising costs of the nation’s care.


  • Jessica Plante
    Jessica Plante