Population Health Management, 2021 Style

By Lola Butcher
October 12, 2021

Two health systems at the forefront of population health management share how their experiences in 2020 will influence their work going forward.

Covid-19 and racial inequities so dominated 2020 that one of the healthcare sector’s favorite topics — population health management — barely got a word in edgewise. But the ongoing pandemic and racial reckoning present important lessons for population health initiatives, and leaders in value-based care are seizing on those lessons to propel even greater success.


Patients’ focus on preventive care fades fast.

COVID-19 pushed aside patients’ willingness to keep up with routine elements of care that are essential to population health management, including vaccinations, cancer screenings, and blood pressure and cholesterol checks.

“What we discovered is how dependent population health is on that 15-minute physician office encounter,” says Jaan Sidorov, MD, MHSA president and CEO of PA Clinical Network, a clinically integrated network affiliated with the Pennsylvania Medical Society. “We’ve got to figure out a way for persons with diabetes to manage and take care of their diabetes without being so dependent on 2.3 office visits a year.”

COVID shined a brighter light on racial health disparity data.

COVID-19’s toll on the America’s Indigenous, African- American, and Hispanic populations mirrors the high rates of chronic disease among those groups.

While many health systems have been working to reduce health disparities, the fact that they still exist in such extremes — COVID-19 hospitalization rates for Indigenous People, Blacks, and Latinos are at least 4.5 times greater than Whites — shows that efforts to date have not been fully successful.

“We already had data and knew where those health disparities existed,” says Byron C. Scott, MD, MBA, a member of the AAPL board of directors. “This ongoing issue is asking us what we are going to do, along with what processes and structures we are going to change.”

The direct link between health disparities and success in value-based contracts is obvious, according to Sidney H. “Beau” Raymond, MD, FACP, medical director of Ochsner Health Network in Louisiana. The rate of health screenings within the network is about equal for all racial and ethnic subgroups, but control rates are not.

“We’re looking into that aggressively within our system — hypertension and diabetes control rates in particular,” Raymond says. “We want to identify those patients early and support them with access to the tools and digital technology that can help prevent down-the-road complications like heart attacks and strokes.”

Friends count.

The benefits of participating in a clinically integrated network paid off when physicians needed to quickly pivot to telehealth visits at the beginning of the pandemic. When any of the member practices learned fast-emerging details about payers’ billing practices for telehealth, Sidorov’s team quickly disseminated the information among all the CIN practices.

“Our clinically integrated network acted like a clearing- house,” he says. “I think the practices that went out of business because of COVID and were unable to make telehealth a go were practices that were socially and professionally isolated.”

Crises force innovation.

Scott serves on the board of Direct Relief, a humanitarian aid organization that works in all 50 states and more than 80 countries. When COVID-19 hit, the agency became a major source of personal protective equipment (PPE) for U.S. healthcare facilities. In November 2020 alone, Direct Relief sent more than 1.2 million N-95 respirators and surgical masks to U.S. health facilities, along with thousands of gowns, face shields, ventilators, ICU medications, thermometers, and pulse oximeters.

“When Direct Relief has to donate PPE, medical supplies, and medications to a major hospital and health systems, then all of us need to understand that something is wrong with our supply chain and systems as it relates to pandemic preparedness,” Scott says. “But I have seen some tremendous innovation going on during COVID-19.”

That suggests to him that nonprofit agencies — along with the philanthropic organizations and corporations that sup- port them — may be able to help healthcare organizations in other ways. “When you look at the successes around COVID, waiting on the government to do things did not work well,” he says.

Looking ahead, two health systems at the forefront of population health management share how their experiences in 2020 will influence their work going forward.


Ochsner Health, based in New Orleans, is Louisiana’s largest nonprofit health system, with 40 owned, managed, and affiliated hospitals and specialty hospitals throughout Louisiana and Mississippi. Ochsner Health Network is the largest Louisiana-managed super clinically integrated network of more than 2,500 providers who serve nearly 500,000 lives under value-based arrangements ranging from pay-for-performance and shared savings/shared risk to bundles, capitation, and four insurance products.

In 2019, the Ochsner Accountable Care Network served about 30,000 patients in the Medicare Shared Savings Program (MSSP) Track 1+ and Enhanced Tracks and earned $23 million in shared savings. Having been successful with increasing levels of financial risk, the organization is now pushing into a broader geographic area, Raymond says. Using its experience with the MSSP and its Medicare Advantage (MA) capitation contract, Ochsner is engaging community physicians and physician networks to expand its reach.

“We continue building upon our success and, at the same time, increase the scope of what we’re doing throughout the state to improve how we perform as a state while driving up population health across the entire region,” he says.

A primary focus for 2021 is engaging with patients in their homes, either in person or via technology. “Expecting the patient to come to your brick-and-mortar is not going to work anymore,” Raymond says. “You need to go where they are.”

The goal is to promote the most appropriate level of care and avoid unnecessary, high-cost care — emergency department (ED) visits and inpatient stays — by making the right care, at the right time, convenient for patients. “It’s really about engaging with patients more proactively as opposed to waiting for them to come into your office or hospital,” he says.

Ochsner seeks to have an enhanced annual wellness visit (EAWV) — a one-hour visit with a nurse practitioner to make sure all care gaps are closed — with about 50 percent of its patients who are covered under an MA capitation contract or one of the MSSP tracks. Two patient groups are prioritized: those who are new to Ochsner and those with multiple chronic conditions that put them at high risk for health problems.

While those enhanced wellness visits traditionally have been conducted in physician offices, Ochsner introduced home visits before COVID-19 emerged. “We realized that the people we were not capturing were the people who were at higher risk,” Raymond says. “It was worthwhile for us to go to the home, so we started offering that as an option.”

When the pandemic threatened the safety of in-person visits, Ochsner offered enhanced wellness visits through virtual technology, courtesy of the federal government’s temporary relaxation of some telehealth rules. Going forward, Raymond believes a hybrid approach may work well for enhanced wellness visits. For example, a medical assistant might go to the patient’s home to handle some parts of the exam while a nurse practitioner communicates with the patient virtually.

“Honestly, patients still want to have someone there with them most of the time for that visit — that’s what we have found,” he says. “So we’re trying to meet the patients where they are and do what works best for them.”

Another at-home strategy is home visits after a patient has been discharged from the hospital.

Traditionally, Ochsner’s strategy to reduce preventable readmissions has been to ask patients to visit one of its “priority clinics” shortly after a hospital stay. But only about half of newly discharged patients scheduled an appointment, and 20 percent of those who did were no-shows. “What we found was that the ‘no-shows’ or people who didn’t schedule the appointment were the people who got readmitted,” Raymond says.

Now patients at high risk of readmission are identified by a post-discharge phone call, and a home visit with a nurse practitioner is scheduled. Most patients appreciate the convenience, he says, but the strategy has other benefits as well. In addition to a clinical assessment and medical reconciliation, the nurse practitioner can verify whether the patient has appropriate food, social support, and the durable medical equipment that will help him or her recover safely at home.

The result: The 30-day hospital readmission rate for high-risk patients in the program has dropped from 10 percent to 5 percent since post-discharge home visits started.

A third at-home strategy is the use of a vendor, Ready, to reduce avoidable ED utility through on-demand at-home urgent care visits and short-term case management for ED frequent fliers. The program has reduced ED use among the targeted patients by more than 50 percent.


Lehigh Valley Health Network, based in Allentown, Pennsylvania, includes 11 hospital campuses serving a population of more than 1.5 million people spread across an eight-county area. In late 2014, the health system went “all in” on value-based care when it announced its intention to become “an innovative population health leader.”

President and CEO Brian Nester, DO, Chief Physician Executive Robert X. Murphy Jr., MD, and other LVHN leaders knew theoretically where they were heading, but how it would work out was not clear at the time. “We had no idea where this population health journey was going to lead us,” Nester says. “But just look where it took us.”

LVHN has entered into six shared-risk contracts that collectively cover nearly 175,000 lives. LVHN’s own employee health plan, which covers some 26,000 workers and their dependents, had cumulative savings of $89 million in the five years ending June 2019, courtesy of the health system’s ability to manage costs while improving patient health.

The health system’s electronic medical record system — one system that integrates both inpatient and outpatient care — is highly optimized and was recognized for achieving the highest proficiency level by the Healthcare Information and Management Systems Society (HIMSS). “Telehealth and remote patient monitoring are in place with the vision for hospital-at-home,” he says. “All of our top leaders have value-based objectives and are developing tactics and strategies for their domains.”

LVHN’s biggest differentiator, however, may be Populytics Inc, a wholly owned subsidiary of the health system that converts data from insurance claims and clinical records into actionable information for clinicians. The data points and analytics allow LVHN to align the incentives of the health system, physicians, and payers so that all are working on the same definition of value. “We need real measurable causality between our actions and the outcomes we get,” Nester explains.

Beyond that, LVHN’s sophisticated use of data opens up opportunities that the health system would have never had in its pre-population health days. That includes an unusual five-year strategic partnership with Medtronic, one of the world’s largest medical device companies, that has led to new life-saving processes and technology for LVHN patients. The two organizations were attracted to one another because they share a passion for data-driven healthcare delivery that proves its ongoing value.

“Medtronic was looking to partner with a health system that has data, understands their data, can share their data, and work to show that their devices have improved the quality of care and demonstrated economic value if used in the appropriate cohorts,” he says.

Since 2018, LVHN and Medtronic have been developing programs in enhanced respiratory monitoring, cardiac device placement, and telestroke, seeking to improve patient outcomes, efficiency of care, and patient experience in every initiative. The respiratory monitoring program used a combination of data from Medtronic’s capnography devices, LVHN’s EMR, and Populytics-provided claims and cost data to create a clinical intervention for high-risk patients.

By last year, the program had proven itself as a value-based “win” by dramatically reducing the occurrence of potentially deadly respiratory depression linked to opioid use after major surgery. When COVID-19 hit, LVHN seized the opportunity to use the technology for this new medical condition. “We started using it with high-risk COVID patients to proactively identify respiratory failure early,” Nester says.

Succeeding at value-based care is possible only because of what Murphy calls the “cultural evolution” that LVHN undertook at the beginning of its commitment to population health management. “This doesn’t come without investing in the culture to take on the mantle of value,” he says.

The health system partnered with Thomas Jefferson University's Jefferson College of Population Health to train physician and operational leaders in the core concepts of population health management and value-based care. “This education allowed our leaders to understand the path that needed to be taken and have enough knowledge to be reassured that this wasn’t pie-in-the-sky,” Murphy says.



Lola Butcher is a freelance healthcare journalist based in Missouri.

This article appeared in the July/August 2021 issue of Physician Leadership Journal.




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