A Primer in Population Health Management

Abstract

Population health management (PHM) and value-based care (VBC) aim to enhance care quality and reduce costs, and may include additional goals. The definition and implementation of PHM vary among organizations. Although definitions vary, central to PHM is improving the health of a specific population. It is distinct from other disciplines, particularly public health, which it often is confused with. Although PHM program designs vary from one organization to another, they share common characteristics, including multidisciplinary teams, data analytics, information sharing, and a broad range of interventions. Data analysis and reporting are key elements of PHM programs, supporting informed decision making and guiding evidence-based activities. Risk stratification is an important feature of analytics that identifies population segments where interventions are likely to have the most impact. PHM teams require expertise from different disciplines, and clinicians should be involved in the design of programs and stratification models, the development and monitoring of interventions, the communication of goals and opportunities, and the evaluation of a program’s success. Physician leaders play an important role not only in these activities but also in trust building. PHM operations entail clear roles and expectations; participatory input, and regular information sharing are essential. Many challenges that may impact the evaluation of PHM programs include annual variations, outcome realization times, and limited ability to attribute outcomes to specific interventions. Investment in PHM, alignment with VBC, proactive efficient interventions, adaptable operations, dependable analytics, and strong collaboration drive success.