Population Health Management- Part 2- Making It Work For You

Population Health Management- Part 2- Making It Work For You


The global population health management (PHM) market is believed to reach $40.6 billion by 2018 and many are joining the bandwagon by delivering solution to manage population proactively and delivering highest quality care. Many believe that PHM is software or tool or a process for managing health of people coming to a hospital. Contrary to this belief, PHM is a healthcare model or a strategy, which is the admixture of proactive patient care and care management, empowering the healthcare providers to look after the masses with simultaneous screening of those at risk. It enables the caregivers to work on a specific framework utilizing the stored patient-related information. The market is briefly classified into software and services based on the delivery model -web-based, on-premise, cloud-based software and by the end users profile- providers, payers, employer groups, and government bodies.


Healthcare Model; Engagement Analytics; Big Data; EHR; Health Information Exchange; Risk Stratification

At a Glance

  1. Introduction
  2. Market Trends for PHM
  3. Impact of PHM
  4. Essentials for Commercializing the PHM Idea
  5. Software Used in the Operation of PHM
  6. List of Companies Operating the PHM Approach
  7. Use of analytical tools in PHM
  8. Engagement Analytics
  9. Successful PHM organizations
  10. Optimization of Big Data
  11. Upcoming Educational Conferences on PHM
  12. The Final Word


PHM can store a wide variety of data ranging from a patient’s laboratory investigation reports, medical history such as surgeries undergone, social history such as smoking, alcoholism etc., present illness, and also the socio-economic factors such as access to transportation and nutrition. This information is collected from Electronic Health Records (EHRs), laboratory reports, and claims-data, which is subjected to prescriptive and predictive analytics that helps in categorizing the patients according to their requirements. 

PHM fetches an excellent association of the primary healthcare providers, pharmacists, nurses, paramedical staff, and the social workers and permits them to intervene at the appropriate stages of healthcare.

Market Trends for PHM

To boost the business potential of PHM, the Department of Health and Human Services has laid a target of shifting 30% of fee-for-service Medicare payments to quality alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by late 2016 and 50% of payments for the above models by 2018. It also aims to convert 85% of conventional healthcare revenue to quality healthcare revenue by 2016 and to 90% by the end of 2018, via programs such as Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs. 

This revolution may also transform the ideology of the healthcare provider from “high-cost patient to high-utility patient.” In other words, the caregivers would be incentivized for minimizing the patient’s hospital visits.

A survey reveals that 45% of the U.S. population has at least one chronic disease condition, which contributes to greater than 75% the total healthcare expenditure. The application of PHM would help in early identification of the disease, thereby eliminating the chances of inappropriate spending by the patient and enhance the patient-care. The analysts predict that successful implementation of PHM would save the U.S. over $1 trillion by 2023, only by tackling 7 most common chronic diseases.

Impact of PHM

There are no standard approaches for PHM and they differ from one organization to the other, depending on several factors. However, the intent remains the same, i.e., reaching out to the whole population, not just the diseased.   

In order to achieve this, many organizations seek the help of community groups and local employers. The providers gather the information by conducting health risk surveys and biometric screenings, which is then analyzed to give health scores to the patient. This data then enters into the provider’s EHRs and offers advantages like –

  • Identification of the members at-risk
  • Obtaining the health trends in the community
  • Educating the people and equipping the hospitals to help patients with disease prophylaxis

Case 1

California’s ACO has been witnessing the true scope of PHM. It has seen an astonishing improvement in the area of patient care. It is on a mission to reduce the number of emergency department (ED) visits to the hospitals.

The center set up an ED tracking system which would record the details of the patient’s visit to the ED and let the providers know when the patients’ come for a revisit. Moreover, an account of the patients who do not report despite of taking an appointment was also made. This system helped them to identify the patients who were new and was easy for them to send letters asking for follow up. It also helped them to recognize the set of patients who came to the emergency department and those for a follow up. This made the task easy for drawing conclusions about patient education. Lastly, it was found that the set of patients reduced their ED visits by 12%, thereby indicating improved patient outcomes.     


Case 2

A company located in Dallas-Fort Worth, TX managed to reduce 2.4% of the cost when compared to others in 2010. The physicians group in 2009 conducted projects with Blue Cross Blue Shield and CIGNA to serve as a Patient-Centered Medical Home PCMH. By December 2010, all the primary healthcare providers were awarded Level 3 Recognition by the National Committee for Quality Assurance (NCQA) Physician Practice Connections®—Patient Centered Medical Home™ (PPC-PCMH), because of the following achievements:

  • High-tech scans decreased by 12% for every 1000 patients.
  • Unavoidable emergency department visits reduced by 13.3%
  • The cost incurred for outpatient surgical equipments was 5.6%, which was 15% in the market.
  • The cost incurred for outpatient lab investigations increased by 1.9%, which was 9.7% in the market.
  • Overall cost performance excelled against the market in regions such as ambulatory services by 5%, other medical services by 6%, and professional services by 1%.

Case 3

Montefiore Medical Center, NY was a member of CMS’s Pioneer ACO program. It managed to improve patient outcomes with lowered costs, attained Tripe Aim of improved quality, and saved $14 million. The driving factors to success were as follows:

  • Commitment and devotion towards the goal
  • Well-built network of primary healthcare providers
  • Good health-IT infrastructure to supervise the patients
  • Excellent administrative management for allocation of budgets to different areas

Essentials for Commercializing the PHM Idea

Successful PHM implementation involves a simple formula – “Maintain the heath of the healthy, help the patients with acute illness recover, and help those with chronic ailments manage their illness.”

a) Pre-launch requirements

A proper business plan is a prerequisite to launch any idea. Individuals willing to take the risk must collaborate with other organizations/personnel to launch any PHM program. The following associations have to be made for a successful PHM plan.

1. Human Resources Partnership: Tie-ups with the Human Resource (HR) departments would result in enhanced patient care, because the HR department is in constant touch with the masses and will leverage its best by offering open enrollment benefit information packages and presentations.  

2. Association with the Primary Care Providers: Interaction with the rulers of the healthcare (CMO, CMIOs, and Group Practice Medical Directors) would help in assessing the willingness of the population to adapt to cultural changes. Identification of the best physician will uplift the business by valuable inputs in disease-specific management programs involving physical and mental wellness.

3. Legal Advisor: The legal advisor should work in close proximity with the coach, so as to inform the patient about particulars not included in the consent form. Moreover, he/she can also put efforts on risk management, in case insurance is needed for the coach himself.  

4. Alliance with Lab Personnel: A good relationship with the hospital lab is crucial in laying the costs for laboratory tests for self-insured patients and also in discussing the establishment of biometric tests for common lab investigations.   

5. Financial alliance: The allotted budget should include the following elements-

  • Agreement for staff including phlebotomists, hiring of coaches and patient support members
  • Screening requirements such as gloves, centrifuge, scales, measuring tape, batteries, and labels
  • Marketing funds for emblem, flyers, banners etc.
  • Electronics such as laptops, label printers for laboratory, telephones, and glucose finger stick machines etc.

6. Return on Investment (ROI): Analysis of profits and losses of companies who have been running PHM would be an ideal for drawing conclusions on ROI and extent of cutting of healthcare costs in the coming 3-5 years.

7.  Integration of Clinical Care with Information Technology (IT):Enhanced patient-centered care can be only achieved with the union of IT, because of the ease of monitoring and the feature of automation.   

8. Community Outreach and Marketing Support: Outreach and marketing of PHM can be effectively done by communicating with the Human Resources (HR).

In the long run, these collaborations will help achieve the reduced healthcare costs with ultimate quality of care.

b) Make correct use of data obtained from PHM companies

This pool of information can be used in the following ways to improve patient outcomes –

  • Data from the EHRs can be used by public health personnel to maintain a record of the immunizations provided in order to prevent the spread of the disease.
  • The genomic and clinical data can be compared to screen subjects required for clinical trials.
  • Consolidation of clinical data and community data will help in identification of areas that require immediate community outreach.
  • Patient data can be used to track the best treatment option for a set of diseased patients receiving a particular therapy.

Software Used in the Operation of PHM

As the patient’s health data obtained is put through analytics, it requires use of several software, thereby offering many openings for the software companies. The following are the software used for managing population health:

  • Administrative Software
  • EHR Management Software
  • Patient Engagement software
  • Practice Management Software
  • Physician Management Software
  • Pharmacy Management Software
  • Revenue Cycle Management Software
  • Hospital Information System Software
  • Clinical Decision Support System Software

List of Companies Operating the PHM Approach

1.  Adventist Health System (Altamonte Springs, Fla.): This system is based in Florida with total of 45 organizations extending in 10 states, having almost 8,100 licensed beds. It engages more than 74,000 personnel in the hospitals, nursing homes, and home health agencies.

2. Advocate Health Care (Downers Grove, Ill.):  Advocate, a 20 year-old-nonprofit health organization located in the Chicago suburbs, is the largest organization in Illinois. It offers more than 250 care sites, counting 12 acute-care hospitals. It also boasts the state’s largest integrated children’s network.

3. Baylor Scott & White Health (Dallas): This was formed in October 2013 by the union of Baylor Health Care System and Temple and Texas-based Scott & White Healthcare. It is the largest nonprofit healthcare organization in the state and has made noteworthy contributions with a short span.

4. Carolinas HealthCare System (Charlotte, N.C.): This was started as a community hospital in 1940, but emerged into a large organization with more than 900 care sites, serving 7,460 licensed beds with an annual budget running over $7.7 billion.

5. Carilion Clinic (Roanoke, Va.): It was known as Carilion Health System in the past. About 1 million Virginians receive care provided by this nonprofit organization. It’s expansion includes a group of multispecialty primary care providers, eight hospitals, Jefferson College of Health Sciences and a medical school conglomerate with  Blacksburg-based Virginia Tech.

6. Cleveland Clinic.: It is very familiar for its flagship facility in Ohio, with its expansion around the world. The system serves with 4,450 beds, out of which more than 1,400 lie in the Cleveland Clinic main campus. The staff includes more than 3,000 full-time salaried primary health care providers and researchers and 11,000 nurses.

7. Mayo Clinic System (Rochester, Minn.): Its headquarters are located in Rochester, while its operating branches are located in Arizona and Florida. It has 4,200 primary care providers and scientists, 2,400 inhabitants, fellows etc., and 52,900 allied health staff. 

8. Mercy (Chesterfield, Mo.): This centre was established by Sisters of Mercy in 1986 and it ranks fifth in the Catholic healthcare system of the U.S. It houses 40,000 employees in it.

9. Methodist Health System (Dallas): This is the second contribution of the proprietors of this system, which was initiated by building of Dallas Methodist Hospital in 1927. A tremendous growth has been seen since its establishment, reaching 420 beds in the era of 1960s from 1927. Today, it has more than 1,160 licensed beds.

10. Providence Health & Services (Renton, Wash.): Providence Health & Servicesruns 34 hospitals, 475 primary healthcare providers, 19 home care programs, and provides 693 supportive houses in 14 areas. The entire system accounts to more than 76,000 employees.

Use of analytical tools in PHM

AHIMA believes PHM to be the best way to reduce healthcare costs in the patients and also enhance the patient outcomes. The Institute for Health Technology Transformation (IHTT) in 2013 stated, “PHM focuses partly on the high-risk patients who generate the majority of health costs, it systematically address the preventive and chronic care needs of every patient. Because the distribution of health risks changes over time, the objective is to modify the factors that make people sick or exacerbate their illnesses.”

The ongoing trends in achieving this goal are –

1. Electronic Health Records (EHRs): EHRs include filling of vital signs, diagnoses, diagnostic tests, therapies, and populate registries. This organized data is then used for advanced analytics.

2. Patient Registries: These are used for monitoring the patient’s health, patient outreach, to stratify patients according to the risk, performance evaluation, identifying gaps in healthcare, and also for performance evaluation.  

3. Health Information Exchange: This would help care coordination different members of the care team. Exchange of clinical information between two healthcare providers can be facilitated by secure messaging, which uses a standard protocol.

4. Risk Stratification:  This toolin combination with predictive analytics would help the healthcare providers in providing timely interventions to patients those at-risk and the high-risk patients as well.

5. Automated Outreach: The integration of healthcare with IT offers such a great advantage such as sending automated messaging to patients who need chronic care or prophylactic care. Collaborating analytics with the patient registries help in detection of patients those need instant outreach.

6. Referral Tracking: This system would aid in following the referral reports given by the referred consultants.   

7. Patient Portals: Patient portals would result in self-management by the patients as the providers share EHRs attached to web portals.  

8. Telehealth/Telemedicine: Use of audio and video conferencing is another method of effective providing patient care. This would also reduce the number of hospital visits.

9. Remote Patient Monitoring: This tool helps patients with chronic conditions such as diabetes and hypertension.

10. Advanced Population Analytics: These analytics not only provides information about the health status of the patients but also gives financial picture of the providers and their care sites.

The conventional PHM program eases clinical actions. However, the challenges experienced by the patient are often neglected, which are the most often the cause of adverse events. Therefore, a new approach called “Engagement Analytics” is under practice, which merges scope of clinical action and behavioral actions of the patients, which focuses on their daily activities and change if required.

Engagement Analytics

With engagement analytics, the healthcare providers can monitor both individual patient and the whole set of population, thereby evaluating the health and predicting the need for patient engagement. Individual attention would also help in the determination of obstacles of engagement such as language, literacy, socioeconomic status, physical or mental disabilities etc.

Benefits of Engagement Analytics

Healthcare engagement analytics can improve retention and satisfaction, improve quality of care, and lower re-admissions. It can also help prevent unnecessary utilization and improve medication adherence. It does this by identifying engagement issues and promoting behavioral change. Doing so requires identifying risk, prioritizing stakeholders, understanding behavioral drivers and channel preferences, micro segmenting populations, and predicting behaviors.

With healthcare engagement analytics, organizations have a new, proactive tool that provides a multi-dimensional, actionable view of both individuals and populations. Once deployed, it can improve patient outcomes and bottom line value for healthcare providers and payers. We are just beginning to see how effective this practice can be.

Successful PHM organizations

1. Anthem ACO: Six medical groups participated in Anthem Blue Cross’ Accountable Care Organization (ACO), saving $7.9 million in a year by implementing PHM for patients with chronic illnesses. Their approach could successfully reduce ED visits by 7.3% per 1000 patients, reduce outpatient visits by 2.2%, and increase generic drug prescribing by 4.2% per 1000 patients.

2. Rio Grande Valley ACO: Starting from April 2012 to 2013, the Rio Grande Valley ACO saved more than $20 million. The plan execution involved home visits of those patients who couldn’t come to the hospital and telephonic conversation with those who had problems in communicating with their physicians.

3. Wellmark Blue Cross Blue Shield: Wellmark is the largest insurer of the State of Lowa and shared the ACO model with 3 organizations in 2011. It managed to save $12 million dollars in the first 2 years of contract. Additionally, it has noticed a remarkable decrease in the number of E.D visits and inpatients.  

Optimization of Big Data

Large sets of data which requires computational analysis for sorting out the patterns, especially in relation to human behavior is called big data. The large volume of data has helped the business world to become richer. In medicine it is used to forecast epidemics, treat/cure a diseased condition, enhance patient’s life, and reduce mortality.

Greatest Achievements

1. Kaiser Permanente, an integrated association has developed a computer operated system, called “HealthConnect”, which makes sure that data is exchanged over all the health care facilities. It also encourages the use of EHRs. It has accomplished $1 billion savings in cardiology department by decreasing the ED visits and laboratory investigations ordered.

2. Blue Shield of California imparts advanced healthcare by using technology that enables physicians, healthcare centers, and providers to render evidence-based care, which is more individualized and customized, thereby providing coordinated care. 

Upcoming Educational Conferences on PHM

•         ACO Population Health Management Summit- Hilton Atlanta Airport on January 27-28, 2016, at Atlanta, GA

•         HIMSS 16 – Sands Expo, Las Vegas, on Feb 29-Mar 4 at NV

•         The Sixteenth Population Health Colloquium – Loews Philadelphia Hotel on March 7-9, 2016 at Philadelphia, PA

•         Fourth Medical Informatics World Conference 2016 – Seaport World Trade Centre on April 4-5, 2016 at Boston, MA

•         iHT2 Health IT Summit on January 19 – 20, 2016 at San Diego, CA

The Final Word

For better patient outcomes, the providers need to use right tools/intervention to the right patient at the right time. Inculcating engagement analytics would definitely improve medication adherence and decrease the number of medicines ingested, ultimately imparting quality care to the patient. The USA is at its peak of fully utilizing the medical data available from numerous sources. However, the number of ACOs having treasure of this patient data is scanty. Nevertheless, many of them are on their best to track the patients instantly when they are in the hospital in order to improve patient outcomes. Regardless of the big data, many of the stakeholders don’t have proper IT framework for its maintenance. Furthermore, there are security concerns about who owns the data and how is it used.


1. Cassidy, Bonnie S. “The Next HIM Frontier: Population Health Information Management Presents a New Opportunity for HIM .” Journal of AHIMA 84, no.8 (August 2013): 40-46.

2. Data Mining for Healthcare Management. D. Prasanna, Kuo-Wei Hsu, Jaideep Srivastava. SIAM International Conference on Data Mining, 2011

3. Institute for Health Technology Transformation.  Population Health Management- A Roadmap for Provider-Based Automation in a New Era of Healthcare. http://www.waystationinc.org/FilesToView/PHMReport.pdf

4. Raghupathi and Raghupathi: Big data analytics in healthcare: promise and potential. Health Information Science and Systems. 2014 2:3.

5. http://www.partners.org/innovation-and-leadership/population-health-management/about-phm/ Accessed on 9th January, 2016.

6. https://www.healthcatalyst.com/population-health/  Accessed on 9th January, 2016.

7. Population health management-A strategy for success in the new age of accountable care.

http://www.ey.com/Publication/vwLUAssets/Health_Industry_Post_population_health_management/$FILE/Health_Industry_post.pdf  Accessed on 9th January, 2016.

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