Hospitals, health systems struggle to define population health

Joseph Burns

About Joseph Burns

Joseph Burns (@jburns18), a Massachusetts-based independent journalist, is AHCJ’s topic leader on health insurance. He welcomes questions and suggestions on insurance resources and tip sheets at

Population health was a term that became popular as Congress was passing the Affordable Care Act in 2010. In the seven years since then, hospitals and health systems have struggled to define the term consistently.

For example, you see from this article by Tamara Rosin for Becker’s Hospital Review that health system administrators use the terms “population health” and its twin “population health management” to describe what they do to keep patients healthy and out of the hospital. The problem is that settling on one definition is a challenge, Rosin wrote.

In a new AHCJ tip sheet, we explain why there are so many definitions and show that a recent report sheds some light on what there are so many ways to describe an important and relatively simple concept: Insurers do not pay for population health. Instead, they pay physicians and hospitals to deliver care that will raise their quality and patient satisfaction scores. However, before we get into that, take a look at some of the definitions that Rosin gathered.

One hospital CEO narrowly defined population health as focusing on managing high-cost and high-risk patients, who are often called high health care utilizers, or (more derogatorily) “frequent flyers.” Another said population health was what hospitals do by delivering both acute care and public health, again mentioning including efforts to provide care for those with chronic conditions, in an attempt to reduce hospital length of stay rates low.

One executive cited the Triple Aim, a concept the Institute for Healthcare Improvement developed to encourage health systems to focus on those three elements of care that are perhaps most important. Those objectives are 1) improving patients’ experience of care, 2) improving the health of populations and 3) reducing the cost of care. The federal Centers for Medicare and Medicaid Services and other organizations have adopted the triple aim. Some have an additional objective to improve the work life of clinicians and staff.

All of these examples show how hospitals and health system struggle to define the concept. The underlying problem may be found in a report last year from the Robert Wood Johnson Foundation on accountable care organizations (ACOs). In that report, an unnamed ACO executive defined the concept this way: “Technically, we view population health as the overall health of a population over a period of time.” This definition is short, to the point, and accurate, especially when compared to the definition offered by the Thomas Jefferson University School of Population. Population health is a broad-based response to the challenges health systems face: rising costs, poor outcomes, and economic inefficiencies:

“It aims to prevent and cure human disease through social interventions that engage the community and the larger society by integrating clinical care and public health practices in a new paradigm of health delivery.”

This all-encompassing approach to population health certainly is a workable definition but clearly is at odds with health insurers pay for, which is the point the unnamed executive made in response to the RWJF survey. The executive said health insurers have a different focus on care because they want ACOs to manage patients’ transitions from one care setting to another, monitor and report quality data and reduce hospital length of stay. “That definition has been basically forced upon us by the contracts that we have to do just those things as an ACO,” the executive said. “It has nothing to do with the true meaning of population health which is taking a population of patients and keeping them healthy.”

The reason health insurers do not focus broadly on keeping a population healthy, the executive explained, is that in any given year about one in four of all health plan members will move to another insurer. In other words, health insurers care less about the long-term effects of their actions. “A health insurer, other than Medicare, is only concerned about the amount of money expended on their subscriber base during a particular year,” the executive said.

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