Tip Sheets

So which is it? Providers develop wide variety of definitions for population health

Joseph Burns

By Joseph Burns

One of the main ideas behind the Affordable Care Act was the concept that physician practices, hospitals, accountable care organizations and other groups of providers would deliver population health. But since Congress passed the act in 2010, defining how population health is delivered has been challenging

The terms population health and population health management have become ubiquitous among health care providers, wrote Tamara Rosin, a reporter for Becker’s Hospital Review. But, she added, “Despite their prevalence, the industry has yet to decide on a single definition of ‘population health.’” She was reporting on a panel discussion that Becker’s sponsored on the topic and included in her article definitions of the term from five hospital executives.

One hospital CEO defined population health narrowly as focusing on managing high-cost and high-risk patients, who are often called high health care utilizers, or more derogatorily, "frequent flyers."

Another characterized population health as a merger of initiatives to deliver acute care and public health, including efforts to care for patients who have chronic conditions and to reduce hospital utilization rates, Rosin wrote.

Yet another executive defined population health as meeting the Triple Aim and being responsible for the total cost of care for a population “without losing our shirts.” The Triple Aim is a concept the Institute for Healthcare Improvement developed for optimizing health system performance by improving patients’ experience of care (including quality and satisfaction) and the health of populations and by reducing the cost of care.

Most telling perhaps was a comment Rosin quoted from Deb Gage, president and CEO of Medecision, a population health management company. Discussions among health care executives about population health are similar to the conversations teenagers have about sex. “Everyone's talking about it, no one really knows how to do it. Everyone thinks everyone else is doing it so we all say we're doing it,” she said.

Medecision is one of several companies taking advantage of the need that hospitals and physicians have for guidance on how to deliver population health. In an article last year, Bruce Japsen reported for Forbes that population health consulting is becoming a competitive industry. Health insurers’ divisions, such as UnitedHealth Group’s Optum and Aetna’s Healthagen, are selling population health management services to hospitals, employers and others, he wrote.

It’s possible that hospitals and physicians need guidance on how to manage populations of patients because of differences in the theory behind population health and the reality that hospitals, health systems, physicians and other providers deliver. For a report last year on accountable care organizations, the Robert Wood Johnson Foundation cited the results of a survey of health care executives who were asked to define population health.

In response to a survey for the report, an ACO executive gave a defined the concept succinctly: “Technically, we view population health as the overall health of a population over a period of time.” That same executive explained, however, that health insurers have a different focus on care. Health insurers 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. Health insurers call this movement churning. A study published last year in the journal Health Affairs estimated the churn rate among low-income individuals in three states at 25 percent.

As a result of the churn rate, “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. In other words, over four years, insurers will turn over their member populations completely.

“Medicare, on the other hand, is saddled with you once you turn 65,” he added. “They have more incentive to be concerned about the long-term health of that population of patients.” In July, the federal Centers for Medicare & Medicaid Services announced that it would test a population-health approach to patients with heart disease, according to an article in Modern Healthcare by Virgil Dickson and Erica Teichert.

A number of organizations are providing population health effectively and defining how it’s done. One is Oak Street Health in Chicago, which uses a population-health approach to delivering care, as Leslie Small explained in FierceHealthcare. Another example of an organization delivering population health effectively comes from Monarch HealthCare, an independent physician association in Orange County, Calif., as shown in this report from the Commonwealth Fund. Bernie Monegain reported for HealthcareITNews that Aledade, a company that manages ACOs and contracts with physician groups to improve care coordination and population health for Medicare beneficiaries, was expanding beyond Medicare to contract with private health insurers and state Medicaid programs.

The November issue of Health Affairs focused on the culture of health and included seven articles on population health, including one on how pay for success programs are doing so effectively.

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 joseph@healthjournalism.org.