AUGUST 2011 Exploring the Promise of Population Health Management Programs to Improve Health Suzanne Felt-Lisk and Tricia Higgins The concept of population health management (PHM)—programs targeted to a defined population that use a variety of individual, organizational, and societal interventions to improve health outcomes—is increas- ingly being looked on by employers, health plans, and others as a promising practice for helping to improve health outcomes and “bend” the health care cost curve. Improving population health by attacking “the upstream causes of so much of our ill health,” such as poor nutrition, physical inactivity, and substance abuse, is also a core goal of the triple aim for improving health and health care in this nation, articulated by Donald Berwick, administrator of the Centers for Medicare & Medicaid Services. Despite the concept’s growing prominence and interest, there is little understanding of the prevalence of and evidence base behind PHM programs. This issue brief looks at the state of PHM, highlights the evidence related to PHM pro- grams, examines desirable features, and explores the potential future of PHM in the United States. The Concept of Population group of stakeholders that provides to help, analysis of key demographic Health Management services aimed at improving popula- and health data on the target population tion health. Although not the only such is important. PHM programs are a set of interven- model, it conveys many concepts shared tions designed to maintain and improve broadly by those involved in PHM. people’s health across the full con- Prevalence of Programs The CCA framework embeds two key tinuum of care—from low-risk, healthy The Mathematica team conducted an points: individuals to high-risk individuals with environmental scan of promising PHM one or more chronic conditions. PHM 1. Population health is person-centered; practices, finding that these programs has elements in common with disease organizational interventions are tai- have increased in popularity in the past management, preventive services, and lored to the individual and community few years. We also found that programs health promotion, but differs in both resources are targeted to individuals. combine tools and modalities to engage the scope of services and definition Individuals are evaluated to identify and influence individuals to maintain of target populations. PHM programs 1 their place on a continuum of health or improve their health. The most typically are developed to address the risks, from no or low risk to high risk. recent market survey of purchasers by needs of insured population subgroups Specific interventions, such as health CCA (conducted in 2009) found that 68 for which an employer, health plan, or promotion and wellness, risk manage- percent of those surveyed (mostly large other purchaser bears responsibility. ment, care coordination/advocacy, and employers) purchased population health Populations targeted by PHM are often disease/case management, are targeted improvement services and 84 percent delineated by health benefit source to people based on where they fall on expected to purchase more in the future rather than geography. However, some the continuum of risk/care. (Kelly and Neftzger 2010). proponents argue that because improv- ing population health is a national goal, 2. Operational measures and program a target population can also be identified outcomes help improve the interven- State of the Evidence broadly, as in “all citizens of the United tions and refine the “assessment” Despite the popularity of PHM, the field States,” as well as narrowly, as in “all portion of the program that places is still in its infancy and it is not clear people who call Dr. Jones their doctor” individuals on the continuum of risk/ whether PHM programs can deliver (Berwick et al. 2008). care and determines what interven- better health outcomes. Researchers tions they are eligible to receive. Figure 1 shows a conceptual framework have not yet identified a set of effec- for PHM adopted by the Care Contin- To ensure that a PHM program is tai- tive methods for improving the health uum Alliance (CCA), an industry trade lored to the needs of those it is designed of whole populations, short of care- fully designed, community-wide public Figure 1. FIGURE 2– CONCEPTUAL PHM FRAMEWORK Conceptual PHM Framework Population Monitoring/Identification ▼ Health Assessment ▼ Risk Stratification Care Continuum No or Low Risk Moderate Risk High Risk Health Management Interventions Health Promotion, Health Risk Care Coordination/ Disease/Case Wellness Management Advocacy Management ▼ ▼ Organizational Interventions Tailored Interventions (Culture/Environment) Person Community Resources Operational Measures Program Outcomes Psychosocial Behavior Clinical and Productivity, Financial Outcomes Change Health Status Satisfaction, QOL Outcomes Source: Outcomes Guidelines Report Volume 5. (2010). Washington, DC: Care Continuum Alliance. Reprinted with permission. QOL = quality of life. Conceptual PHM Framework In addition to a revised version of the 2009 released PHM Framework, a conceptual population health management framework health campaigns.is included inThis this suggests report, (Figure that 2, above).literature The intent on worksiteof this model health is to promotion, complement the tiondetailed and PHM disease Program management. Process Within when large organizations, or a nation, defined broadly as using a health risk all these areas it will be important to choose toFramework pursue a byPHM identifying program, the general componentsassessment and (HRA) stakeholders with feedbackof population and health. Likelook the at thedetailed quality PHM of Program the research and strong monitoringProcess Framework, and evaluation the Conceptual will PHMfollow-up Model depicts (which the identification, varied widely). assessment Health and stratificationto better understand of program how participants. this research be criticalThe to core guide of the its modelevolution (central over blue box) promotion—throughincludes the continuum the of worksitecare, as well or as healthapplies management to PHM. interventions. The time to personmaximize is central results. in the model, and is surroundedother venues—is by various aoverlapping key part of sources PHM, of as influence on the management of his or her noted previously. The task force con- Evidence suggests that not all PHM Many ofhealth. the individual This can elementsinclude, but of isPHM not limited cluded to, organizational that these interventions interventions, generally provider interventions programs and are family equal: and a recentcommunity survey programsresources. have been Operational separately measures imple- are representedwere effective under program in influencing outcomes, tobacco as are the core outcomeshows that domains many fromlarge theemployers—the PHM mented and studied, as shown in Table and alcohol use, seatbelt nonuse, dietary main customers of PHM programs—do 1, but moreProgram has to Process be done Framework. to determine Finally, the cycle of program improvement based on process learningsnot think andtheir outcomes vendors isare very effec- prominently depicted by the large curved fatgreen intake, arrows. blood pressure, cholesterol, how these elements work together. The summary health risk estimates, worker tive, whereas a smaller portion do find challenge that PHM brings is to fit these absenteeism, and health care service them effective. For example, 66 percent individual pieces together into a patient- use (Soler et al. 2010). However, most responded that their vendors are not at centered, evidence-based whole that is of the studies were not well structured all effective or only slightly effective in more effective than individual elements and most of the participants are likely influencing members to make healthy have proved to date. to be the “worried well,” or those who lifestyle decisions; 51 percent gave the same negative response regarding 19 There are also broader, related areas in are motivatedCARE CONTINUUM to change their ALLIANCE behavior, reducing confidence in this conclusion. vendors’ effectiveness at encouraging which research is being applied. For members to comply with preventive care example, the Task Force on Community Comprehensive research is also being conducted in the fields of care coordina- guidelines (Kelley and Neftzger 2010). Preventive Services recently reviewed The difficulty of effectively changing 2 Table 1. PHM PROGRAM COMPONENTS Program Component Advantages Disadvantages Means of Targeting Interventions to Population’s Needs Health risk appraisals (HRAs) HRAs have demonstrated health benefits when Percentage of target population that completes combined with programs to address identified HRAs is typically low, leading to underestimation needs (Shekelle et al. 2003; Soler et al. 2010) of problems (National Business Coalition on Health [NBCH] and eValue8 Health Care 2010) Claims/lab/electronic health record These sources provide additional information, There is a time lag for claims data; a variety of (EHR) data used to identify appro- compared with using HRAs alone methods are used, but the best approach is unknown priate level of intervention Data on racial, cultural, language, and Using these data is considered a promising The best approach is not known; this method socioeconomic factors used to indicate practice by NBCH is not widely used at present best ways to reach subpopulations Policy and Program