Population health, which encompasses the health outcomes of a specific group of individuals, has become an important concept in modern health care systems. Many public policy initiatives in recent years have included population health measures as a key component of optimizing the performance of the US health care system. While such traditional, incentive-based government programs have increased awareness of the importance of population health, truly meaningful change to the US health care system will require reorganization of the structures of care across populations. Broad, lasting improvements across the medical, social, and economic determinants of health will require innovative thinking and the formation of nontraditional partnerships. We provide examples of novel and effective partnerships that have recently been established between health care providers, patients, commercial insurance companies, government entities, academic researchers, pharmaceutical manufacturers, local community organizations, and other stakeholders.
The discipline of population health has seen a meteoric rise in popularity and attention in the last 15 years since Kindig and Stoddart sought to clarify the term
We propose that population health as a concept of health be defined as “the health outcomes of
a group of individuals, including the distribution of such outcomes within the group.” These groups are often geographic populations such as nations
or communities, but can also be other groups such as employees, ethnic groups, disabled persons,
In 2008, improving population health was identified by the Institute for Healthcare Improvement as part of the Triple Aim for improving the US health care system, along with improving the experience of care and reducing per capita costs of health care.2 Similarly, in 2011, the improvement of population health was included as a key goal of the National Quality Strategy, which was established as a result of the enactment of the Patient Protection and Affordable Care Act (ACA).3 As the United States grapples with trying to improve our health care system, the solution is founded on reorganizing systems of care for populations.
Population health goes beyond medical care, extending into the nonmedical determinants of health, their impact on health outcomes, and potential interventions to impact them. The key determinants of health are genetics, social circumstances, environmental conditions, behavioral choices, and medical care.4 Because medical care only contributes an estimated 10% to outcomes,4 organizations have begun to think beyond health care delivery to identify ways to improve population health. Additionally, since people spend the majority of their time outside of contact with health care systems, it is imperative to identify opportunities to engage patients between medical care encounters.
Diverse Stakeholder Efforts
Numerous policies and experimental value-based care performance programs have been put into place to align incentives, stimulate new behaviors, and create systems to achieve these goals. For providers, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) brought forward 2 tracks of participation through the Merit-Based Incentive Payments System (MIPS) and alternative payment models (APMs).5 The Medicare Star Ratings program introduced rewards for payers that can provide high-quality care for their populations.6 Both private and public accountable care organization constructs are designed to engage and align health systems around value-based contracts.
Additionally, hospital organizations with 501(c)(3) federal tax exemption status are required to complete a Community Health Needs Assessment (CHNA) as part of the ACA. Aimed at addressing population health challenges, this provision requires such hospitals to assess the social and economic condition of the community and to determine how the community perceives its health status and health care needs.7 This outreach and engagement can enable the identification of the major risk factors and causes of health problems, which can then be used to develop a strategy and an implementation plan to address the identified needs. Finally, CHNAs are publicly reported along with the progress made toward addressing those needs, which provides transparency and accountability.
With each of these programs, systems and incentives have been put in place to align health care stakeholders around value-based care. Providers, health systems, and payers each assume key responsibilities to reorganize care. Robust and monumental change to a complex system requires coordinated effort across broad and diverse stakeholder groups. The Centers for Disease Control and Prevention (CDC) states the following about population health, which goes beyond alignment and further specifies partnerships8:
[P]opulation health [is] an interdisciplinary, customizable approach that allows health departments to connect practice to policy for change to happen locally. This approach utilizes non-traditional partnerships among different sectors of the community—public health, industry, academia, healthcare, local government entities, etc.—to achieve positive health outcomes.
Whether health departments or other constituents take the lead, lasting change across health and the social and economic determinants of health represented in broad-based population health will require not only joint effort but also innovation and nontraditional partnerships. It is these interdisciplinary, interconnected partnerships that are the pathway to population health; when all parties can align and contribute, collective organizations are strengthened for improved health care.