What Is Population Health Management? Exploring an Important Care Concept

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Population health management is gaining ground among U.S. health experts as a way to improve healthcare outcomes at the local, state, and national levels. Healthcare expenditures in the U.S. are among the highest of developed nations, but Americans have a lower life expectancy and higher percentage of poor outcomes for chronic conditions. Compared with other countries, the U.S.’s fee-for-service healthcare system is among the most expensive models, yet it’s also among the least effective.

A smiling DNP working on a laptop.

Healthcare providers, government health agencies, and insurance companies are all looking for ways to lower the cost of care while improving outcomes and increasing health equity across all demographics. As a result, population health management is gaining interest among healthcare providers who want to apply their expertise to the knotty problem of high healthcare costs and healthcare disparities. An online Doctor of Nursing Practice degree program can help prepare experienced nurses and nurse practitioners to become leaders who are ready to take on today’s healthcare challenges.

Defining population health

Population health is an interdisciplinary approach that measures, treats, and tracks the health of a specific population or group to work toward improved outcomes. A population can be defined in several ways. It could be a local community or neighborhood, a state or region, or a nation. People who are served by a specific hospital or covered by an insurance provider could also constitute a population, as could people of the same age or with the same chronic condition.

Once a population is defined, healthcare providers, insurers, and government and community organizations combine forces to coordinate care; provide preventive services; promote healthy behaviors; and collect, track, and measure health metrics and analyze results. These results include not just specific healthcare interventions but also data such as environment, culture, and behavior. Experts at RWJBarnabas Health say that these factors, or social determinants of health (SDOH), far outweigh medical care or genetic predisposition in impacting health outcomes.

Population health and public health overlap to some extent, but whereas public health seeks to promote overall health via public policy, research and development, and accident and injury prevention, population health centers on the specific partnerships among providers, insurers, and government agencies to improve health outcomes for a specific community.

Examples of population health management initiatives include:

New Ulm, Minnesota

The community of New Ulm sought to reduce heart disease and hypertension through the combined efforts of hospitals, community organizers, and public health officials. Health officials used medical records, data analytics, and transparency around hospitalization costs to move from a treatment-focused model to a prevention model to improve the health of the community. The results of a 10-year study show an 11% increase in residents with blood pressure in the healthy range and a nearly 40% increase in residents who exercise 150 minutes per week.

Rhode Island Health Equity Zones

In 2019, Rhode Island established Health Equity Zones (HEZs) to address the social, economic, and environmental conditions that adversely impact health outcomes. The state expects each regional HEZ to assess its community and create a plan to implement population health initiatives.

RWJBarnabas, Health Beyond the Hospital

New Jersey healthcare network RWJBarnabas established its Health Beyond the Hospital program in 2020 to identify and measure SDOH for every patient and then connect patients with community services as needed. The program screens patients for health metrics such as weight and blood pressure and for factors such as food and housing security, environmental impact, and education opportunities.

What is population health management?

Population health management combines healthcare, data analytics, community outreach, and cultural sensitivity, among other factors. The goal is what the Institute for Healthcare Improvement calls the Triple Aim: simultaneously improving population health, bettering the patient experience, and reducing healthcare costs.

The first step of any population health management initiative is collecting data. Data defines a population and includes health information from medical records, as well as social, environmental, cultural, and community statistics. Managers and directors must be able to parse that data to identify improvements or setbacks — and then revise their strategies accordingly. Population health managers use data dashboards and other data analytics toolkits to effectively support population health management initiatives.

Population health management emphasizes prevention and healthy outcomes rather than treatment. An initiative seeking to improve the outcomes of a population with Type 2 diabetes, for instance, might conduct an outreach campaign across a community to promote healthy diets and provide support for people with pre-diabetes. While hospital care and doctor visits are part of any healthcare program, here the primary goal is preventive care.

This focus on prevention means that population health management can have difficulty securing funding. The U.S. healthcare system is largely fee-for-service, which rewards hospitals and doctors for treating the sick. Insurers and payers are not set up to reimburse for preventive care that keeps people out of the hospital. Based on this shift, the Centers for Medicare and Medicaid has established a value-based payment modifier, which pays providers based on quality of care instead of just the cost of care.

Key skills for effective population health management

A population health manager or director needs key hard and soft skills to be effective. Leadership, communication, and creative problem-solving are essential for the role. Also crucial are strong technical and analytical skills, as the foundation of population health initiatives rests on the ability to design population health programs and collect and manage data from electronic health records and other sources. The ability to see the big picture, think creatively, and work at the intersection of traditional fee-for-service healthcare and value-based preventive care are all part of the toolkit of a successful population health management professional.

Key technical skills include:

  • Machine learning and AI data analysis
  • Predictive analytics
  • Business intelligence
  • Data visualization
  • Quality-of-care tracking

Key management skills include:

  • Building relationships with primary care physicians, hospitals, and community health leaders
  • Developing effective population health strategies and initiatives, for which goal setting and execution are essential
  • Managing value-based care programs and goals, including payer relationships, making finance and budgeting key
  • Collecting and analyzing population data, establishing data collection goals, and preserving patient privacy
  • Reporting results to stakeholders and assessing and reassessing programs based on results

Career outlook for population health managers

According to Grand View Research, the population health management market is expected to grow at a compound annual rate of 20% between 2020 and 2027. That growth projection stems from data showing that U.S. healthcare costs are among the highest in the world, and yet the country’s health outcomes are often quite poor. As hospitals and other healthcare organizations look for ways to lower costs and improve general health with a value-added care model, they are turning to population health management.

The median salary for a population health manager was around $76,000 as of April 2021, according to PayScale. Compensation can vary based on factors such as experience, education, and location.

Discover your career in population health management

If you’re interested in using data to address inefficiencies and inequitable outcomes in healthcare, the first step is the right education. Maryville University’s online Doctor of Nursing Practice program is aimed at nurses and nurse practitioners who are ready to apply their experience and skills to leadership positions. Courses such as Principles of Epidemiology and Biostatistics and Integrating and Synthesizing Research offer students the concrete skills they’ll need to collect and analyze data in a population health management career. Learn how Maryville can help drive your professional growth today.

Recommended Reading

How Predictive Analytics in Healthcare Saves Lives

12 Common Public Health Issues and How They Can Be Prevented

The Importance of Health Promotion and Disease Prevention

Sources

Adventist HealthCare, “Director of Population Health Operations”

American Hospital Association, “Population Health Definition

Association of Maternal & Child Health Programs, “Rhode Island Health Equity Zones”

Centers for Disease Control and Prevention, “What Is Population Health?”

Dashboard MD, “Population Health Management and Clinical Analysis”

Foresee Medical, “Population Health Management”

Grand View Research, “U.S. Population Health Management Market Size, Share & Trends Analysis Report by Product (Software, Services), by End Use (Providers, Payers, Employer Groups), and Segment Forecasts, 2020–2027”

Health Catalyst, “Four Population Health Management Strategies that Help Organizations Improve Outcomes” 

Health Catalyst, “Population Health Management: Systems and Success

Health IT Analytics, “Harnessing Big Data to Enhance Population Health Management”

IAPHS, “What Is Population Health?”

Minneapolis Heart Institute Foundation, “Reducing Heart Attacks”

Minneapolis Heart Institute Foundation, “The Story of New Ulm — A Population Health Transformation”

NCBI, “Learning Activities to Build Population Health Management Skills for Pharmacy Students”

OSP Labs, “Population Health Analytics to Automate Collection and Analysis of Patient Data”

PayScale, Average Population Health Manager Salary

Phillips, “What Is Population Health Management?

Primary Health Care Performance Initiative, “Population Health Management

RWJBarnabasHealth, “RWJBarnabas Health Launches Nation’s First Universal Social Determinants of Health Program”

U.S. News & World Report, “Population Health: The ‘North Star’ of the Triple Aim”

“Population Health: The ‘North Star’ of Triple Aim”

UW Health, “Director, Population Health”