With value-based models apt to occupy a larger share of health care reimbursement, health system and hospital leaders must place added emphasis on population health management to foster improved patient care.
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According to projections released by CMS in 2015, approximately 90 percent of Medicare fee-forservice payments will be linked to value-based care by 2018. The shift, facilitated by the passage of the ACA, is designed to increase the accountability of health care organizations regarding both the total cost and quality of care and to promote a greater focus on population health management.
In this modern healthcare environment, it is critical for hospitals and health systems to focus improvement initiatives on achieving the quadruple aim: reduce per capita costs, improve both the patient and provider experience, and create healthier patients by focusing on population health. The four tenets collectively set the table for improving the overall quality of America's healthcare system.
Defining population health management with an outcomes-based mindset
Population health has become a ubiquitous term in today's health care environment. Popular variants of the phrase include population health management and population medicine. The precise parameters for the term’s definition have been widely scrutinized; however David Kindig, MD, PhD, of the University of Wisconsin School of Medicine in Madison, and Greg Stoddart, PhD, a professor in the department of health research methods at McMaster University in Ontario, Canada, discussed a more universally accepted definition in the American Journal of Public Health in 2003. Their proposed definition was as follows: "the health outcomes of a group of individuals, including the distribution of such outcomes within the group."
In a 2015 Health Affairs blog, Dr. Kindig revisited the term. In the blog, Dr. Kindig states that the debate to establish a precise definition for population health has largely been fueled by the complex, multiple determinants of health that may affect populations, making a specific definition difficult to pin down. Dr. Kindig argues for not losing sight of the importance of outcomes when discussing population health.
"Some may argue that multiple determinants are so fundamental to population health that they deserve definitional status," wrote Dr. Kindig in the blog post. "I believe, however, that including multiple determinants in the definition could lead to confusion between the outcome goal and the determinants needed to achieve that outcome."
In accordance with Dr. Kindig’s view, healthcare leaders should not get lost in the semantics of population health. If one focuses on how health care can improve health outcomes, the term becomes more palatable. In 2011 the journal Population Health Management published main themes from industry thought leaders after the 11th Population Health and Care Coordination Colloquium in Philadelphia, describing the 3 essential outcome-related goals of population health management as:
- Keeping patients healthy
- Reducing health risks for patients
- Ensuring sick people receive appropriate care
Hospitals and health systems looking to achieve these outcome-centered goals should consider first stratifying their patient populations into risk groups, with higher risk patients defined as those more likely to require medical interventions. Once risk levels are determined, leaders can work to implement preventive strategies and initiatives that may keep low-risk individuals healthy and to move high-risk individuals into lower risk groups. These efforts may work to mitigate the natural progression of patients from lower risk groups to higher risk groups.
Anchoring population health management efforts with a focus on prevention
Preventive healthcare strategies include primary preventions, such as health education and vaccination programs; secondary preventions, such as biometric testing and early detection programs; and tertiary preventions, such as disease and disability management.
In a 2008 study published in Population Health Management, researchers documented the impact of preventive health strategies on an employee population of more than 2,600. Primary, secondary and tertiary strategies were implemented over a one-year period. At the conclusion of the year-long study, there were 5.8 percent fewer employees in the high risk category and 3.6 percent fewer in the moderate-risk category. Overall, there was a 9.4 percent increase in employees added to the low-risk category.
In a CDC Morbidity and Mortality Weekly Report published in 2015, agency researchers examined the receipt of preventive health services by adults from 2011 to 2012. Researchers analyzed a nationally representative sample of survey responses from the National Health Interview and found there was significant room for improvement with regards to prevention practices. The analysis revealed 61.6 percent of women between 50 and 74 years of age reported being screened for breast cancer, 45.3 percent of respondents ages 18 and older reported diabetes screening, and 23.6 percent of men between 50 and 75 years of age reported being screened for colon cancer.
An example of an underutilized preventive care option for America's adult patient population is the influenza vaccine. The flu shot can reduce the likelihood of contracting influenza by 50 to 60 percent, according to the CDC. The possible preventive care benefits being underutilized are significant when considering the lack of adherence among the general population.
The detriment associated with the underutilization of these services on the health of Americans is exacerbated by the nation's aging population, as these patients tend to suffer from more complex chronic health conditions. The number of Americans ages 65 and older is projected to rise sharply in the coming decades, according to a 2015 report from the Population Reference Bureau. By the end of 2014, there were 46 million Americans ages 65 years and older accounting for 15 percent of the overall population.
For the 2014–2015 flu season, influenza vaccine coverage for adults was 43.6 percent, according to the CDC. While coverage for the same season was higher (66.7 percent) for adults ages 65 and older, there remains substantial room for improvement among this vulnerable population. In a 2013 study published in PLOS One, researchers examined influenza vaccination surveillance data compiled from 2005 to 2011. Analysis revealed that between 71 percent and 85 percent of seasonal flu-related deaths occur among adults older than 65 years of age.
Vaccine landscape
Despite the efforts of providers and health agencies to promote adult vaccinations, adherence rates remain low. As stated earlier the influenza vaccination coverage for the 2014–2015 flu season was just 43.6 percent, falling well short of the HHS Healthy People 2020 goal of 70 percent. Additionally, while rates of pediatric vaccination adherence remain relatively high — largely because of mandates issued by schools requiring vaccination — segments of the American population remain susceptible to renascent outbreaks due to poor vaccine adherence.
According to a 2014 CDC survey of vaccination coverage among adult, the prevalence of illness attributable to vaccine-preventable diseases is greater among adults than among children. Adults are recommended to receive vaccinations based on their age, underlying medical conditions, lifestyle, prior vaccinations, and other considerations.
The survey also noted that coverage for all vaccines for adults remained low, and missed opportunities to vaccinate adults continued. Although having health insurance coverage and a usual place for health care are associated with higher vaccination coverage, these factors alone do not assure optimal adult vaccination coverage.
"Vaccines really are central to preventive care," says Melanie Mouzoon, MD, managing physician for vaccination practices at Woman’s Hospital of Texas, Kelsey-Seybold Clinic in Kingwood.
Dr. Mouzoon added that while other preventive care initiatives can certainly be effective in improving the health of patients, most of these strategies are really designed to simply catch potential health issues in their early stages.
An achievable strategy
While tertiary prevention strategies, such as disease management, can be quite complex and multi-faceted, vaccine intervention is typically different. As detailed in a 2015 article published in Mayo Clinic Proceedings, vaccinations typically occur in a single care setting, are one-time or relatively infrequent events, and do not require significant initiative from the patient like a change in diet or a commitment to an exercise routine. For patients achieving immunity, vaccination can help reduce disease transmission, disease burden, and the need for disease specific intervention.
Quality initiatives designed to boost vaccination rates have been implemented in multiple health care settings with great success. One example from Boston Children’s Hospital is documented in a 2014 quality report published in the journal Pediatrics. Boston Children’s was able to boost its vaccination rate for patients aged 24 months to 95 percent by using a database and a patient tracking registry to systemically identify under-immunized patients. The hospital also conducted patient outreach initiatives and used care coordination to notify providers of upcoming appointments with suggested vaccines.
A call to action
As hospitals and health systems navigate value-based health care and strive to achieve the tenets of the Quadruple Aim, leaders must emphasize the implementation of preventive strategies to achieve population health management. Vaccines are evidence-based treatments that may help improve the health of patient populations and help health care organizations as they strive to improve quality of care.