Implementing population health management

Today, it is practically commonplace to say that we need to change our current “disease care” system to one that promotes positive health and wellbeing. The Affordable Care Act (ACA) begins to do this through screening, such as depression screens, SBIRT screens, etc. Similarly, the ACA seeks to implement prevention activities through the Prevention and Wellness Fund (now under attack in the Congress) and the National Prevention Council. Clearly, all of these developments are positive, and they have salutary implications for the future.

Yet, it also is very fair to say that we have yet to address head-on the full breadth of a “health care” system. We have not fully developed a sustainable financial mechanism to pay for community-level interventions that mitigate the effects of the negative social and physical determinants of health, such as poverty, discrimination, etc. And we clearly have not yet fielded either community or personal health promotion interventions in the behavioral health field.

The operant question is how to link “health care” and “disease care” through a viable model. This model must address the full range of health and care needs. It also must provide a basis for creating and sustaining a payment methodology for all persons in any defined population.

A population health management model seems to provide a basis for meeting both of these requirements simultaneously. First, let's introduce the simplest model of population health management. In essence, this model sub-aggregates any defined population into groups of persons with similar disease and health characteristics. To do this, each person in the population needs to be categorized on a continuum from no disease to severe disease. Similarly, each person needs to be characterized on a continuum from very poor to very good health status, specifically based on degree of physical, mental, social, and spiritual wellbeing.

When combined, these characterizations will generate at least four population groups, as follows:

Group 1: Excellent health no disease

Group 2: Excellent health disease present

Group 3: Poor health no disease

Group 4: Poor health disease present

It should be obvious that each of these groups also can be subdivided further into smaller groups depending on degree of health and degree of disease. In a population health management framework, each of these groups will need to be managed differently. For example, Group 4 will require intensive disease care and intensive health improvement interventions.

By contrast, Group 1 only will need mild and aperiodic health maintenance interventions. Applied consistently over time, these approaches will lead to better overall health status in an entire defined population and much better management of disease.

A population health management model also provides a very logical way to calculate overall annual case rates, as well as subpopulation case rates, for Groups 1-4. Of great advantage, the subpopulation case rates can be defined to include both community and personal interventions specific to that subpopulation, rather than just traditional disease care in a clinical setting. This approach provides a mechanism for bridging between community interventions and those traditionally paid for by health inusurance.

Currently, the population health management model is quite foreign to the behavioral health community. As we become more engaged in integrated health and medical homes, we will need to become more adept with this model, so that we can apply it in the manner described earlier. It also should be clear that incorporation of a health dimension into the model can provide a logical foundation for implementing behavioral health interventions to improve health.

How exciting!