What is Population Health?

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DEM white shirtBy David Edward Marcinko MBBS DPM MBA MEd


What is population health?

In its most fundamental sense, population health seeks to improve or manage the health of a specific population. It is a systematic, holistic approach that aims to prevent disease by keeping people healthy and improving the quality of care.



In fact, according to my colleague David B. Nash MD MBA, Founding Dean and Endowed Chair at the Jefferson College of Population Health, population health programs and interventions work to:

  • Connect prevention, wellness and behavioral health with traditional health care delivery
  • Focus on improving the quality and safety of care, improving access to healthcare services and helping to prevent/manage chronic diseases in the service of a specific population
  • Advance policies and solutions to address socio-economic and cultural factors (social determinants of health) that have an impact on health outcomes
  • Leverage technology and information systems to design social and community interventions and new models of health care delivery that facilitate care coordination and access

WHITE-PAPER: Population and Public Health


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6 Responses

  1. Microsoft Founder Bill Gates Pledges To Invest $5 Billion In Africa

    Microsoft founder and philanthropist Bill Gates recently said his charity foundation will invest $5 billion in African development, with a focus on health initiatives, over the next five years.

    Go Bill!

    David E. Marcinko MBBS MBA


  2. What are 10 key elements for improving population health?

    National Quality Forum: 10 Key Elements For Improving Population Health

    1. Collaborative Self-Assessment
    2. Leadership Across the Region and Within Organizations
    3. Audience-Specific Strategic Communication
    4. A Community Health Needs Assessment and Asset Mapping Process
    5. An Organizational Planning and Priority-Setting Process
    6. An Agreed-Upon, Prioritized Set of Health Improvement Activities
    7. Selection and Use of Measures and Performance Targets
    8. Joint Reporting on Progress Toward Achieving Intended Results
    9. Indications of Scalability
    10. A Plan for Sustainability

    Source: National Quality Forum, August 2016


  3. Top 10 Challenges of Population Health Management

    1. Identifying a starting point
    2. Understanding patient attribution
    3. Stratifying patients by risk
    4. Hiring or reallocating staff members
    5. Getting paid for population health
    6. Developing acceptance of new workflows
    7. Bolstering patient engagement
    8. Coordinating care across the continuum
    9. Tracking care quality and outcomes
    10. Communicating best practices and lessons learned

    Source: HealthIT Analytics, July 14, 2017


  4. Global Wellness

    The global wellness industry is now a US$3.7 trillion economy, according to the latest Global Wellness Economy Monitor, revealing just how much individuals are investing in their physical and mental health.

    Corporate spending on workplace wellness programs is rising too: It is currently estimated at $50 billion globally and expected to grow 7 percent annually to 2025.

    Source: Strategy-Business


  5. Population Health

    PH is based on the notion of a dedicated provider taking care of a defined population with a focus on the whole person. So why is it frequently difficult to get patients to take drugs as specified, or engage in chronic disease self-management?For that matter, why do we physicians not always take our own advice? Perhaps our population health strategies would be more effective if we incorporated more learnings regarding how and why humans make the decisions they do.

    Behavioral economics, which relies on psychology as well as traditional economic theory, may prove to be a useful new population health tool by helping us understand why patients do what they do. Behavioral economics argues that people don’t always make decisionsabout their health rationally based on a careful calculation of risks and benefits. Rather consumer and patient decisions are strongly influenced by emotions and the environment, as well as how healthcare choices are presented. In their 2008 book Nudge: ImprovingDecisions About Health Wellness and Happiness”, Nobel prize winning economist Richard Thaler and co-author Cass Sunstein explain how natural human biases can cause people to make poor decisions, and how these choices negatively impact population health. Withknowledge of these biases it may be possible to structure “choice environments” with “peer supports” to better engage patients in their wellness planning, make it more likely people will make healthy choices, and develop “nudges” to improve adherence medicationcompliance and wellness programs.

    One of the key principles of behavioral economists is “loss aversion” or “present bias”—- our tendency to be more sensitive to the potential impact of an immediate loss than the possibility of a future gain. Employers have recognized this and have assumeda more activist role in benefit plan design introducing both rewards and penalties to “nudge” employees to participate in a variety of wellness activities. In our provider world these kind of behavioral “nudges” may include use of telehealth to improve accessof patients to their providers; or new remote technology such as Adhere Tech’s digital “smart pill bottles” reported in the NY Times recently, which can alert patients when it’s time for medication, and send an automatic reminder if they miss a dose in realtime. New technologies, that enable providers to track behavior and connect with patients, however, “are not in and of themselves going to change behavior in high risk patients”, according to Kevin Volpp, MD, PhD., founding director of the University of Pennsylvania’sCenter for Health Incentives and Behavioral Economics: “You have to combine technology with an engagement approach that is really going to provide ongoing active participation”

    Volpp has designed randomized trials to “nudge” physicians to provide evidence-based care, as well as testing how to help consumers choose better health plans depending on how options are provided. And some health plans are trying a variety of behavioral economicconcepts to reward physicians for quality, including peer comparisons and bonuses for continuous improvement instead of basing rewards on hitting one absolute target. My own experience in designing population health programs confirms the need to combine peerand social support to change patient behaviors. The discipline of behavioral economics is still young, and will need further testing to see if the concepts are scalable. But it is already stretching our thinking, and may help provide a more complete understandingof patient and physician decision making, and how we can design more sensible strategies for population health.

    via Miller RN MHA


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