Signature Leadership Series
Local, State& Federal PolicySignature Leadership SeriesPublic HealthAgenciesPhysicians &Other CliniciansPatients, Family& CommunitySocial &Community ServicesHospitals &Health SystemsPost-AcuteCare ProvidersGovernment &Commercial PayersEmployersManagingPopulation Health:The Role of theHospitalApril 2012
Resources: For information related to population health, visit www.hpoe.org.Suggested Citation:Managing Population Health:The Role of the Hospital. Health Research & Educational Trust, Chicago: April2012. Accessed at www.hpoe.orgAccessible at: http://www.hpoe.org/population-healthContact: Natasha Goburdhun, ngoburdhun@aha.org or 312-422-2623 2012 Health Research & Educational Trust. All rights reserved. All materials contained in this publication areavailable to anyone for download on www.hret.org, or www.hpoe.org for personal, noncommercial use only. Nopart of this publication may be reproduced and distributed in any form without permission of the publisher, or inthe case of third party materials, the owner of that content, except in the case of brief quotations followed by theabove suggested citation. To request permission to reproduce any of these materials, please email HPOE@aha.org.1Managing Population Health: The Role of the Hospital
Table of ContentsExecutive Summary.3Introduction.4Defining population health.4Why Population Health?.5Forces are driving hospitals toward population health.5ACA encourages hospitals to adopt population health management strategies.5The Hospital’s Role in Population Health Management.6How Hospital Leaders View Population Health Management.7The shift from managing individuals to managing populations varies by hospital size.7A focus on population health is already occurring at most organizations.7Population health requires partnerships for success.8Successful Population Health Management: Partnerships Focus on Patients, Family,and Community.9Hospitals are already partnering to achieve goals of population health. 10Establish provider collaborations that span the care continuum. 11Partner with physicians for an expanded focus on quality and outcomes. 12Create hospital-payer collaborations to advance care coordination. 13Work directly with community employers to improve health outcomes. 14Look beyond clinical care partnerships to improve access to care and other necessary15community services.Work with public health agencies, the government, and other partners to achieve16improved health care outcomes.The Discussion Is Just Beginning. 17Endnotes. 182Managing Population Health: The Role of the Hospital
Executive SummaryThe American Hospital Association Committee on Performance Improvement’s inaugural report,Hospitals and Care Systems of the Future, prioritizes population health as a must-do strategy for hospitalsand health systems to succeed in the evolving health care environment. As the publication asserts, “Theaging population and the onset of value-based payment structures demand hospitals to take a moreprominent role in disease prevention, health promotion, and other public health initiatives.”To meet patient needs in the current market, hospitals have traditionally focused their efforts on caring for individuals and personalizing care for each person admitted to their facility. Common communityhealth initiatives, such as mobile vans, health screenings and education fairs, are sometimes deliveredapart from an overall strategy or impact analysis. However, external forces to simultaneously reduce cost,improve quality, and implement value-based payment programs command that organizations examinehow to manage the health of their patient populations to improve outcomes.Hospitals and health systems of varying size, patient demographics, and geographic regions have begun torecognize that the main mechanisms to advance population health—improving quality and patient safety,increasing care coordination, and expanding preventive services—are the outcomes of initiatives they arealready pursuing. Although the financial incentives are not yet truly aligned, there are efforts that healthcare organizations can take to improve care delivery in the current volume-based market that will beeven more essential in the future value-based reimbursement system.This guide is designed to define population health, describe strategies to improve the health of a hospital’s patient population, inform leaders why these initiatives are essential, and explore potential partnerships that can help achieve the desired goal as illustrated in the diagram below. Short case examplesprovide supporting evidence and show that every health care organization already possesses some of thecapabilities necessary to institute programs that improve health outcomes within a defined population.Figure 1. Population Health Requires Partnerships to Improve OutcomesPhysicians &OtherCliniciansLocal, State& FederalPolicyPublicHealthAgenciesHospitals &HealthSystemsPatients,Family cialPayersSocial &CommunityServicesEmployersSource: HRET, 2012.3Managing Population Health: The Role of the HospitalExecutive Summary
IntroductionDefining population healthPopulation health can serve as a strategic platform to improve the health outcomes of a defined group ofpeople, concentrating on three correlated stages:1. The distribution of specific health statuses and outcomes within a population;2. Factors that cause the present outcomes distribution; and3. Interventions that may modify the factors to improve health outcomes.Population health resides at the intersection of three distinct health care mechanisms (see figure 2).Improving population health requires effective initiatives to (1) increase the prevalence of evidence-basedpreventive health services and preventive health behaviors, (2) improve care quality and patient safety,and (3) advance care coordination across the health care continuum.Figure 2. Mechanisms to Improve Population HealthPreventionQuality &Patient SafetyCareCoordinationSource: HRET, 2012.Table 1 below outlines the childhood asthma program at Cambridge Health Alliance1 to illustrate the useof prevention and care coordination strategies to improve population health management.Table I. Defining Population Health Initiatives at the Cambridge Health AllianceSource: HRET, 2012.Process QuestionsResultsOutcomesWhat health statistics are inadequatefor our catchment area and whatpopulation does this affect? Asthma is the leading chronic disease amongchildren. Cambridge Health Alliance was seeing a highnumber of pediatric inpatient admission for asthma.FactorsWhat is causing the outcome that weare seeing? Low adherence to medication regimen. Lack of knowledge about asthma attacktriggers in children.InterventionsWhat initiatives can we implement tomodify and improve on the factorslisted above? Web-based registrey used by physicians andschool nurses to assess correct prescription andmedication adherence. Home visits by providers to help parentdecrease or remove asthma triggers.ImpactWhat are the results of theintervention? Increased adherence to asthma medicationregimens. Astha-related hospital admissions dropped by45% from 2002-2009. Asthma-related ED visits dropped by 50% overthe same time period.4Managing Population Health: The Role of the HospitalIntroduction
Why Population Health?Forces are driving hospitals toward population healthThe current volume-based reimbursement system is designed to address acute care needs, and in thissystem, hospitals can succeed by treating patients that come to them. The increasing rates of chronicdisease and the change to a value-based reimbursement system are among the demand and performanceforces pressing organizations to take a more proactive approach to patient care—that is, reaching out tothe population beyond the traditional four walls of the hospital.Figure 3. Forces toward Population HealthDemand ForcesPerformance ForcesAging populationPopulation diversityIncreasing life expectancyRising chronic disease ratesDesire of patients to remain athome for treatment Increasing number of insuredindividuals Gap between physician supplyand demand Technological advances Emphasis on evidence-basedcare (including prevention) Shift to outpatient care Change to value-basedreimbursement Shared risk structures withpayers Source: HRET, 2012.ACA encourages hospitals to adopt population health management strategiesSeveral sections within the Patient Protection and Affordable Care Act (ACA) are driving hospitals toward population health management by promoting and incenting prevention, quality and safety, and carecoordination strategies. Table 3 summarizes the most actionable initiatives.2Table 2. Population Health Management Strategies through ACA1.ACA requires tax-exempt hospitals to conduct community health needs assessments everythree years and adopt implementation strategies that meet the identified needs, includingidentifying reasons why any such needs are not being addressed.2.The law expands coverage for a wide range of prevention and wellness services, increasingincentives for employers that establish wellness programs and eliminating copayments forimmunizations, screenings, and other clinical preventive services.3.The elimination of payment for unnecessary readmissions and the development of deliverypayment pilots increase the hospital’s accountability for care outside its four walls.4.Medical home demonstrations, coordination grants, and increased financial support forhealth centers encourage partnerships between hospitals and other community organizations.5.ACA creates a fund to provide sustained national investment in preventive and publichealth programs, including those offered by hospitals to increase access to clinical preventiveservices and create healthier communities.Source: HRET, 2012.5Managing Population Health: The Role of the HospitalWhy Population Health?
The Hospital’s Role in Population Health ManagementAs hospitals move toward population health management, they face considerable barriers to practicing itas an overall strategy. For example, the current volume-based reimbursement system does not providesignificant funding to pursue population health initiatives. Additionally, the traditional definition of population health encompasses a broad range of factors that may change health outcomes—everything fromthe physical environment to social structure to resource allocation. As a result, hospitals may find it difficult to identify which population health factors they can directly impact with their limited resources.Hospitals and health systems have started to realize that the mechanisms to advance population health—improving quality and patient safety, increasing care coordination, and expanding preventive services—support the patient initiatives they are already pursuing. Although the financial incentives are not yet fullyaligned, specific efforts by organizations to improve care delivery in the current volume-based marketalso will be essential for care delivery in the future value-based market.Table 3 identifies factors typically included within population health, grouped according to those outsidethe health care system and those inside the health care system. Another tier separates the factors withincontrol of the health care system into groups based on care delivery and the external regulatory environment. The orange box in the middle represents opportunities for hospitals to explore. Not all effortsto improve the health of the population necessarily address the entire community. Some organizationalefforts may focus on changes for one segment of the overall patient population.Table 3. Factors Influencing Population Health3Outside Health Care SystemSocietal Factors Food safetyHealthy food availabilityHousing conditionsNeighborhood violenceOpen space and parks/recreation availabilityGenetic inheritanceDisease prevalenceIncome levelsPoverty ratesGeographic locationUnemployment rateUninsured/underinsured rateMedian ageSexRace/ethnicityPharmacy availabilityCare-seeking behaviorsHealth literacyPatient choiceMorbidity ratesTransportation availabilitySource: HRET, 2012.6Related to the Health Care SystemCare DeliveryRegulatory Environment Quality of careEfficiencyAccessPhysician trainingHealth IT system availabilityDistance to and number ofhospitals, primary andurgent care centers, retailclinics, etc.Provider supply (MDs, RNs,etc.)Physician mix (primaryversus specialty care)Payer contractsPhysician employment andpayment structureDisease managementPopulation subgroupdisparityAdvanced technologyavailabilityCare integration andcoordinationBehavioral health availabilityCultural and linguistic accessManaging Population Health: The Role of the Hospital Medicare payment ratesand policies Medicare and Medicaidcare delivery innovation CON regulation Medicaid/CHIP policies(payment rates, eligibility) Implementation of ACA Local coveragedeterminations (LCDs) Other local, state, andfederal laws that impactthe way health care isdelivered and whichtreatments are providedHospital’s Role In Population Health Management
How Hospital Leaders View Population Health ManagementThe shift from managing individuals to managing populations varies by hospital sizeA recent American Hospital Association survey of hospital chief executives shows that leaders of largerfacilities are more likely than leaders of smaller facilities to focus on population health management as anecessary strategy in the current market to guarantee success in the future. The variation is attributedto the overall size of the organization’s patient population—the larger the patient base, the stronger thepush will be to examine and explore solutions in the aggregate. Additionally, smaller rural and criticalaccess hospitals typically will have neither the human capital nor the financial resources to implementoverarching population health strategies in ways comparable to larger facilities.Figure 4. Hospital CEO alignment to pursue population health by bed size (n 652)Source: SchellingPoint, LLC, and AHA Committee on Performance Improvement survey, November 2011.A focus on population health is already occurring at most organizationsThe AHA survey revealed that 98 percent of chief executive respondents agree, at least at some level,that hospitals should investigate and implement population health management strategies. More than75 percent of senior management, even at the smallest organizations, recognizes the value of exploringthese initiatives. Anecdotal quotes from organizational leaders indicate that it is not “if” they will have topursue these strategies but “when” — within the timed shift to a value-based reimbursement system.Responses from hospital leaders are more varied when they detail their individual roles within theoverall strategy for population health management. The chief executives of smaller and more rural hospitals and health systems indicate they will most likely be collaborating on a larger organization’s chargetoward population health rather than implementing their own strategy. As previously noted, many largerorganizations with more resources are already pursuing population health strategies such as chronicdisease registries and disease management programs for their bigger base of patients.7Managing Population Health: The Role of the HospitalHospital Leaders’ View
Population health requires partnerships for successThe mechanisms to improve population health—improving quality and patient safety, increasing carecoordination, and expanding preventive initiatives—demand greater accountability from all parties withinthe health care system. Hospital leaders point to a variety of collaborations that may help them achievethese goals, exhibited in figure 5. Although the area of most agreement among executives is the desire towork with physicians and other clinical providers, a majority indicated the need to go beyond historicalpartnerships and explore relationships with community organizations, payers, and other clinical care sitesto address health care issues that they cannot accomplish on their own.Figure 5. Percentage of CEO respondents who would explore collaborations with the following partners (n 652)56%PayersOther sites of care64%Community, public healthand government agencies67%Other clinical providers98%Physicians98%0%25%50%75%Percent of Respondents100%Source: SchellingPoint, LLC, and AHA Committee on Performance Improvement survey, November 2011.8Managing Population Health: The Role of the HospitalHospital Leaders’ View
Successful Population Health Management:Partnerships Focus on Patients, Family, and CommunityTrue population health improvement is not an outcome that hospitals and health systems will be able toachieve without collaboration and shared ownership of goals with other sectors. As depicted in figure 6,several segments of the health care system play roles in population health management. The solid lines inthe diagram represent the sectors that have more direct interaction with individuals within the population, whereas the dotted lines signify a service relationship with the population more generally. Whileeach sector plays a distinct role, all follow the mechanisms to advance population health—improvingquality and safety, increasing care coordination, and expanding preventive care services for patients, theirfamilies, and the overall community. The methods to achieve successful outcomes will vary by the missions and abilities inherent within each sector of the health system.Figure 6. Population Health Requires Partnerships to Improve OutcomesPhysicians &OtherCliniciansLocal, State& FederalPolicyPublicHealthAgenciesHospitals &HealthSystemsPatients,Family cialPayersSocial &CommunityServicesEmployersSource: HRET, 2012.9Managing Population Health: The Role of the HospitalSuccessful Population Health Management
Hospitals are already partnering
3 Managing Population Health: The Role of the Hospital Executive Summary The American Hospital Association Committee on Performance Improvement’s inaugural report, Hospitals and Care Systems of the Future, prioritizes population health as a must-do strategy for hospitals and health systems to succeed in the evolving health care environment.
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