In my last post I wrote about the 3 P’s of Population Health – Population, Patient, and Practice. Pop Health has become a ubiquitous concept not only in healthcare IT (see HIMSS 2015), but in healthcare at large. That said, there is no one way to define Pop Health – it can mean many things to many people. I am hoping the 3 P’s will help start a new way of thinking about the definition and execution of Pop Health. In this post I will talk about the ‘Pop’ in Pop Health – the Population.

Traditionally, providers have had three distinct populations – Commercial, Medicare and Medicaid. Sure, there were a couple of exceptions, but by and large those three were the types of populations that comprised a provider’s total population. That status quo has changed dramatically as Pop Health has begun to take hold and more “sub-populations” have been created to meet the distinct financial, quality and health challenges faced by purchasers, payers, providers and patients. Here are a few examples:

Medicare Populations:

• Traditional: This is the fee-for-service sub-population of Medicare, and is an approach and population that CMS is planning to fade out over the next couple of years.
• Medicare Advantage: MA plans are essentially outsourced traditional Medicare patients – a commercial insurance company takes responsibility for managing a Medicare population. Well executed MA plans with a pop health strategy can lead to significant quality and financial opportunities for providers and payers.
• Medicare Shared Savings Program (MSSP) and Pioneer ACOs: In this sub-population, a provider agrees to drive savings and quality across a Medicare population. The provider must not only create savings relative to a baseline, but they must maintain quality standards (ACO33s) as well if they wish to partake in those savings in part or in full.

Medicaid

• Medicaid programs vary greatly from state to state. Currently, most states are in the midst of Medicaid reform – the ACA has greatly expanded Medicaid eligibility and many states are either consolidating Medicaid programs or restructuring them all together to meet this demand for access and quality. This can greatly increase population variability for a health system.

Commercial

• Traditional: Here we have the traditional fee-for-service patient where volume of patient services typically drives system revenue.
• Direct Purchasing: Where purchasers of healthcare, typically companies or local/state governments purchase care directly with a health system and with a contracted quality standard required to maintain good standing.
• Accountable Care Networks (ACNs) or Clinically Integrated Networks (CINs): Health systems teaming up to enable large, direct healthcare purchasing contracts. These organizations share financial risk and resources like IT systems or drive purchasing agreements.
• Bundled Payments: This has typically been a subset of direct purchasing, except a purchaser has arranged for a fixed-fee for a procedure – typically high-cost procedures like knee or hip replacements. This places the provider at risk and incentivizes them to drive better outcomes through quality.

A Population of Populations

While these sub populations are likely to be quite familiar to a number of readers, noting them together highlights the sheer number and complexity of the Populations that are a part of Pop Health. Indeed, providers now have a “Population of Populations.” Why did I run through the list of sub-populations above? While most of the sub-populations are self-evident on their own, I find it useful to literally see the number and diversity of a provider’s care models and contracts. In this time of increasing model and population diversity and complexity, providers are also taking on more risk. Providers are changing multiple, complex and difficult variables in their business and operational models to serve these populations. Most healthcare workflows and technology were established in a time of transactional fee-for-service, not dynamic and highly interactive pop health. Each sub-population has its own needs, financial drivers and quality measures, and new technology will enable providers to scale to meet the demands of those requirements. Real-time data and analytics, feeding a scalable technology platform and applications will enable providers to manage this Population of Populations. I’ll get deeper into “the how” when I take a closer look at the technology requirements needed to manage these populations in my next post. For now, the “Pop” in Pop Health has truly become a “Population of Populations.”