The “population health” movement began two decades ago and the term was solidified by David Kindig, MD, PhD, and Greg Stoddart, PhD, in 2003. Population health has come a long way these past two decades. Last week’s Twenty-Third Population Health Colloquium was a clear demonstration of the sector’s success and ongoing commitment to improving health and wellness in the United States.
Hosted by David Nash, MD, MBA, Founding Dean Emeritus, Jefferson College of Population Health and his co-chair, Billy Oglesby, PhD, MBA, MSPH, FACHE, the forum included dozens of educational sessions and panels, inspiring fireside chats and insightful evening documentaries. This year’s event was my first Population Health Colloquium. And I was constantly impressed with the sector’s commitment to improving healthcare outcomes through better people, process, and technology.
Some of healthcare’s biggest challenges were covered from all perspectives including:
- The ongoing pursuit of value-based care
- Growing health disparities and inequity
- How to harness the power of artificial intelligence (AI) to improve population health program efficiency and outcomes
Below are my four top takeaways from the industry’s most influential leaders in population health. For more information, listen to four insightful conversations held during the Colloquium regarding new ways to address health inequity on Healthcare NOW Radio’s View in Two podcast below.
1. Boards Drill Down on Community Focus and Health Equity Initiatives
One of the most unique sessions I attended was a preconference forum that included panel sessions with healthcare organization (HCO) board members across the healthcare ecosystem. These panelists highlighted initiatives most important to HCO board members and potential investors. Several panelists recommended that HCOs:
- Address health inequity in every way possible. For providers this includes a strong focus on community partnerships while technology vendors should consider offering lower tier pricing for developing nations.
- Focus on the communities you serve. Build community partnerships and programs to extend your organization’s reach into the community, and clearly articulate all the ways your organization works at the community level to promote wellness and overall community health.
Health inequity was covered during many other sessions at the Colloquium with key takeaways:
- Expand data analysis to rapidly address specific underserved populations for immediate intervention with cost simulation capabilities including those provided by companies such as Epistemix.
- Invest in systems that pay for wellness versus pay for disease treatment.
- Consider all unique patient groups as having nuanced disparities—rural healthcare, elderly, socially isolated, etc.
- Connect isolated patients using new digital health companions such as those offered by SociAVI.
2. Optimal Patient (and Member) Engagement Also Requires Care Delivery and Organization
Jeffrey Brenner, MD, CEO, Jewish Board of Family and Children’s Services, delivered Monday’s keynote address with an urgent plea from the ranks of primary care. “Care coordination without delivering actual patient care is a road to nowhere.” Brenner emphasized that care coordination programs must truly engage patients and members, organize their care, and close loops with community programs.
Brenner shared his experiences as founder of the Camden Coalition and as a primary care physician serving the needs of underserved complex patient populations. Brenner’s team used the term “hot-spotters” to describe high-cost patients with chronic conditions and complex needs. These patients experience significant difficulties navigating the healthcare system. They desperately need extra support and clinical engagement.
Many HCOs partner with outside agencies that specialize in high-risk populations to deliver this deeper level of patient and member engagement, including companies such as 86Borders, a new entrant into the member engagement sector. However, Brenner warns against redundant and disconnected care coordination. Multiple agencies calling the same patient or member only adds to the disconnectedness of healthcare.
According to Brenner, “If you can organize care for complex patients, you can make a tremendous difference.”
Multiple other sessions on patient and member engagement identified with best practice ideas for both healthcare providers and health plans to consider:
- Improve chronic care coordination prevention and management.
- Expand avenues for accessing behavioral health.
- Evolve case management strategies, technologies, and tools.
- Healthcare is not just “medical” care, it addresses social and economic needs.
- Address community needs and expectations one patient/member at a time.
- Healthcare quality and safety are interwoven with population health.
- Implement the most effective processes and tools to optimize results at lower costs.
- Measure the effectiveness of patient/member engagement interventions.
One of the most inspiring sessions related to patient engagement was a fireside chat with Kristen Valdes, Founder and CEO of b.well, a connected health company and Colloquium sponsor. Valdes is an evangelist for patient and family access to healthcare information as an essential pathway to better care outcomes. Her personal journey is compelling. Hear my two-minute interview with Kristen below.
3. Value-Based Care Takes Commitment, but Rewards Are Worth It
Value-based and population health gurus Dan Marino and Cliff Frank, both from Lumina Health Partners, led a valuable session on strategies to enhance value-based performance and prepare physician practices for at-risk payment models. Attendees were reminded that healthcare’s RVU model is contradictory to risk-based success. With this fact in mind, the duo shared a wealth of advice for all types of HCOs. Here are the highlights:
- Look at data coming from all EHRs and practice systems differently. Truly understand the patients at risk.
- Know what is happening in the patient’s home, neighborhood, personal life, etc.—not just in the exam room.
- Improve clinic-based clinical documentation, especially with an eye on ACO quality reporting changes to eCQM in 2025.
- Focus on collaboration between primary and specialty care providers. Specialist selection is probably one of the easiest things to fix before entering at-risk contracts.
- Ensure clean, accurate data. Physicians respond to numbers.
- Create the right incentives and compensation programs for the entire care team—physicians and other staff.
- Establish processes, procedures, and technology to navigate care transitions.
- Move to a risk-ready organization.
4. Artificial Intelligence Gets the Last Word, and All Other Words Too
Tom Lawry, one of healthcare’s top 20 AI voices to watch according to Medika Life, presented a thought-provoking session on the use of AI in population health programs. Lawry focused on the existential opportunity for artificial intelligence and suggested that AI technology will:
- Liberate clinicians from the keyboard.
- Reduce cognitive burden by delivering more information to our clinicians.
- Refresh all human resource and DEI plans since AI will have the greatest impact on the future of work. HCOs need to upskill staff as soon as possible.
To follow-up on the use of AI in population health management, I also spoke with Mayur Yermaneni, MBA, MS, EVP of Innovation at AssureCare, a population health management and care coordination company. AssureCare recently released an AI physician decision support tool designed to optimize physician resources by up to 60 percent during medical reviews for all types of population health programs.
This solution is one of many new AI tools designed to reduce clinician burdens and improve operational efficiency in healthcare. Certainly, there are many more ahead.
The 23rd Population Health Colloquium was my first. But it won’t be my last. Great insights were shared by healthcare’s most dedicated knowledge experts. Count me in for 2024!