The population health management industry has been experiencing rapid growth in the United States, according to a report by Towards Healthcare.1 With healthcare costs growing and cases of chronic conditions on the rise,1, 2 investing in solutions that improve outcomes while lowering costs on a broad scale is more important than ever. For health plans, health systems, accountable care organizations (ACOs), and at-risk provider groups, understanding the key components of a population health management approach is essential when assessing programs that deliver clinical and financial benefits to all constituents.
Key Components of a Population Health Management Approach
Researchers Greg Stoddart and David Kindig define population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”3 More specifically, population health management aims to not only eliminate disease within a defined population, but it also addresses the underlying social, behavioral, environmental, and economic factors affecting the group. This is a holistic approach, centered on data-driven decision-making and tailored interventions needing to be addressed. The below components form the framework for successful population health outcomes.
- Preventive Healthcare: Preventive care is a key pillar of population health management. By identifying diseases and risk factors in early stages and closely monitoring conditions in real time, we can often prevent costly adverse events and avoid drastic interventions that become necessary in late-stage disease states.
- Patient Engagement: Patient engagement is crucial for the success of population health management. By educating individuals on their specific disease(s) or condition(s) and establishing consistent lines of communication, patients will feel more empowered and become active participants in their own care.
- Social Determinants of Health: Social determinants of health (SDoH) play a large role in population health management. SDoH refers to factors such as economic stability, healthcare access and quality, education, environmental factors, and other social barriers. By taking these factors into account, we can ensure that patients receive the care they need, while tailoring interventions to become much more impactful.
- Reducing Healthcare Costs: Reducing healthcare costs for high-risk populations is a key goal for value-based contracts. By preventing avoidable hospitalizations and other costly interventions, patients’ quality of life is improved, providers have more time to engage with patients and provide proactive treatment, and healthcare systems can divert expenditures to other areas of need.
- Predictive Data Analysis: Data plays a pivotal role in population health management. To understand the complex combination of factors affecting each population, data from many disparate sources must be analyzed (e.g., environment, education, socioeconomic status, lifestyle). By closely tracking these factors and measuring outcomes, we can predict and monitor patient risk, thus improving the quality of care and creating more proactive, tailored interventions.
Why is a Population Health Management Approach Necessary for CKD/ESRD Populations?
Addressing chronic conditions like chronic kidney disease (CKD) and end-stage renal disease (ESRD) at the population health level can have an enormous impact on healthcare costs and health outcomes across the population. The American Kidney Fund states that in the United States, over 35 million people have CKD; that is one in seven adults.4 It is likely that this number is even higher, as CKD can progress without noticeable symptoms and, if noticed, the symptoms are sometimes mistakenly attributed to other conditions. Additionally, patients with CKD/ESRD in most cases have multiple comorbidities (hypertension, diabetes, cardiovascular disease), making them a complex, high-risk population. CKD requires closely monitored care coordination and targeted interventions to slow the progression of the disease and prevent patients from “crashing to dialysis,” or having an unplanned dialysis start.
In addition to being a complex, highly prevalent disease, CKD is also very costly. According to the National Kidney Foundation, Medicare spends upwards of $130 billion annually on patients with kidney disease—more than 24% of total spending.5 By taking a population health approach and utilizing predictive analytics, CKD can be caught earlier, and progression of the disease can be slowed.
Because of its complexity and various comorbidities, CKD can be difficult for patients and their providers to manage. Treating care coordination concerns at the population level can ensure that the condition is well managed, especially with support from a third-party vendor with expertise in the kidney space.
Healthmap’s Approach to Kidney Population Health Management
Healthmap’s Kidney Population Health Management program provides personalized, whole-person care management through the following value levers:
- Early Identification: Through predictive analytics, we can identify patients early in their CKD progression and establish treatment pathways based on their risk and stage of disease.
- Member Engagement: By engaging directly with patients and providers in each local market we support, Healthmap is able to tailor communications on a member-by-member basis and significantly increase engagement.
- Slowing Disease Progression: We work with patients and their provider teams to deliver proactive, coordinated care based on actionable and timely data and clinical insights.
- Planned Dialysis Starts: By coordinating early referrals to nephrologists and assisting patients in developing their personal renal replacement therapy plan, we can avoid “crashing to dialysis.”
- Optimizing Renal Replacement Therapy: We empower patients through education, to consider the use of in-home dialysis or transplant whenever possible.
- Reducing Unnecessary Emergency Department Visits, Hospital Admissions, and Readmissions: By proactively engaging with patients and providers, we avoid unnecessary admissions and ensure appropriate transitions of care to prevent readmissions.
Healthmap’s multidisciplinary Care Navigation team consists of registered nurses, social workers, behavioral health specialists, registered dieticians, wellness coaches, medical directors, and pharmacists, who utilize local market resources to ensure each member receives the best possible care. Our industry-leading Kidney Population Health Management program has achieved significant results across the full eligible population, with guaranteed total cost of care gross savings for our clients of 8% to 12% by the end of Performance Year 2, and ~20% to 30% reductions in unplanned dialysis starts. We are able to achieve 70% to 80% engagement of eligible members—resulting in better patient experiences and a significantly improved clinical outcomes. Managing CKD and ESRD can be daunting, but Healthmap’s population health approach enables providers to provide the best possible care, empowers patients to become active participants in their treatment, and reduces the total cost of care for our clients.
References
- https://www.towardshealthcare.com/insights/population-health-management-market-sizing
- https://www.cdc.gov/pcd/issues/2024/23_0267.htm
- https://pubmed.ncbi.nlm.nih.gov/12604476/
- https://www.kidneyfund.org/all-about-kidneys/chronic-kidney-disease-ckd
- https://www.kidney.org/get-involved/advocate/legislative-priorities/federal-investment
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