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POPULATION
HEALTH
POPULATION
HEALTH MANAGEMENT
By Alan M. Preston, MHA, Sc.D.
As a former professor teaching Epidemiology, the phrase “Popu-
lation Health Management” resonates with me. Epidemiology is the
study of the incidence and prevalence rates of diseases within certain
populations. Incidence rates describes the sudden onset of a disease
and the prevalence describes how long a disease may be present in a
given population. However, in the context of a physician’s practice,
“Population Health Management” takes on an entirely different per-
spective.
Physician’s manage one patient at a time. Over the course of a year
however, if we added up all the patients seen by a primary care physi-
cian, the entirety of that population may have some common char-
acteristics that may need to be tracked and managed. And to the
extent a primary care physician averaged 20 patients visits a day for
210 days out of the year, they would encounter approximately 4,200
patient visits. Some of the visits are repeat follow-up visits and prob-
ably account for over 50 percent of the patient “population.” Thus,
a primary care physician may have a panel of patients for a year of
approximately 2,500 to 3,000 patients.
Of that “population” of patients, there are some characteristics of
patients that have similar disease classifications. Take Type II diabetes
for example; The prevalence rate of Type II is approximately 9.3 per-
cent (i.e. 29 million people) according to the CDC. However, over
86 million have “pre-diabetes.” And of the 29 million people who
22 San Antonio Medicine • February 2017
have Type II, approximately 8.1 million people don’t know they have
it and are undiagnosed.
This is a good example where population health management can
play an important role for both the patient and the doctor. Imagine
if a physician’s practice ran a report that looked at many of the risk
factors for Type II diabetes. Some of the risk factors would be: age,
weight, ethnicity and gender, to name a few. That list could be cross-
referenced with known lab data to determine whether the “popula-
tion of interest” had their Hba1c or blood sugars tested and resulted.
If not, scheduling the patient for a visit to perform such a test in the
population of interest might reveal undiagnosed patients and pre-
diabetic patients. Treating the undiagnosed patient and the pre-dia-
betic patient is the benefit of population health management.
And the Centers for Medicare and Medicaid Services (CMS) is
very interested in physicians that understand how to perform pop-
ulation health management functions. CMS understands that physi-
cians that understand the benefit of population health management
should be paid for their patients’ improved healthcare outcomes.
Of course, the private Medicare Advantage insurance companies
are already contracting with physician groups and Independent Prac-
tice Associations to share in the savings these organizations deliver
in helping physicians achieve such outcomes. And for the independ-
ent physician, teaming up with an experienced IPA can add value