EVOLVING PERSPECTIVES ON POPULATION HEALTH MANAGEMENT

Health care costs are unevenly distributed, with a small percent of patients accounting for most health care costs in this country.^1,2 A population health perspective is necessary to understand and address the complex needs of patients in the high risk, high cost segment.

In the late 1980s and 1990s, managed care, characterized by “gatekeeping” and heavy-handed utilization authorization, was a version of population cost management.³ Contemporary population health approaches, exemplified by highly integrated delivery systems such as Kaiser Permanente and Geisinger are achieving demonstrable success in the Triple Aims of better care, healthy people/healthy communities, and affordable care.⁴ Current approaches to managing the most complex chronically ill patients range from turning over their care to highly specialized academic medical centers to building a longitudinal relationship with a primary care medical home employing highly functional interprofessional teams. In contrast to the managed care of the 1990s, the current medical home models are without strict gatekeeping and promote a cooperative relationship between primary care and specialists to create a highly coordinated medical neighborhood.

Academic health centers will always deliver quaternary services that few community providers can provide and will maintain a unique patient mix. They cannot succeed, however, in the new health care paradigm of population health without a strong primary care base. Primary care physicians provide the majority of care to patients with chronic illness in the United States.⁵ Nearly one-half (42%) of patients with chronic illness have more than a single condition⁶ and are, therefore, ill-suited for disease-specific, specialty-based medical homes. Primary care physicians comprehensively attend to the multiple medical needs and social needs of these patients, while collaborating with specialists as appropriate. These patients with multimorbidity are not a static group; rather, they frequently move from health to serious medical exacerbation and back to better health. These transitions in health status accompany changes in their life situations, which is why having primary care–based population management and continuity of relationships is critical. Mounting evidence indicates that advanced models of primary care are increasing value, especially for this subgroup of patients in the highest tier of medical costs.⁷

We, in the Association of Departments of Family Medicine (ADFM), recognize that academic health centers are not Kaiser Permanente and Geisinger. Many departments of family medicine around the country are vigorously engaged in the movement to transform care and to create high-performing medical homes and medical neighborhoods at academic health centers. A major pressure most academic health centers are currently facing is a need to enhance primary care capabilities to provide even the institution’s own employees with highly accessible, well-coordinated, affordable care. We have devoted considerable effort in ADFM to understand how we can help move our academic health centers from volume-based to value-based care delivery⁸ with the ultimate goal of delivering the Triple Aim to all populations served by these large institutions.

As we look to the future, we need to partner with others to proactively facilitate work of many individuals and organizations to address delivery of health care to populations within our communities. We applaud the innovative work by individual family physicians such as Jeff Brenner from Camden, New Jersey, who has demonstrated how health care costs can be cut by finding community “hot spots” where emergency departments are over-utilized.⁹ We commend the Association of American Medical Colleges (AAMC) for publishing their report on how academic medical centers of the future must be system-based to survive.⁹ In a recently published report, the AAMC describes 4 options for academic medical centers to move toward a system identity, from forming a new system, to partnering, to merging, or to facing the reality of shrinking in isolation.¹⁰ Within ADFM, we are tracking how departments of family medicine (DFMs) are leading health care transformation within their academic health centers. Many of our DFMs are actively engaged in moving to team-based care, improving delivery of preventive services, and promoting more appropriate use of consultations and referrals.¹¹ We will continue to collaborate with others who share the goal of using population health management approaches to improve affordable health care for the nation.

• © 2014 Annals of Family Medicine, Inc.