Blog Post

New year, new resolutions: Your population health action items for 2017

January 11, 2017

    The rollout of MACRA and programs like CPC+ kick start a new era of care transformation in which providers have strong incentives to adopt value-based care delivery models.

    Whether you're in the early stages of transformation or accelerating your shift, here are three resolutions for population health-focused organizations in 2017.

    1. Innovate on your traditional approaches to care delivery

    Beyond the initial opportunities to reduce avoidable cost, providers that are growing the number of lives under management need to set a new standard for care transformation.

    For example, I did not interact with a single population health manager in 2016 that wasn't taking a proactive approach to care manage the high cost patients in their population. However, dedicating an extensivist clinic for multi-morbid super-utilizers is an evolution of high-risk care management that is only starting to gain traction beyond progressive, early adopters.

    The most advanced organizations continue to innovate on 1.0 and 2.0 care delivery models. Key to this strategy is deploying different solutions across subpopulations within the traditional high- rising- and low-risk population segments.

    2. Partner with targeted community-based organizations to scale a strategy for addressing non-clinical needs across your attributed population

    I've seen estimates that medical care accounts for only 10% of overall health. If you remove genetics from that equation, upwards of 60% of health is attributed to individual behavioral patterns, social factors, and environmental exposures.

    Providers managing the total cost of care cannot afford to ignore the impact that non-clinical risk factors like food insecurity, low levels of health literacy, housing instability, and inaccessible transportation has on avoidable health care utilization.

    First, screen patients for non-clinical risk factors as part of your care management assessments. Care teams cannot account for these barriers if unaware that they exist.

    Next, determine a streamlined approach for linking those with unmet social needs to applicable community resources as part of the care plan prescription. Some organizations dedicate a centralized specialist to link patients to the right resources, while others incorporate that task into existing care team roles.

    Regardless of your approach, the right group of partnerships—tied to prevalent social risk factors—can extend your system's reach beyond the clinical care continuum, anchor community health, and reduce the total cost of care.

    3. Determine the best benchmark to measure the ROI of your population health enterprise

    For those who have seen 2016's care transformation priorities, this resolution should look familiar. Beyond measuring ROI for discrete pilots, population health managers must understand the overall impact of their population health efforts in aggregate. Stated more clearly: Were you successful in reducing the total cost of care while maintaining (or improving) quality?

    The goal of population health investments is to inflect the rate of growth in health care costs. At a minimum, risk-based contracts require providers to bend the cost-to-payer growth curve for an attributed population. To measure overall ROI, some organizations define savings as the difference between actual spending (and utilization) compared to expected year-over-year trends.

    You can start by choosing a benchmark for expected trends in spending using market- or population-specific growth rates.

    Expected Versus Observed Illustrated Trends in Population Spend

    Don't see any of your resolutions on the list? Let us know what they are and how we can be helpful in 2017 by leaving a comment below or emailing me at

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