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February 19, 2021/Geriatrics

Common Challenges in Population Health

Engaging populations and communities to reduce high-cost utilization

LT Geri

It’s no secret that healthcare in the U.S. is expensive and doesn’t always achieve the best outcomes. A newer model that focuses on the health and wellness of populations might help rectify this problem.


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“In general, it’s pretty clear that we’ve not done a spectacular job in this country with healthcare outcomes or cost control. In population health, our goal is to improve outcomes by leveraging a wealth of data and expanding care teams to proactively address the health needs of a defined populations in cost-effective ways,” says Nirav Vakharia, MD, President of Cleveland Clinic’s Medicare Accountable Care Organization. “We do a great job caring for patients who are already sick – people travel here from all over the world for medical care when they are sick. But with population health, we are looking at how to keep a person well.”

Dr. Vakharia and his team at Cleveland Clinic are addressing other questions related to outcomes, patient experience, prevention and utilization, looking for opportunities for improvement. They are looking at questions like: How do we reverse the factors that put our patients at risk for developing chronic diseases? How can we address social and behavioral health upstream? How do we engage with communities?

“It’s an exciting place to be right now – when the payment model focuses on and rewards good outcomes, it is better for patients, providers and health systems. The incentives are finally lining up,” says Dr. Vakharia. “That said, a paradigm shift like this is not without its challenges.”

One size doesn’t fit all: new model still needs continuous improvement

The population health model works very well for a majority of patients, according to Cleveland Clinic internist Robert Jones, Jr., MD. “Over the last decade, we’ve learned not all patients will get the care they need in the population health model. Elder, frailer patients, along with patients with chronic conditions, require a far more personalized care model. There’s a lot of work happening in this space right now as we seek ways for traditional players to meet the needs of 100% of the patients in a population health model,” he says.

Engaging communities: social determinants of health

Another challenge is the need to have a way to understand and measure data related to social determinants of health for our patients. At Cleveland Clinic, one way this is accomplished is through an annual patient survey. In a private setting, patients answer sensitive questions that give insight into the issues each patient faces, from hunger to healthcare costs, to transportation and intimate partner violence.

“Currently, about 65% of our patients complete the survey. It’s not a low number, but we certainly have some room for improvement,” says Dr. Vakharia. “As primary care providers, we may think we have great relationships with our patients; however, some topics are very sensitive and private. The survey gives them another way to share their experiences with us. It opens up conversations, and gives us the opportunity to provide support and resources.”


High-cost utilization

Despite efforts to reduce unnecessary healthcare costs, preventable high-cost utilization remains an issue. “Specifically, there are patients who go to the emergency room for non-emergent situations and hospital admissions that may have been prevented if we, in healthcare, had been more organized and systematic upstream,” Dr. Vakharia notes. “These trends are starting to turn in the right direction, but are still high. So a lot of our work right now in population health is focused on defragmenting the system, and ensuring that our patients understand how best to access care.”

“We want to ensure that our patients are more likely to seek care in a primary care or other ambulatory setting, or even better, sending resources into the home because we want patients to be safe and comfortable there. We also want to take a systematic approach to disease management, setting standards of care for chronic conditions with specialists. Our goal is to keep our patients well by managing their risk factors so they are less likely to need a high-cost emergency room visit. It’s better for everyone.”


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