For decades, health care has been organized primarily around episodic interactions with individual patients. With population health management, however, care is organized around patients’ health needs regardless of whether they are seeking health care. The goal is better health for these patients as well as lower costs.
Transforming health care: from episodic interactions to population health management
AMONG THE KEY TENETS of health care reform is increasing the focus of clinicians on the health care and cost of health care of populations of patients. It sounds simple. But population health management (PHM) is not the way health care traditionally has been provided. For decades, health care has been organized primarily around episodic interactions with individual patients. With PHM, however, care is organized around patients’ health needs regardless of whether they are seeking health care. The goal is better health for these patients – including more coordinated experiences and improved outcomes – as well as lower costs.
“It’s really about ensuring that we are building a system that enables us to proactively address the health needs of a population,” says Timothy Ferris, MD, vice president of the recently launched PHM effort at Partners HealthCare. Ferris also is an MGH primary care physician and medical director of the MGPO.
PHM requires some changes in how care is organized and delivered as well as how success is measured. It also requires identifying and engaging different patient populations. With this in mind, the first phase of the PHM program at Partners – part of the systemwide Partners Care Redesign – involves three main components:
In the next phase, Ferris and his team will add specialty care and patient engagement programs to their charge. While the ultimate goal is managing the health of all patients who receive primary care through Partners, the PHM currently includes patients for whom Partners has risk-based, accountable-care contracts with payers.
“That’s approximately 500,000 patients, including those in our Pioneer ACO with Medicare, Partners employees, and patients covered by Blue Cross and Tufts contracts,” says Ferris. “We know that care is better using population health management tactics and having contracts that identify a target population and also include specific incentives to meet our goals helps us stay focused.”
Working with Ferris as medical directors for PMH are Sree Chaguturu, MD, an MGH physician, and Namita Seth Mohta, MD, a BWH physician.
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