A Path to Value: What is Population Health Management?

Team Innovaccer
Tue 28 Feb 2023
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In today's world, healthcare goes beyond clinical settings. Any clinical setting can be controlled in terms of how and when care is provided to patients with appropriate measures. But if we move beyond these clinical settings, healthcare is much more complex, and socio-economic factors impact the well-being of those same patients. In fact, outside clinical settings, it is difficult to manage health at the population level. 

This is where the concept of population health management comes into the picture. Population health management has evolved from an idea into a clinical discipline that works on consistently refining and developing measures to improve citizens’ health status. In this blog, we will discuss what population health management is, what its key components are, its current state, and a sneek peek into its future.

What is Population Health Management?

Population health management ( also referred to as pop health management ) is a multidisciplinary approach that aims to improve the overall health of a defined population. It is based on the concept that health is determined by more than just access to quality medical care. Instead, it recognizes that a multitude of social, economic, and environmental factors contribute to an individual's health status. For example, poverty, lack of access to healthy food, and exposure to polluted environments can all negatively impact an individual's health. Similarly, factors such as education, job security, and social support can have a positive impact on health. By addressing these determinants of health, population health management seeks to improve the health of the entire population, not just individual patients.

What are the key components of population health management?

There is no doubt that we are moving towards 100% value-based care but providers need multiple elements—data analytics, care coordination, health promotion, clinical integration and community engagement—of population health management to sustain this transition. Here’s why organizations can never overlook any of these components:  

  1. Data Analytics: To identify trends and patterns in health outcomes, as well as to track progress and evaluate the impact of population health management initiatives. 
  2. Care Coordination: The coordination of care between healthcare providers and other stakeholders to ensure that individuals receive the right care, at the right time, and in the right place.
  3. Health Promotion: Programs and initiatives aimed at improving health by addressing the underlying determinants of health, such as poverty, lack of access to healthy food, and exposure to environmental pollutants.
  4. Clinical Integration: The integration of medical and behavioral health services to ensure that individuals receive comprehensive care that addresses both physical and mental health needs.
  5. Community Engagement: The engagement of communities in population health management initiatives to ensure that they are culturally and socially relevant, and to build trust and support for these initiatives.

The Current Scenario of Population Health Management 

Population health management is becoming increasingly important as the healthcare system faces a number of challenges, including rising healthcare costs, increasing rates of chronic disease, and disparities in health outcomes between different populations. Despite spending a significant amount on healthcare, the U.S. has worse health outcomes and a lower life expectancy than any other high-income nation, as per the study from the Commonwealth Fund. Of the countries covered in the study, the U.S. performed equally poor for chronic conditions such as diabetes and had the lowest life expectancy at birth - 78.8 years. The U.S. ranks 27th in the world for its level of healthcare. The U.S. has not been applying public health concepts to chronic disease management and in understanding patterns of risk for such patients. Other countries with better health outcomes are doing by spending a comparatively lesser amount on healthcare.

With right population health technologies, providers can gain insights into every patient’s unique needs and create personalized plans to those in needs in real-time. The result will be healthier communities and services at lower costs - the very definition of value-based care. In a recent report on “The State and Science of Value-Based Care”, over 50% of respondents believe that the use of the right analytics with the use of the right technology is the most crucial element in succeeding in VBC. The right analytics must also be able to address critical insights such as Social Determinants of Health (SDOH). The report also mentioned that only 42% of healthcare organizations are successfully able to add SDOH Management their pop health programs. The remaining 58% of healthcare organizations struggle to do so due to lack of standardized assessments, no resources to build community alliances, and budget constraints and lack of reimbursements by payers.   

Healthcare providers and public health agencies are starting to realize the importance of addressing the root causes of ill health, and are turning to population health management as a way to improve the health of the entire population. For example, many hospitals and healthcare systems are now investing in care coordination programs, health promotion initiatives, and data analytics to improve health outcomes and reduce healthcare costs. Additionally, there is a growing trend towards integrating medical and behavioral health services, as well as engaging communities in population health management initiatives.

The Future of Population Health Management

According to Marketsandmarkets , the global population health management market is expected to grow at CAGR of 13.9% from $27.8 billion in 2022 to $53.3 billion in 2027. Certainly, the future of population health management is bright, with many exciting developments and innovations on the horizon. As technology continues to advance, we will see an increased use of data analytics and digital health tools to improve population health outcomes. For example, wearable technology and mobile health apps will become increasingly important in monitoring and managing chronic conditions, and in providing individuals with the tools and resources they need to improve their health.

The industry will also see a trend of end-to-end population health management solutions with analytics as one of the key capabilities, matured enough, to drive holistic care. These solutions will help reduce in-house development time and cost and significantly accelerate enterprise-wide digital transformation. 

Additionally, we will see a growing trend towards community engagement, with communities playing an increasingly important role in shaping population health management initiatives. This will include the development of new partnerships between healthcare providers, public health agencies, and community organizations, as well as the involvement of community members in the design and implementation of these initiatives. Another important development in the future of population health management will be the increasing use of telehealth and telemedicine. This will allow healthcare providers to reach more individuals, regardless of their location, and to provide high-quality care in a cost-effective and convenient manner.


In conclusion, population health management is a holistic approach to improving health outcomes that recognizes the importance of addressing the underlying determinants of health. By using data analytics, care coordination, health promotion, clinical integration, and community engagement, population health management has the potential to significantly improve the health of the entire population.

As the healthcare system faces increasing challenges, population health management plays an increasingly important role in improving health outcomes, reducing healthcare costs, and addressing disparities in health outcomes between different populations. The future of population health management is bright, with many exciting developments and innovations on the horizon, and it has the potential to transform the way we think about and approach healthcare.


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Tags: Population health management, Value-based care, Value based health care
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