With the United States having the highest healthcare expenditures of any high-income nation, you’d assume the country also has the best health outcomes. Unfortunately, you’d be wrong. 

Even though the U.S. spends more than $4 trillion annually — almost 18 percent of gross domestic product (GDP) — on healthcare, it has the dubious distinction of having the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions and the highest maternal and infant mortality. 

The healthcare industry has introduced and implemented numerous initiatives aimed at reducing costs, from transitioning from fee-for-service to value-based care (VBC) to Meaningful Use programs designed to promote provider adoption of electronic health record (EHR) systems. One of the most recent strategies, though, focuses on population health, which creates some efficiency as groups of patients who share similarities like age, gender and diagnosis become a defined population. Their interventions to engage can be scaled and therefore consume fewer  resources. 

Goals of Population Health Management 

The strategy to which we’re referring is population health management (PHM). Basically, it is the aggregation of patient data across multiple health information technology resources, the analysis of that data and the actions through which providers and their care teams can improve both clinical and financial outcomes.  

There are multiple goals of PHM. One is to maintain or improve people’s physical and psychosocial well-being and address health disparities through tailored, cost-effective solutions. Another is to minimize the need for expensive medical interventions by incentivizing healthcare providers to develop new skill sets and new infrastructures for delivering high-quality care. 

These new infrastructures — or models of care — maximize the ability to scale engagement initiatives and leverage different roles of the healthcare team, from the provider to behavioral health care, integrated or traditional, nursing care and other areas of expertise. These team members are then utilized to identify and bridge some of the barriers imposed by SDOH variables.  

Any comprehensive PHM program first identifies at-risk patients, including those with chronic diseases. It precipitates patient-centered care and requires attention to disease screening and prevention. 

There are, of course, challenges to population health management, including the time and other resources necessary to conduct such programs. Some providers find it too overwhelming, even with the myriad advantages it offers. Others don’t put enough emphasis on patient engagement, which is a crucial component of PHM. 

Quite frankly, many providers don’t know where to start with population health management. They either don’t know how to overcome patient barriers to care or don’t have the available time to develop a detailed PHM strategy. 

The Top Three Tenets of Population Health Management 

A key to creating and maintaining a successful population health management program is understanding its three central tenets: navigation, patient education and behavioral economics. Without these components, a PHM program most likely won’t reach its full potential, thereby negating many of the benefits it’s designed to achieve. 


The U.S. healthcare system certainly isn’t always the easiest to navigate. It’s often fragmented and confusing for patients, especially for those with low health literacy and limited access to care. That’s one of the reasons the focus on social determinants of health (SDOH) has become so prominent. 

An efficient population health management program proactively engages and manages patients by anticipating needs from their perspective and addressing them in a timely manner. Effective navigation is not only key to successful patient outcomes but also positively impacts the patient experience by reducing anxiety. Some examples of patient navigation used in PHM include post-discharge instructions, care management of chronic disease populations and continuity of care

Post-Discharge Navigation 

According to a report from the American Health Insurance Management Association (AHIMA), nearly two in three Americans are not extremely confident in their understanding of the health information they discuss with their doctor. Roughly 37 million Americans admit they sometimes feel more confused about their health than they did before their appointment. 

Unfortunately, the same is the case with hospital discharge instructions. Studies show that many patients don’t fully understand or recall the instructions they receive, leading to reduced patient satisfaction and compliance. There are multiple factors that contribute to this confusion, including physical and emotional discomfort, low health literacy and a busy hospital setting. Additional aspects, such as premature discharge and inadequate follow-up care, coupled with complex co-morbidities, often lead to readmission. 

To combat these issues, population health management programs can be implemented to adequately coordinate post-discharge home services, share instructions on medication and treatment adherence, promote the importance of re-engaging early and consistently with primary care and address any provider-patient communication barriers. Standard discharge navigation programs also must prepare patients for appropriately managing their condition(s), whether newly diagnosed or chronic.

Care Management 

Aimed at customizing healthcare to meet each patient’s unique needs, care management consists of activities such as patient education, risk stratification, care planning, medication management and adherence and coordination of care transitions. It’s another crucial element of PHM and is key to improved outcomes and reduced costs. 

Though the goals of care management often vary slightly from provider to provider, these programs help avoid unnecessary utilization of emergency department and other hospital services. Similarly, they help integrate the appropriate clinical resources to deliver needed services proactively. 

Continuity of Care 

Defined as care over time by a single individual or team of healthcare professionals and the effective and timely communication of health information, continuity of care builds trust between patients and providers. It’s influenced by multiple factors, including demographics, inter-professional, organizational and patient-healthcare professional relationships. Such relationships encompass roles from the provider and nursing and mental healthcare professionals and extend to medical assistants and financial eligibility employees.   

In addition to better patient outcomes and increased patient satisfaction, especially for those with chronic disease, continuity of care offers improved appointment follow-through and improved medication adherence, reduced emergency department utilization, enhanced quality of care and increased access and engagement with preventive care and screenings. It’s important to note that patients of full-time general practitioners possess higher levels of continuity than patients of part-time ones

Patient Education 

As an important part of patient engagement, education from clinicians should include basic health information along with content that’s relevant to the individuals to whom they’re providing care. It empowers patients to not only actively participate in their own care but also engage in shared decision-making when they can clearly understand the value to them or their family by consistently engaging in their own health.

One study showed that people who read patient education material and communicate their understanding back to the doctor are 32 percent less likely to be hospitalized and 14 percent less likely to visit the emergency department. However, research shows that clinicians have trouble identifying patients with limited health literacy, a problem that has the potential to negatively affect these individuals by lowering their levels of self-reported health, increasing their occurrence of and severity of illnesses and reducing their overall health. 

For patient education to be successful, it’s necessary for providers to overcome common barriers to patient learning, such as:

  • Physical condition
  • Financial considerations
  • Lack of support system
  • Misconceptions about disease and treatment
  • Low literacy/comprehension skills
  • Cultural/ethnic background/language barriers
  • Lack of motivation
  • Environment
  • Negative past experience
  • Denial of personal responsibility

Providers also should consider the economic, social, cultural and geographic barriers of SDOH to reduce health disparities. These factors might prevent them from comprehending medical information, processes and/or treatment options. 

When patients receive written health communication materials that don’t match their reading level, education from providers isn’t effective. Therefore, being succinct in patient communication mitigates the possibility of a message getting lost in the noise. Patient education that’s both motivational and consistent is most consumable. 

Payers and providers should offer more value by delivering customized or personalized messages that contain patient education and health information that motivates patients to make a healthcare decision. A streamlined method for achieving this is through a HIPAA-compliant, two-way texting solution, as data suggests that patients would rather be contacted via text message. 

Behavioral Economics 

Centered on the study of psychology as it relates to the economic decision-making processes of individuals and institutions, the principal of behavioral economics explains why individuals may make irrational choices by demonstrating how their decision-making is influenced by biases, heightened emotions, faulty problem-solving, mental fatigue, loss aversion, choice overload, perceived social norms, situational framing and context. It anticipates needs patients experience along the healthcare continuum, enabling providers and their teams to then proactively address them. 

Increasing patient engagement while leveraging behavioral economics is essential for improved healthcare outcomes. Applying insights and principles from it has the potential to increase and improve patient engagement for healthcare providers of all sizes. 

A few key technology tools used in a successful behavioral economics strategy should consist of two-way text messaging, telehealth, predictive analytics and automated population health platforms. How can these technologies be applied to the primary concepts of behavioral economics and corresponding strategies? Here are a few examples: 

Behavioral Economics Chart

Key Capabilities of a Population Health Management Platform 

When the combination of navigation, patient education and behavioral economics in a population health management program is achieved, healthcare providers realize numerous advantages — not only reduce costs. By utilizing real-time data more effectively to improve patient care, providers can more accurately address care gaps within a patient population and engage those individuals in their care. 

PHM programs also promote inclusion of patients not currently treated by a healthcare provider and help coordinate care that was previously siloed and fragmented. They can even lower healthcare costs for employees of organizations that utilize a PHM program. 

What, then, should healthcare providers look for in a population health management platform? The most comprehensive PHM solutions offer and enable:

  • Demonstrated results with complex patient populations
  • A patient outreach strategy with proven message cadence, content and velocity
  • Customized and personalized patient outreach and engagement
  • Leverage of EMR data to identify high-need populations
  • Automated, two-way real-time communications
  • A curated messaging content library that accounts for health literacy levels
  • Reduced administrative burden, especially as workforce challenges mount
  • Identification of populations at high risk for readmission
  • Easy access to real-time data
  • Automated management of routine patient education and communication
  • Integration with digital health tools that enable patients to easily:
  • Schedule appointments
  • Access patient education information
  • Properly prepare for tests and procedures
  • Pay medical bills online

Whatever population health program your healthcare organization decides to employ should start with detailed planning and a strategy that aligns with your overall operational goals. By using those primary PHM tenets as a guide and integrating the ideas of behavioral economics, you should soon start to realize positive results for both you and your patients.