Healthcare. It’s a basic right to which all individuals should have access. However, in the United States, perhaps the most developed nation on this earth, there remain glaring disparities — lack of access to care, higher burden of disease, shorter life expectancy, less insurance coverage — among certain populations

A variety of factors contribute to these disparities, from genetics and poverty to language barriers, environmental conditions, geography and more. Think social determinants of health (SDOH). 

Health disparities primarily affect racial and ethnic minority, rural, low-income and other underserved populations. Individuals with cognitive and physical disabilities also are often disproportionately exposed to higher rates of health disparities. 

This isn’t simply an opinion, either – variations in the levels to which some individuals have a more difficult time accessing care are well documented. Communities of color, populations with a lower socioeconomic status, rural communities, people with cognitive and physical disabilities are often disproportionately exposed to conditions and environments that negatively affect health risks and outcomes and lead to higher rates of health disparities. 

Similarly, Americans living in rural areas are more likely to die from unintentional injuries, heart disease, cancer, stroke and chronic lower respiratory disease than their urban counterparts. According to one study, health disparities cost $42 billion in lowered productivity and $93 billion in excess medical costs each year. 

The COVID-19 Effect 

The COVID-19 pandemic has only exacerbated these disparities. It exposed long-standing gaps in access to care, both physical and mental. 

Some public health members of ethnic and racial minority groups have a higher chance of getting COVID-19 and of experiencing the severe and longer-lasting impacts of the virus. Also, as noted by the National Conference of State Legislatures (NCSL), discrimination in the U.S. health systems along with higher uninsured rates, increased rates of employment in essential work settings with minimal or no paid sick days and more likelihood of reliance on public transit and crowded housing situations intensified COVID-19 exposure to racial and ethnic minority groups that experience lower educational and income levels. 

Along with expanding the focus on health disparities in this country, the pandemic also highlighted the need of the U.S. healthcare systems to invest more in population health. Many healthcare providers are now implementing programs for population healthcare management — or at least developing a strategy to do so. 

The Importance of Population Health Management 

As we mentioned in a previous blog, population health consists of individual health care interactions that share many similarities, thereby consuming considerable resources. So what is population health management exactly? Population health management (PHM) is the aggregation of patient data across multiple health information technology resources, the analysis of that data into a single, actionable patient record and the actions through which care providers can improve both clinical management and financial outcomes.  

What’s the goal 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. 

Because of the shift from fee-for-service to value-based care, population health management was already a priority at most healthcare practices. However, it’s more important than ever now that we’re starting to recover after the devastating impacts the COVID-19 pandemic has had on the distribution and accessibility of healthcare in the U.S.  

Primary Elements of Successful Population Health Management 

By developing and implementing PHM, healthcare providers are better able to facilitate the identification of demographic-based disparities to reduce them. Doing so, though, requires a strong organizational structure, efficient information systems and an appropriate mix and sufficient quantity of providers. It consists of multiple elements, including care integration and coordination, teamwork, patient engagement, value-based care measurement and data analytics and health information technology. 

Components that must be considered to successfully operationalize a population health manager strategy consist of: 


It’s no secret that the health care landscape can be fragmented and confusing for patients to navigate. A population health approach restructures a sometimes fragmented and confusing healthcare landscape by proactively engaging and managing patients. It anticipates needs from the patient perspective and addresses 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. 


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.

Behavioral Economics

Centered on the study of psychology as it relates to the economic decision-making processes of individuals and institutions, the principle of behavioral economics anticipates needs patients experience along the healthcare continuum. Providers can then proactively address those needs, correlating with rising population health trends. 

These components can be utilized for each population you target, whether it be patients with specific chronic diseases or those demonstrating risk factors. For example, these factors might consist of demographic, diagnoses, economic status, advanced age, hereditary diseases or utilization history. Patients also can be segmented by based on when they last received preventative care, including annual and wellness visits, cancer screenings, immunizations and vaccinations, prenatal and postnatal care and sports physicals. 

The Providertech PHM Solution 

Implementing a population health outreach platform not only helps you engage patients, it also reduces the burden on your staff. That decreased stress is especially important as the healthcare industry continues to face staffing shortages. 

At Providertech, our CareCommunity population health platform automates and scales patient outreach for you, resulting in increased appointments, reduced no-shows and cancellations, less wasted time and, most importantly, improved clinical outcomes for your complex patient populations. Schedule a demo of CareCommunity to see how to enhance your population health management.