June 4, 2018

From Chronic Disease Management to Personalized Population Health

By Peggy Fischer

While the country celebrates the lowest unemployment rate in nearly 20 years, we shouldn't lose sight of a very different economic indicator: the spiraling rate of chronic disease. The cost of treating diabetes, heart disease, cancer and other chronic conditions - combined with the cost of lost productivity - is taking a massive toll on the U.S. economy, according to a new Milken Institute report. In 2016, that toll reached $3.7 trillion, nearly one-fifth of the U.S. gross domestic product.¹ And there's no end in sight. The Partnership to Fight Chronic Disease (PFCD) expects more than 80 million people in the U.S. to face three or more chronic health conditions by 2030, up from 31 million in 2015.²

For employers, this means continued struggles to improve the health and well-being of employees and bend unsustainable healthcare cost trend at the same time.

Prevention is Key, but U.S. Dollars Go to Treatment

The answer, many say, is preventing the onset of chronic disease in the first place, rather than directing all efforts to treating it. Unfortunately, government efforts are moving in the opposite direction: Disease prevention budgets have been slashed at the federal level and remain flat at the state level. According to Trust for America's Health, the Centers for Disease Control and Prevention spends just $4 per person per year to prevent chronic disease.³ As the PFCD points out: “The issue of chronic disease does not register with large segments of the public and policymakers as an issue of primary concern.”4

Employers are Turning to Population Health Management

So where does that leave employers who have a vested interest in keeping employees healthy and out of the high-cost band? Increasingly, the answer is population health management, which promises to improve the health of the entire population - improving productivity and reducing healthcare costs.

“Interestingly, this trend represents a sea change among employers,” says Marion McGowen, chief clinical officer and senior vice president of population health, UPMC Insurance Services Division, in an interview with Smart Business.5 “The goal is to try to prevent those who are well from becoming ill, while improving the quality of life and enhancing health outcomes for those who have developed chronic conditions,” she says.6

The Pitfalls of Population Health Management

But employers turning to population health management should be aware of common pitfalls with the approach:

  • The majority of population health strategies continue to focus on the sickest, costliest patients, attempting to prevent more high-cost events, such as a hospital readmission or stroke. And that's because it's difficult to identify and support people before they are diagnosed with a chronic condition. Nearly 80% of provider-led population health strategies today are focused on helping patients manage their chronic disease.7
  • Providers typically don't have the time to focus on an individual's full life context - including social, emotional and behavioral factors that play a major role in health. Nearly 60% of doctors say they spend 16 minutes or less with each patient.8 Life context is considered less than half of the time.9
  • Up to 85% of healthcare comprises cases in which the individual, not the provider, has control over the outcomes.10 But it's not easy for people to change their behavior, and providers have little ability to influence an individual's healthcare decisions between visits.

A New Approach to Population Health Overcomes these Challenges

To improve the health of employees and bring down the cost of healthcare, a population health strategy must overcome these challenges. It must:

  • Address the needs of the whole population, not just those diagnosed with one or more chronic diseases. It's critical to support the "rising risk" and the healthy to keep them from becoming high-risk and high-cost in the future.
  • Understand the needs of the whole person, not just their condition. This means understanding an individual's financial challenges, level of health engagement, cultural values and any other factors that influence their health and relationship with healthcare.
  • Influence the individual beyond the walls of healthcare, in the manner that fits into their life. Coaching, motivating, checking-in and influencing every day decisions that add up to better health and well-being.

In short, population health strategy must be proactive, personalized and connected. To learn more about this approach, tune into our live webinar on Thursday, June 21, 2018: Managing Employee Populations with a Clinical and Personalized Approach.


1 Waters, H. and Graf, M. (2018 May 25). The Cost of Chronic Diseases in the U.S. Retrieved from: http://www.milkeninstitute.org/publications/view/910.

² Ibid.

³ Trust for America's Health (2017 April), A Funding Crisis for Public Health and Safety: State-by-State Public Health Funding and Key Health Facts, 2017. Retrieved from: http://healthyamericans.org/report/136/ A Funding Crisis for Public Health and Safety: State-by-State Public Health Funding and Key Health Facts, 2017. R

4 About the Partnership to Fight Chronic Disease. Retrieved from: https://www.fightchronicdisease.org/about

5 Smart Business Staff (2017, Aug. 1), How population health management can save you big money. Smart Business. Retrieved from: http://www.sbnonline.com/article/population-health-management-save-money/

6 Ibid.

7 Heath, S., (2016, Feb 29), Boosting Chronic Disease Management through Pop Health Management, Health IT Analytics. Retrieved from: https://healthitanalytics.com/news/boosting-chronic-disease-management-through-pop-health-management https://healthitanalytics.com/news/boosting-chronic-disease-management-through-pop-health-management

8 Medscape Physician Compensation Report 2017. Retrieved from:https://www.medscape.com/slideshow/compensation-2017-overview-6008547

9 Weiner, S. (2016, Sept 13), Listening for What Matters: Lessons about Caring from Concealed Recordings of Medical Encounters. Retrieved from: http://www.theschwartzcenter.org/media/Listening-for-What-Matters-HANDOUT-1.pdf

10 Gottlieb, K., MBA; Sylvester, I., MBA: and Eby, D., MD, MPH, (2008 Jan.), Transforming Your PRactice: What Matters Most. Retrieved from https://www.southcentralfoundation.com/wp-content/uploads/2017/01/NEWS-Transforming-Your-Practice_press-packet.pdf