What ‘population health’ means, and what it could mean to you

May 10, 2017

For many people, the term “population health” may be new and undefined concept. What do you know about it, and does it involve you? Find out.


How would you explain “population health” to someone who’s never heard the term before?

The answer from Al Hammonds, Executive Director of Millennium Collaborative Care, is “its chronic disease management for a population or a small sub-group of people, looking at the social determinants of health and making sure that there’s value in the total care, versus just an episodic situation or episodic need.”

Dr. Jon Burroughs explains population health
Credit Avery Schneider / WBFO News

Millennium is an organization in the middle of a five-year initiative to create a better health care system in Western New York. They’re trying to educate the region’s health care providers and community organization on their role in population health. It’s why they brought in health care consultant Dr. Jon Burroughs for a population health conference at the Buffalo Niagara Convention Center on Wednesday. Burroughs has his own take on the explanation. He said the term “population health” is a misnomer and should actually be referred to as “sub-population health.”

“What you’re trying to do is identify people with the greatest needs who, frankly, we grossly under-treat, and identify people with very low needs, who we tend to over-treat,” said Burroughs. "It’s a form of rationalizing or right-sizing the care that we provide to the right people. We want to provide the right care to the right people in the right way in the right time.”

But population health – however you define it – is not just one thing. Among health care providers, there are building blocks of all shapes and sizes needed to create an aligned network. Things like nursing homes and home health programs, long-term care and skilled nursing facilities, and doctors, as well. Take all that and extend the network to look at palliative care and disease management, outpatient care, retail clinics, and even the new technologies available in electronic health.

“So you need all of these operational building blocks, and you have to put them together with what’s called a health information exchange, which means you have to share information with everybody all the time – eventually around the world – so people can show up anywhere in the world and get the care they need because everyone will have the same information,” Burroughs explained.

Of course, all that information needs to be backed up by analytics, so everyone from patients to doctors to health care organizations can make good decisions in real time.

But ‘what’ must shift towards population health has to be preceded by ‘why.’ People have to understand why they have to change what they’ve spent years practicing, even if they’re uncomfortable with it.

“People have to have a compelling reason why they would want to go through the hard work – and it’s hard work to learn new skills, to adapt to a new environment, to learn a new business, new care model, new skills – in order to provide people better health at a lower cost,” said Burroughs.

Patients have a role to play, too. Their end is about making decisions. Burroughs believes wise choices by individual patients can help cut costs dramatically. He uses the example of e-health:

“If your kid has an ear ache, instead of going to the emergency room you go pick up your smartphone and download an app. Go to the app, go to a pediatrician, and have the pediatrician or the emergency physician look at your child’s ear and do a diagnosis. And they can look at the ear through the smartphone.”

Burroughs estimates the cost of e-health to be about ten percent of what it would be to go to an emergency room and get the same care.

When trying to make those wiser decisions, Hammonds said individual citizens need to look at health care through a consumer’s lens.

“What do they want and what do they need – what they think they need from their health care,” are the questions Hammonds encourages people to think about. “Right now, health care is kind of inflicted on people. It’s got to change, just like in the financial industry and other industries.”

Western New York is still in the beginning stages of change towards population health, according to Hammonds, and Millennium’s five year initiative is only in its second year, partnering with physicians, health care providers, and community based organizations. He said most areas he’s seen take a long time to adjust, but noted that an immediate impact can occur in small groups. And those impacts can become an example of how population health works on a larger scale.

In population health, key players exist outside of the health care community

When it comes to health care, many people picture doctors, government, and individuals as key players in the system. But what about community organizations?

Reverend Kinzer Pointer was among the more than 250 attendees at a Millennium Collaborative Care’s population health conference in downtown Buffalo on Wednesday. You might not expect a minister to be part of the conversation about health care – but Pointer sees things differently.

Credit Avery Schneider / WBFO News

“This really huge discussion about the change in the way we approach medicine, from individual, personal service to population health is the only way we can really improve our national health care system,” he said.

Population health takes on the challenges of health care by changing the way it’s approached – from a case-by-case basis to involving all aspects of a person’s life. But changing to that approach requires action by community organizations like Greater Buffalo United Ministries, where Pointer is president. The group links faith-based partners – many of them in the African-American community – with local health care network Greater Buffalo United Accountable Healthcare Network.

“What we really need African-Americans to do is learn as much as possible about their own individual health and how they improve their own health,” said Pointer. “Because as pastors, we want to do less funerals for people who are dying from chronic preventable diseases way too early.”

Pointer said the message to share through ministry is that the church has to be willing to collaborate with all healthcare deliverers. It’s how he sees them maximizing a change in health care.