February 15, 2017

5 Things to Know About Population Health Management

5 Things to Know About Population Health

Population health management (PHM), it’s a term you hear often, but what is it? PHM is a collection of activities, not reimbursed in the fee-for-service model, but important in the care we deliver to our patients. We work closely with leadership at our hospitals and community health centers to design and execute a system-wide accountable care strategy. Partners Population Health provides resources and technology to support the implementation of PHM across all phases of care. This work is a collective and collaborative process. Thousands of people across Partners are working together to achieve our five main goals:


Improve quality of care

5 Things to Know About Population Health: Improve Quality of Care

A primary goal is to make sure our patients have the most appropriate and highest quality care. This means caring for patients at every step along the way – preventative health, medically complex and chronic health issues, behavioral health, and even end-of-life care. We do this in many ways – one way is our high risk care management program. This program cares for 13,900 of our most vulnerable and complex patients with dedicated care managers that address health and socio-economic issues. Results have shown that patients in the high risk care management program have lower rates of hospitalization, emergency room visits, and reduced costs. We also integrated behavioral health services into primary care and offer a suite of services to our physicians and patients to help manage and support patients with behavioral health issues. With the opioid epidemic at the forefront of our minds, we have developed a new care delivery model focused on working with patients with Substance Use Disorders (SUD). This includes clinician trainings, SUD specialty consultations, a new nationally recognized screening program, and resources for patients and their families. Further, as part of our medical home efforts, we are beginning to roll-out several programs focused on patients at end-of-life to make sure care is coordinated and consistent with their wishes and preferences.

Slow down the overall growth of health care costs

5 Things to Know About Population Health: Reduce overall health care costsA primary goal of PHM is to improve the quality of care provided to our patients while also reducing health care costs. As many people know, this is no easy task. Partners HealthCare has been on the forefront of a national experiment to transform the payment system from a fee-for-service model to a new model that requires keeping costs below a target. Since 2012, we entered into new contracts with all the major insurers including Medicare, Commercial, and Medicaid. After four years in the Medicare Pioneer Accountable Care Organization (ACO), we saved $31.5 million and received a quality score of 96% – one of the highest in the nation. In 2017, Partners became a Next Generation Medicare ACO, a newer model geared towards health care organizations with previous experience managing large populations. Our Medicaid ACO, part of the MassHealth pilot program, is one of the first Medicaid ACO pilots in the country. With practical experience under our belt, we continue to focus on new ways to reduce costs while improving the quality of our services.

Enhance care coordination

5 Things to Know About Population Health: enhance care coordination

To help patients navigate a complex health care system, we offer services to improve the coordination of care between physicians and the care team ranging from primary care and specialists to post-acute care transitions. One program, called eConsults, is geared towards patients with less serious conditions who may benefit from a specialist’s input to help guide their treatment plan. Using an electronic platform through our medical record system, primary care physicians (PCPs) can request an “eConsult” from a specialist, such as a cardiologist, urologist, or an infectious disease specialist. With an easy, accelerated way to get advice from specialists, PCPs, when appropriate, can treat certain patients themselves. This can be faster and more efficient than waiting for an in-person visit with a specialist. For patients who require an in-person visit, lab results and other tests can be ordered prior to the visit with the specialist resulting in a more productive visit. Since 2012, when the program first launched at Massachusetts General Hospital and Brigham and Women’s Hospital, over 7,000 eConsults have been conducted across 40 specialties with an estimated savings of $1.8 million. As of this year, the eConsults program has expanded to several primary care clinicians in our community network. By 2018, all primary care clinicians in the Partners network will be offering eConsults.

Engage patient in their own care

5 Things to Know About Population Health: patient engagement

Across our programs, we believe patients should be engaged in their care, be involved in making decisions, and have clear information and tools to take care of themselves at home. The shared-decision making program aims to provide patients and clinicians access to evidence-based educational materials, known as decision aids, to help patients learn more about their health care options. This process encourages better conversations between patients and clinicians and assures that medical decisions are aligned with patient preferences and care goals. Since 2005, over 38,000 decision aids have been distributed to patients across the network. We are also piloting self-care programs that include a virtual health coach app for diabetes management, healthy heart care, and mindful eating, and on-line communities such as PatientsLikeMe. This forum, open to patients and their caregivers, provides a space to share information, talk about related health issues, and support to patients who share similar medical problems. Engaging patients makes a difference – evidence has shown that patients engaged in their care have better clinical outcomes and lower costs of care.

Use technology and analytics to support patient care

5 Things to Know About Population Health: support patient care

Technology is a cornerstone of our work in population health. It allows us to monitor our performance and develop convenient ways for doctors and nurses to interact with patients and each other. For example, using a program called Virtual Visits, patients are able to securely video-chat with their doctors from the comfort of their own living room. This reduces time spent away from work, driving to and from the doctor’s office, and sitting in the waiting room. A virtual visit is a convenient replacement for an in-person visit, especially for follow-up visits that may include discussing labs. Although virtual visits are great for patients and providers, they are often not reimbursed by insurance companies. At Partners, we provide our physicians with a stipend to cover the cost. However, with the adoption of the Next Generation ACO, virtual visits will be reimbursed for our Medicare patients, which will allow us to expand this service to more of our patients. Since 2012, we have conducted over 7,000 virtual visits across Massachusetts General HospitalBrigham and Women’s Hospital, and Emerson Hospital.


At its core, PHM is a set of coordinated activities, enabled by new approaches to payment, that are intended to improve patient care, lower costs, and increase efficiency for everyone. Although we are only five years in, accumulating evidence suggests the investment and the work are making a real difference for patients and improving our health care system.

© 2020 Partners Population Health All rights reserved.