Abstract
As the world emerges from the worst of the COVID-19 pandemic, the field of population health is entering into what can be considered its fourth paradigm. The initial paradigm was the period during which patient-centered medical homes flourished and served to introduce population health into many medical offices. The second, somewhat overlapping, paradigm featured value-based programs gaining broad acceptance by health systems. 1 Accountable care organizations (ACOs) and commercial shared savings arrangements brought the potential of added revenue, usually without much financial risk, and care coordination across the care continuum was broadly expanded.
The third paradigm added downside risk components to insurance contracts, which fueled the broader interest of organizations to becoming payers themselves. The recent pandemic has accelerated the move into a fourth paradigm by (finally) demonstrating how social determinants of health (SDOH) and societal health inequities directly and indirectly negatively impact health. 2 The coming years will focus the attention of health care organizations on the significant impact of these topics on both health outcomes and overall health care-associated costs.
Organizations are already moving quickly with attempts to address SDOH in anticipation of this subject accelerating further in the near term. For some, this has been to initiate basic patient screening programs, whereas others have gone much further and are already working to improve both clinician and patient engagement in efforts to create true clinical transformation. The drive to expand teams of social workers and community health workers to partner with community-based organizations, even going so far as to directly supply food and housing for patients, are prime examples of the opportunities for health care delivery organizations to impact the outcomes for vulnerable populations. 3,4
Centers for Medicare & Medicaid Services (CMS) has also weighed in through efforts such as their new Framework for Health Equity 2022–2032 by prioritizing the building of workforce capacity within health care organizations. 5 Similarly, the new CMS ACO REACH program, which began in 2023, requires that participants design and execute a detailed Health Equity Plan, demonstrating the ongoing emphasis on addressing health disparities. 6 It is expected that a growing number of programs will be implemented in the coming years seeking to bridge the numerous equity gaps, particularly in diabetes and obesity care, cancer screening, and other areas of chronic care management and preventive care.
Progress in these areas will be hampered without attention to improving the data with which decisions are made. Although data have improved for the past 20 years, significant challenges remain particularly since low-quality data continue to disproportionately impact vulnerable populations. 7 Having the necessary data to target interventions in the community and at the point of care is necessary in an environment with limited resources. The receipt of real-time data is an ongoing challenge, although efforts continue to bring true electronic medical record interoperability and widespread adoption of Health Information Exchanges (HIEs) remain sporadic at best. In the near term, more robust enterprise-level data platforms have the potential to mine large data sets to identify health disparities by geographic region, socioeconomic status, and race. The continuation of efforts such as this to generate meaningful and timely data will be increasingly necessary to deliver care to specific populations when, where, and how they need it.
Telehealth (non-face-to-face audio/visual care visits) experienced tremendous growth and innovation during the pandemic and will continue to play a role in the provision of care. However, the next area poised for meaningful expansion is the use of remote digital monitoring. The use of technologies such as wearable devices and health monitoring applications are particularly effective when used in patients requiring post-hospital discharge services. These modalities can enhance monitoring and access to services and have been shown to reduce health care costs. 8
Ideally, these measures can also avoid initial admissions and improve the overall management of chronic diseases by helping patients to better manage their conditions. Particularly in an era of staffing shortages, it is of great value to have the ability to monitor patients with minimal cost and effort. Although inequities in areas such as access to internet service were also made more apparent during the pandemic, efforts will accelerate to better facilitate the links between patient and clinician, and to reduce health disparities, through delivery on the promise of digital health and monitoring technology.
Population health has matured by shifting the focus from treating individuals only in the hospital and medical office toward a view that incorporates populations of patients. By prioritizing preventive measures, the proactive management of chronic conditions, and introducing financial opportunities and risks, tremendous progress has been made. To succeed in this emerging fourth paradigm of population health, health care clinicians and organizations must shift their current (and still largely prepandemic) focus toward one that truly engages entire communities by addressing societal factors and health disparities and makes meaningful impacts on the maintenance of health and the avoidance of disease. Further efforts to incentivize this collaboration, when paired with better data, and more widespread use of digital technology, should lead to demonstrably improved health outcomes.