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#TBT: Population Health and Primary Care Providers

#TBT: Population Health and Primary Care Providers

In celebration of National Primary Care Week (October 1–5), we are sharing one of our most popular posts on the topic. If you want to read more about primary care providers, here is some further reading:


Editor’s Note: This post originally appeared on
inforMD on November 29, 2017. Edits have been made to update the content. 

Now that we’ve defined population health (a feat that many in healthcare avoid in the first place), let’s dive into what population health means to primary care providers. When it comes to operationalizing population health — reducing cost, improving quality, decreasing a physician’s daily administrative work and increasing revenue — it all begins with primary care.

Primary care physicians (PCPs) are well positioned to succeed in population health, better than most caregivers in healthcare, due to their unique place within the system. You’re the initial access point for your patients care when they’re sick, you define their fundamental care plan, and you can coordinate their care across a complex ecosystem. You, as cliche as it sounds, are a patient’s quarterback of care. Payers, such as Medicare or commercial insurers, recognize this and typically go to PCPs as the starting place for their value-based care contracts. So you not only have the tools to drive success in value-based care, you are best positioned to reap the rewards.

As you start your journey into population health, however, be cautioned, because it’s very easy to over-engineer solutions when it’s best to start with basic common sense. The healthcare system is so broken, complex, and wasteful, that it’s surprisingly not hard to improve it, at least initially. Starting in population health simply requires your time, continuous learning, and an action-oriented mindset.

Here’s how we recommend PCPs start that journey:

Meet monthly to review your data

Population health starts with understanding your patient population, and for that, you need data. At Privia, our physicians meet monthly in what we call physician-organized deliveries. These “PODs” host physician-led meetings that review data, discuss issues, and develop action plans. With your group, start asking some of these basic questions:

  • How can we understand our patient populations? (e.g. Where do they live? How old are they? What conditions do they have?)
  • Where are we doing well and should continue? Can we take that learning and apply it elsewhere?
  • Where do we need to improve?
  • Instead of worrying what’s outside our control, what is in our control to improve that area?

Establish your quality goals

Quality is one of the easier concepts for clinicians to grasp in the shift to value-based care. Great physicians gravitate towards quality care and patient satisfaction in the first place, and the concept of improving quality is a lot more digestible than the daunting concept of “lowering total cost of care.” Implementing a strong quality program is simply a matter of creating operational discipline around that focus. (And candidly, you are building the discipline that will work well when you tackle more gnarly value-based problems.) Start by asking:

  • What are the quality metrics we are judged by in payer programs? (e.g. MSSP’s quality measures)
  • Do we have workflows and training that teaches providers and staff to succeed in each measure?
  • Is our EHR system built or configured to capture quality metrics? (Unfortunately, there are still a significant number of bad EHRs for this task.)
  • Do we have ways to reach patients who have gaps in care and get them back in the office?
  • Do we continually deliver metrics to our physicians on how they are performing? (This helps to track progress and identify opportunities for improvement.)

Conquer cost by first conquering your own access

Lowering total cost of care can be an intimidating objective, especially when you’re just getting started with population health. For PCPs, that journey usually starts with lowering unnecessary utilization of expensive healthcare services. That includes unnecessary hospitalizations, specialist visits, tests, and imaging. But rather than getting your head spinning with complicated analytics, care coordination programs, or other complex solutions, start with a simple question: Are you accessible to your patients? My guess is you probably aren’t accessible enough. From there, ask yourself:

  • Do my patients know where to go for immediate care … or do they have to figure this out on their own?
  • Do my patients have same-day or next-day access to me (or another member of my team) in the case of an urgent issue? Or does it take three or more weeks to schedule an appointment?
  • Do my patients have access to support after practice hours or do they get an automated message telling them to immediately go to the emergency department?
  • Do my patients have access to me via online scheduling or does my office only take appointments over the phone? 

Manage your network

In a fee-for-service world, you aren’t impacted financially by what specialist or facility your patients go to, or whether they go at all. But in a value-based world, you need to manage your network and where your patients go across the healthcare ecosystem. As a PCP focused on population health, you need to make sure your patients get the right care, at the right place, at the right time. How do you start to tackle this? Start by asking:

  • What are the dynamics in our market?
  • Who are the key hospitals in our area? What is our relationship with this hospital?
  • Can we find cost and quality data on our network? (Hint: start with public sources or payers.)
  • Based on that data, who are our preferred partners, specialists, and facilities that we want to refer our patients to?
  • How do we institute workflows to ensure our patients go to a preferred partner?
  • Can we collaborate more closely with that preferred partner to make sure our patients receive the proper care?

Turn your goals into an action plan

Once you have asked these types of questions and understand where your practice can start to implement population health initiatives, make a list of actions you can take to improve.

  • Write it down on paper for all to see and refer to later.
  • Keep it to less than 10 action items, preferably about five, for simplicity. It should all fit on one page.
  • Assign an owner and deadline to create accountability.
  • Revisit the list monthly to measure progress and continually improve.

Starting with this simple exercise will help you logically get to the next step while also improving your muscle memory on when population health can serve you best. These steps can be implemented at any level of an organization, down to a small physician practice.

Want to learn more about population health? Start at the beginning with “Population Health: Great, Now What Exactly Is It?”

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