Benefits of Population Health Management

The Evolution of Population Health Management

The evolution of Population Health Management, or PHM, is a compelling story that traces its roots back to public health initiatives of the 19th and 20th centuries. Back then, population-wide measures were introduced to combat widespread diseases. Fast forward to today, PHM has evolved into a strategic approach that aims to improve the health outcomes of a group by monitoring and identifying individual patients within that group.

The kick-start of PHM was primarily due to an increasing emphasis on disease prevention and providing high-quality, value-based care. Over the years, you’ve probably noticed a shift from fee-for-service models to more patient-centered care. This partly stemmed from reforms and regulations that highlighted the need to control healthcare costs while enhancing patient outcomes.

Let’s delve deeper. With the onset of 21st-century health threats, where chronic and lifestyle diseases are more prevalent, the Infectious Disease Management model has significantly changed. The current model now seeks to prevent chronic illnesses in high-risk populations through early detection and intervention.

A defining moment for PHM came with the introduction of big data and analytics in healthcare. This has led to the development of sophisticated predictive modeling tools. Now, you can identify high-risk patients, allocate resources effectively, and intervene much earlier than you could in the past.

Thanks to technological advancements, we see the proliferation of health information exchange (HIE) systems. HIEs enable you to obtain and disseminate medical information across various healthcare facilities quickly. This has considerably improved care coordination.

The Connection Between Population Health Management and Individual Health

In your healthcare journey, you’ve probably encountered the concepts of population health management and individual health. The connection between these two facets of healthcare is significant and shouldn’t be underrated.

Population health management is a comprehensive approach embracing the health outcomes of a group of individuals. On the other hand, individual health focuses on a single person’s well-being and health outcomes.

The intersection of these two concepts boils down to precise healthcare delivery. Population health management strategies use broad data to identify risks and proactively manage a group’s wellness. For example, if data shows high rates of obesity within a community, programs can aim to reduce that statistic with exercise initiatives or dietary education.

These strategies directly impact individual health. Employing population health management means you’re equipped with better data to understand your patients and their potential health concerns. According to a study by the American Journal of Managed Care, a strategic approach to population health can lead to a 15% reduction in hospital admissions, directly witnessing improved individual health outcomes.

Bridging the Gap Between Healthcare Providers and Patients

One of the key benefits of PHM is that it can help to bridge the gap between healthcare providers and patients. PHM programs typically involve a team of healthcare professionals working together to coordinate care for patients across the continuum of care. This can include primary care physicians, specialists, nurses, social workers, and other healthcare providers.

By working together as a team, healthcare professionals can provide more comprehensive and coordinated care to their patients. This can help to improve patient outcomes, reduce costs, and increase patient satisfaction.

Here are some specific ways that PHM can help foster a more direct relationship between health professionals and patients:
  • PHM programs can help identify patients at risk for developing chronic diseases or other health problems. Once these patients are identified, healthcare professionals can contact them and provide them with preventive care and education. This can help to prevent the development of chronic diseases and other health problems in the first place.
  • PHM programs can help to coordinate care for patients with chronic diseases. This can include ensuring that patients receive all of the necessary medications and treatments and follow up with their healthcare providers as needed. Good care coordination can help to improve patient outcomes and reduce the risk of complications.
  • PHM programs can help to improve communication between healthcare professionals and patients. PHM programs often use technology to make it easier for healthcare professionals to communicate with their patients. For example, PHM programs may use patient portals, text messaging, or email to communicate with patients about their care. Better communication can help to build trust and rapport between healthcare professionals and patients.
  • PHM programs can help to empower patients to take control of their health. PHM programs often provide patients with education and resources to help them make healthy choices. For example, PHM programs may provide patients with nutrition, exercise, and chronic disease management information. By empowering patients to take control of their own health, PHM programs can help to improve patient outcomes and reduce the need for expensive medical interventions.

Overall, PHM is a valuable tool that can help to bridge the gap between healthcare providers and patients. By working together as a team and using data and analytics to identify and address the needs of specific populations, PHM programs can help to improve health outcomes, reduce costs, and increase patient satisfaction.

Reducing Healthcare Costs with Population Health Management

One of the key ways that PHM reduces costs is by preventing unnecessary hospitalizations. By identifying and managing patients at risk of hospitalization, PHM providers can help to keep them healthy and out of the hospital. This can save a significant amount of money, as hospital stays are one of the most expensive components of healthcare.

Another way that PHM reduces costs is by improving chronic disease management. Chronic diseases, such as diabetes, heart disease, and cancer, are responsible for many healthcare costs. PHM providers can help patients with chronic diseases to manage their condition more effectively, which can lead to reduced medication use, fewer complications, and better overall health.

PHM can also reduce costs by improving the efficiency of care delivery. By coordinating care across multiple providers and settings, PHM providers can help reduce duplication of services and ensure that patients receive the right care at the right time. This can lead to shorter wait times, improved patient satisfaction, and lower costs.

In addition to reducing costs, PHM can also improve healthcare quality. By focusing on prevention and early intervention, PHM can help to keep people healthier and reduce the need for more expensive and invasive treatments. PHM can also improve patient satisfaction by providing more coordinated and personalized care.

PHM is a promising approach to reducing healthcare costs and improving health outcomes. By identifying and addressing the root causes of disease and illness, PHM can help to keep people healthy and out of the hospital. PHM can also improve the efficiency of care delivery and healthcare quality.

Here are some specific examples of how PHM is being used to reduce healthcare costs:

  • A study by the Commonwealth Fund found that a PHM program for Medicare beneficiaries saved an average of $1,400 per patient per year.
  • A study by the American Heart Association found that a PHM program for heart disease patients saved an average of $8,000 per patient annually.
  • A study by the American Diabetes Association found that a PHM program for diabetes patients saved an average of $10,000 per patient per year.

These studies demonstrate that PHM can significantly reduce healthcare costs, particularly for patients with chronic diseases.

As the healthcare landscape evolves, PHM will likely play an increasingly important role in reducing costs and improving health outcomes.

The Role of Technology in Population Health Management

Technology is rapidly transforming the healthcare landscape, and population health management (PHM) is no exception. From electronic health records (EHRs) and patient portals to telehealth and remote monitoring devices, technology is helping doctors and healthcare professionals better understand and manage the health of their patient populations.

One of the pivotal technological advancements in this domain is the Electronic Health Records (EHR). The EHR benefits population health management by providing a centralized database of patient information, which can be accessed by healthcare professionals across different facilities. This ensures continuity of care and aids in data-driven decision-making, predictive analytics, and proactive interventions.

Here are some of the key ways technology is impacting PHM:
  • Data collection and analysis: Technology makes it possible to collect and analyze large amounts of data about patient populations, including demographics, health history, and treatment outcomes. This data can be used to identify trends and patterns and to develop targeted interventions to improve population health.
  • Care coordination: Technology can help to coordinate care across different providers and settings. For example, EHRs can share patient information between doctors, hospitals, and other healthcare providers. This can help to improve communication and collaboration and to ensure that patients receive the care they need when and where they need it.
  • Patient engagement: Technology can be used to engage patients in their own health care. For example, portals allow patients to view their health records, schedule appointments, and communicate online with their doctors. Telehealth allows patients to receive care from their doctors remotely, and remote monitoring devices allow patients to track their own health data at home.
Here are some specific examples of how doctors and healthcare professionals are using technology to improve PHM:
  • Using EHRs to identify patients at high risk for certain diseases or conditions: Doctors can use EHR data to identify patients who are at high risk for developing chronic diseases such as heart disease, stroke, and diabetes. These patients can then be targeted with preventive care and interventions to reduce their risk of developing these diseases.
  • Using patient portals to encourage patients to adhere to their medication regimens: Patient portals can be used to send patients reminders to take their medications and to provide them with information about their medications and their side effects. This can help improve patient adherence to medication regimens, leading to better health outcomes.
  • Using telehealth to provide care to patients in remote areas or who have difficulty traveling: Telehealth can provide care to patients living in rural areas or traveling to see their doctor in person. This can help ensure all patients have access to the care they need, regardless of location.
  • Using remote monitoring devices to track patients’ health data at home: Remote monitoring devices can be used to track patients’ blood pressure, glucose levels, and other health data at home. This data can then be transmitted to their doctor’s office, which can be reviewed by healthcare professionals and used to adjust their treatment plans as needed.

Overall, technology is playing a vital role in transforming PHM. By helping doctors and healthcare professionals to collect and analyze data, coordinate care, and engage patients, technology is enabling them to understand better and manage the health of their patient populations.


  • According to a 2023 survey by the American Medical Association, 83% of physicians use EHRs in their practices.
  • A 2022 study published in the Journal of the American Medical Association found that patients who used patient portals were more likely to receive preventive care and to have better chronic disease management.
  • A 2021 study published in Telemedicine and e-Health found that telehealth effectively delivers care for various medical conditions, including chronic diseases, mental health conditions, and acute illnesses.
  • A 2020 study published in the Journal of Medical Internet Research found that remote monitoring of patients with chronic diseases effectively reduced hospitalizations and improved health outcomes.

The Future of Population Health Management

Predicting the future of Population Health Management (PHM) isn’t like seeing a spaceship’s trajectory, but we can spot some distinct trends. Everything we’ve seen suggests this field will grow in importance, and technology will play a significant part.

In the coming years, you can expect a shift towards preventive care and personalized medicine. Rather than treating patients once they are ill, PHM will increasingly be about anticipating health issues and heading them off. You’ll see more use of genomics, pharmacogenomics, and various biomarkers for risk assessment and personalized treatment plans.

Artificial Intelligence (AI) will soon be a core component of PHM. AI algorithms can help in risk stratification, identifying patients who need intervention ahead of time. It can predict potential disease outbreaks or disease progression based on the patient’s health records. A 2019 report from Optum indicated up to 54% of healthcare executives have already implemented AI in their organizations, with PHM being a key area of focus.

Wearables and Internet of Things (IoT) devices in PHM will expand. These devices allow you to monitor patients’ health in real time, which means faster intervention. Juniper Research projected that by 2023, 5 million individuals will be remotely monitored by healthcare providers employing wearable technology.

Interoperability – the ability for different IT systems to communicate, exchange, and use patient data – is another trend. In the future, you can expect population health data to be leveraged more effectively due to seamless sharing across platforms.

Integrating social determinants of health (SDoH) into population health strategies is yet another promising trend. Evidence shows that SDoH – such as income level, education, and environmental factors – can account for up to 50% of health outcomes.


Population Health Management is a progressive step toward a healthier global community in the evolving healthcare landscape. As we delve deeper into technology’s promises, PHM will continue to advance while providing quality, value-based care. Equipped with trending tools like Artificial Intelligence, predictive analytics, and IoT devices, doctors, and healthcare professionals will more efficiently manage and improve the health outcomes of their population. Moreover, incorporating social determinants of health into this strategy promises to yield even more comprehensive results. As we all journey towards the future of healthcare, it’s clear that PHM will be at the vanguard of this expedition.

Published On: October 25th, 2023Categories: Healthcare Trends

About the Author: Mousa Kadaei

Moses is a writer and content creator passionate about the intersection of healthcare and technology. As a content manager at Ambula, a leading EMR software provider and healthcare technology solutions, Moses profoundly understands the industry and its evolving landscape.

Elevate your practice to the next level

Let us show you how to save 2 hours a day.