The need for population health management (PHM) in this country has never been greater. Medical advances have improved Americans' longevity, but longer lives are not necessarily healthier lives. Nearly one-half of Americans report at least one lifestyle-related chronic disease (Partnership to Fight Chronic Disease, 2009), and this group accounts for 84% of all healthcare spending (Anderson, 2010). Despite this level of spending, clinical outcomes for this population are poor. The prevalence of lifestyle-related chronic disease is steadily increasing, with the greatest increases occurring in younger individuals (Ford, Croft, Posner, Goodman, & Giles, 2013). As the population ages, the need for complex care coordination and a system to support it will increase. The current system, designed for episodic treatment of acute illness, is incapable of delivering high-value healthcare that meets the needs of the American public (Institute of Medicine, 2001).
Several interrelated concepts contribute to high-value healthcare. Value is enhanced by improving quality—that is, outcomes, safety, and service/patient experience—relative to costs (Smoldt & Cortese, 2007; Porter & Teisberg, 2006). Outcomes are improved with PHM, which includes care coordination, prevention, health and wellness education, and lifestyle changes (Nash, 2012). Service quality and the patient experience are improved with a comprehensive, data-driven approach (Kennedy, Caselli, & Berry, 2011), an emphasis on physician communication (Kennedy, Fasolino, & Gullen, 2014), and promotion of a culture of accountability (Kennedy, Didehban, & Fasolino, 2014). Berwick, Nolen, and Whittington (2008) assert that the Triple Aim goals—improve the patient experience and population health while reducing per capita costs—are interrelated and recommend a broad approach when implementing Affordable Care Act initiatives. Our experience supports this assertion.