Population Health Management最新文献

{"title":"Short-Term Gains, Enduring Potential: An Integrated SDOH-Focused Care Model Delivers Cost Savings and Patient-Reported Benefits.","authors":"Sasha Ruben Sioni, Lesley Manson, Nicholas Arledge","doi":"10.1089/pop.2024.0245","DOIUrl":"10.1089/pop.2024.0245","url":null,"abstract":"<p><p>High-need, high-cost (HNHC) adults require comprehensive strategies that address both clinical and social determinants of health (SDOH). This retrospective, propensity score-matched study (<i>n</i> = 526) evaluated a care model integrating monthly SDOH screenings, medication oversight, and real-time admission-discharge-transfer alerts in four urban primary care clinics. Compared to usual care, the intervention significantly reduced acute utilization within 60 days: emergency department (ED) visits decreased by 0.17 (<i>P</i> < 0.001) and hospital admissions declined by 0.12 (<i>P</i> < 0.001). Gross per-participant costs fell from $6,019 to $2,422 (a $3,597 reduction); after accounting for intervention expenses, net savings reached $3,222 (<i>P</i> < 0.001), yielding an estimated 6.9:1 return on investment. Patient-reported outcomes also demonstrated significant gains: EQ-5D-5L scores increased by 0.082 (<i>P</i> < 0.001) in the intervention cohort, exceeding the threshold for clinically meaningful change, while Net Promoter Scores rose by 8.8 points (<i>P</i> < 0.001). Subgroup analyses revealed slightly smaller quality-of-life gains among non-White cohorts, highlighting the need for culturally tailored approaches to advance equity. These findings align with prior Population Health Management research showing that integrated care models can reduce costs and enhance patient satisfaction. Overall, this multifaceted model effectively curbs avoidable ED visits and admissions, generates short-term cost savings, and boosts patient satisfaction-key outcomes under value-based care contracts. Future research should investigate longer-term outcomes and refine equity-focused strategies to ensure sustained and inclusive benefits.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"161-172"},"PeriodicalIF":1.8,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143731500","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Leading with Love: An Evidence-Informed Framework for Leading Health System Transformation.","authors":"Patrick Runnels, Peter Pronovost","doi":"10.1089/pop.2025.0055","DOIUrl":"https://doi.org/10.1089/pop.2025.0055","url":null,"abstract":"","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-05-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144181208","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Essential Workforce and Competencies for Effective Population Health Management: A Scoping Review.","authors":"Munirah K AlSaqabi, Majed Naif AlOsaimi, Nawaf H Albali, Rufaidah Dabbagh","doi":"10.1089/pop.2025.0043","DOIUrl":"https://doi.org/10.1089/pop.2025.0043","url":null,"abstract":"<p><p>The increasing demand for skilled professionals in population health management (PHM) has highlighted the need for a clear understanding of workforce requirements and competencies. This scoping review aims to address this gap by identifying key roles, responsibilities, and competencies necessary for effective PHM implementation. The review was conducted using PubMed and Google Scholar. Articles focusing on PHM workforce requirements, job titles, roles, responsibilities, and competencies were included. Data were extracted and synthesized to address the research questions. A total of 30 records were reviewed, revealing a diverse range of PHM leadership roles, the importance of interdisciplinary teams, and the need for strategic workforce planning. Five core competency domains were identified: Population Health Knowledge and Expertise, Leadership, Data Literacy and Analytics, Business and Operations, and InterpersonalCommunication Skills. Effective PHM implementation requires a diverse, skilled workforce with clearly defined roles and competencies. These findings provide a framework for workforce development and highlight the need for standardized competency-based training in PHM.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-05-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144143397","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Factors Associated with Health Care Costs in Older Adults with Type 2 Diabetes: Insights for Value-Based Payment Models.","authors":"Winston Liaw, Omolola E Adepoju, Jiangtao Luo, Bill Glasheen, Ben King, Ioannis Kakadiaris, Todd Prewitt, Pete Womack, Jess Dobbins, Mohammad Madani, Rajit Shah, Carlos G Fuentes, LeChauncy Woodard","doi":"10.1089/pop.2025.0054","DOIUrl":"https://doi.org/10.1089/pop.2025.0054","url":null,"abstract":"<p><p>Diabetes accounts for 1 in 4 health care dollars spent. Succeeding in value-based payment models depends on identifying those at risk for high costs and providing them with appropriate treatment. The objective was to determine factors associated with type 2 diabetes mellitus costs. In this cohort study, this study used longitudinal data from a national insurer between 2016 and 2020. The authors included individuals aged 65 and older with type 2 diabetes mellitus with at least 12 months of continuous enrollment in Medicare Advantage. Exclusions included those who died during the study period or had incomplete data. Factors included study year, demographics (age, sex, race/ethnicity, language, dual eligibility, rurality), and diabetes complications (Diabetes Complications Severity Index). The outcomes of interest were medical and prescription costs. The study included 49,843 individuals. Diabetes complications (coefficient = $3582.11, <i>P</i> < 0.001), year (coefficient = $1003.22, <i>P</i> < 0.001, 2020 vs. 2016), sex (coefficient = $238.35, <i>P</i> < 0.001, female vs. male), dual eligibility (coefficient = $618.61, <i>P</i> < 0.001, yes vs. no), and rurality (coefficient = $1242.38, <i>P</i> < 0.001, yes vs. no) were associated with higher medical costs. Age (coefficient = $-2851.67, <i>P</i> < 0.001), race/ethnicity (coefficient = $-1458.03, <i>P</i> < 0.001, Black vs. White; coefficient = $-1679.81, <i>P</i> < 0.001, Hispanic vs. White), and language (coefficient = $-2523.29, <i>P</i> < 0.001, Spanish vs. English) were associated with lower medical costs. Individuals who had complications, were female, were dually eligible, and lived in rural communities had higher medical costs. Black, Hispanic, and Spanish-speaking individuals had lower medical costs, mirroring well-known disparities. Policy makers and health care organizations can use these data to more efficiently deliver care to some while ensuring adequate access for others.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-05-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144120331","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Transforming Population Health in Saudi Arabia: Aligning Strategies with Vision 2030 for a Healthier Future.","authors":"Assim M AlAbdulKader, Mohammed Jabr","doi":"10.1089/pop.2025.0047","DOIUrl":"https://doi.org/10.1089/pop.2025.0047","url":null,"abstract":"","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-05-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143994828","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Enhancing Machine Learning Explainability of Disaster Preparedness Models from the FEMA National Household Survey to Inform Tailored Population Health Interventions.","authors":"Taryn Amberson, Wenhui Zhang, Samuel E Sondheim, Wanda Spurlock, Jessica Castner","doi":"10.1089/pop.2024.0243","DOIUrl":"https://doi.org/10.1089/pop.2024.0243","url":null,"abstract":"<p><p>Devastating mortality, morbidity, economic, and quality of life impacts have resulted from disasters in the United States. This study aimed to validate a preexisting machine learning (ML) model of household disaster preparedness. Data from 2021 to 23 Federal Emergency Management Agency's National Household Surveys (<i>n</i> = 21,294) were harmonized. Importance features from the preexisting random forest ML model were transferred and tested in multiple linear and logistic regression models with updated datasets. Multiple regression models explained 42%-53% of the variance in household disaster preparedness. Features that improved the odds of overall disaster preparedness included detailed evacuation plans (odds ratios [OR] = 3.5-5.5), detailed shelter plans (OR = 4.3-11.0), having flood insurance (OR = 1.5-2.0), and higher educational attainment (OR = 1.1). Having no specified source of disaster information lowered preparedness odds (OR = 0.11-0.53). When stratified further by older adults with Black racial identities (<i>n</i> = 350), television as a main source of disaster-related information demonstrated associations with increased preparedness odds (OR = 2.2). These results validate the importance of detailed evacuation and shelter planning and the need to consider flood insurance subsidies in population health management to prepare for disasters. Tailored preparedness education for older adults with low educational attainment and targeted television media for subpopulation disaster-related information are indicated. By demonstrating a feasible use case to import ML model findings for regression testing in new datasets, this process promises to enhance population management health equity for those in sites that do not yet utilize local ML.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":""},"PeriodicalIF":1.8,"publicationDate":"2025-04-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143796215","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Assessing the Relationship Between Behavioral Health Integration and Alcohol-Related Treatment Among Patients with Medicaid.","authors":"Lina Tieu, Nadereh Pourat, Elizabeth Bromley, Rajat Simhan, Weihao Zhou, Xiao Chen, Beth Glenn, Roshan Bastani","doi":"10.1089/pop.2024.0170","DOIUrl":"10.1089/pop.2024.0170","url":null,"abstract":"<p><p>Behavioral health integration (BHI) is increasingly implemented to expand capacity to address behavioral health conditions within primary care. Survey and claims data from the evaluation of the Public Hospital Redesign and Incentives in Medi-Cal program were used to examine the relationship between BHI and alcohol-related outcomes among Medicaid patients within 17 public hospitals in California. Key informant survey data measured hospital-level BHI at 3 levels (overall composite, infrastructure, and process domains, 10 themes). Multilevel logistic regression models estimated the relationship between BHI and outcomes indicating receipt of appropriate alcohol-related care (any primary care visit, any detoxification, timely initiation, timely engagement) and acute care (any emergency department [ED] visit or hospitalization, classified as alcohol-related or all-cause) in the year following an alcohol-related index encounter. Of 6196 patients, some had an alcohol-related primary care visit (33%), detoxification (16%), timely initiation (14%), or engagement in treatment (7%). ED visits resulting in discharge were more common (40% alcohol-related, 64% all-cause) than hospitalizations (15% alcohol-related, 26% all-cause). Controlling for patient-level characteristics, no significant relationships between overall BHI and these outcomes were observed. However, greater BHI infrastructure was associated with alcohol-related (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.14-3.05) and all-cause hospitalization (OR 1.25, 95% CI 1.01-1.55). Associations emerged between BHI themes (eg, related to support of providers) and greater likelihood of alcohol-related detoxification, primary care visit, timely initiation, and acute care utilization. Findings suggest that implementing specific BHI components may improve receipt of alcohol-related treatment, and warrant future research into these relationships.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"88-97"},"PeriodicalIF":1.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142807776","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Transitional Care for Older Adults: Demonstration of the Role of a Partnership Payvider.","authors":"Alexis Kurek, Carlos Weiss, Kennedy M Boone-Sautter, Aiesha Ahmed","doi":"10.1089/pop.2024.0189","DOIUrl":"10.1089/pop.2024.0189","url":null,"abstract":"<p><p>A payvider organization provides both payer and provider services and has been linked to administrative and patient cost reduction by improving right-sized utilization of patient care services. A geriatric-focused transitional program was offered to patients covered under a value-based care risk contract formed by the payvider relationship of an integrated health system. This article describes a prospective study comparing utilization and cost metrics of patients enrolled in the transitional care program with the goal of analyzing utilization of services to better understand patient behavior patterns and care needs after hospital admission and consecutive enrollment in the program. Patients enrolled in the program incurred lower costs in all categories but home health care than the reference population. The cost avoidance achieved during the study period was estimated to be over $1.1 million. Individuals participating in the program had similar emergency department visit rates during the 90- and 180-days following the hospital as the reference population but had significantly lower inpatient readmissions (7.8% vs. 15.4%) even with a higher average readmission risk score (66.8 vs. 65.5). The implementation of the transitional care program led to reduced costs and more efficient utilization of services than those not enrolled in the program. The payvider relationship allows systems to think proactively about new initiatives and programs that will better serve their communities, especially when identifying groups with high projected costs and service utilization. Patients benefit from the assurance that the services they are receiving are covered by their insurer and their trusted organization.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"98-104"},"PeriodicalIF":1.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142886136","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hospital Safety-Net Burden is Associated with Perioperative Outcomes in Primary Total Hip Arthroplasty: A Multistate Retrospective Analysis, 2015-2020.","authors":"Margaret Darko, Virginia E Tangel, Abbey Gilman, Maressa Cumbermack, Deirdre C Kelleher, Tiffany Tedore, Robert S White","doi":"10.1089/pop.2024.0194","DOIUrl":"10.1089/pop.2024.0194","url":null,"abstract":"<p><p>Total hip arthroplasty (THA) is a widely performed surgical procedure in the United States, but disparities in THA outcomes related to hospital-level factors, such as safety-net burden, are underexplored. This study expands on previous research by analyzing multicenter, multistate data from 2015 to 2020 to investigate the impact of hospital safety-net burden-defined as the proportion of services billed to Medicaid and uninsured patients-on THA outcomes. This study is a retrospective analysis using data from the State Inpatient Databases for Florida, Kentucky, Maryland, New York, Washington, New Jersey, and North Carolina. The study cohort included 543,814 inpatient primary THA admissions, with patient demographics, comorbidities, and hospital characteristics analyzed across 3 categories of hospital safety-net burden (low, medium, and high). Generalized linear mixed models assessed the association between safety-net burden and in-hospital mortality and postoperative complications, whereas multilevel negative binomial regression evaluated the impact on hospital length of stay. The study findings indicate that patients undergoing THA at hospitals with high safety-net burden had significantly higher odds of in-hospital mortality (adjusted odds ratio [aOR]: 1.20, 95% confidence interval [CI]: 1.02-1.42), postoperative complications (aOR 1.33, 95% CI 1.20-1.48), and longer hospital stays (adjusted incidence rate ratio 1.15, 95% CI 1.10-1.21) compared with those at low-burden hospitals. These results suggest that hospitals with higher safety-net burden, often serving more vulnerable populations, may have suboptimal perioperative processes and protocols, leading to poorer outcomes. The study underscores the need for targeted interventions to improve THA outcomes in these hospitals.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"57-70"},"PeriodicalIF":1.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143010389","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Profiling Social Needs Activities in Publicly Traded Medicare Advantage Organizations.","authors":"Khyathi Gadag, Fred Ullrich, Keith J Mueller","doi":"10.1089/pop.2024.0045","DOIUrl":"10.1089/pop.2024.0045","url":null,"abstract":"<p><p>The objective was to examine Medical Advantage (MA) organizations' commitment toward addressing social determinants of health (SDOH) through their health-related social benefit offerings, and the perceived impact of providing supplemental benefits associated with SDOH in their plans. Public reporting documents were reviewed from six of the largest MA firms: Humana, UnitedHealthcare, Cigna, Elevance Health, CVS Health, and Centene. Public reports were obtained from each company's website (eg, from the \"Investor Relations\" page). Quarterly reports for Q1 2023, annual reports for 2022, and proxy statements for 2023 for all companies were examined. Content analysis of the public reports was conducted under three constructs: (1) Growth of MA in the company, (2) SDOH-related activities in the company, and (3) SDOH-related activities in the MA plans of the company. Each of the three constructs was further analyzed for recurring themes and elements. The findings from content analysis suggests that plans are providing tailored benefits that may address the social needs of vulnerable and underserved populations. Companies that offered supplemental benefits and value-based arrangements that addressed social needs reported beneficiary clinical outcomes resulting in cost savings and increased revenue. Health insurance companies identify MA as a significant growth opportunity and a strategically important market for overall membership and revenue growth. Moreover, companies providing innovative social benefits through their MA plans reported witnessing increased value propositions by underserved and vulnerable populations, leading to increased revenue and cost containment.</p>","PeriodicalId":20396,"journal":{"name":"Population Health Management","volume":" ","pages":"81-87"},"PeriodicalIF":1.8,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142073700","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}