THE TRADITIONAL U.S. HEALTHCARE system was built for the 20th century: a reactive model focused only on treating individual illness.

But the future of health is proactive. Today, leading clinicians and health systems are deploying population health management (PHM) — a data-driven, applied discipline — to use sophisticated insights to personalize care and make it easier for people to stay healthy throughout their lives. PHM is reshaping the systems, environments and policies that influence health long before clinical markers signal trouble.

“We know how to prevent many diseases, including type 2 diabetes,” says Rosalind Franklin University’s President Emerita Wendy Rheault, PT, PhD, FASAHP, FNAP, DipACLM, who led the launch of RFU’s Population Health program in 2017. “PHM makes sure people are healthier before they ever enter the healthcare system. It recognizes that where you live, your income, housing, transportation and education often matter as much as any medical treatment.”

PHM looks at health holistically. It brings together public health, community resources and policy, and it connects naturally to lifestyle medicine and prevention, emphasizing the everyday factors that help people stay well. While reactive care focuses on treating diabetic crises, PHM emphasizes nutrition support, blood-sugar monitoring and care navigation to prevent complications. Instead of just treating asthma flare-ups in the emergency room, PHM works with families to assess housing conditions, air quality and school environments.

This marks a move away from volume-based care, which pays for each visit or procedure, toward value-based care, which rewards keeping people healthy and preventing avoidable crises. PHM is gaining real traction due to cost pressures, the rise of digital tools that help track and coordinate care, and a growing recognition of health inequities. Population-based research by Monideepa Becerra, DrPH, MPH, chair of RFU’s Department of Population Health and Administration, analyzes disparities and contextual factors affecting health across diverse communities. Her investigations have included food insecurity, asthma, hospital-acquired infections (HAIs) and a host of other health threats.

“National databases reveal the reality of what’s happening in the country,” Dr. Becerra says. “For instance, we’re seeing a consistent problem of not just food insecurity, but how that relates to disease management. When families struggle to afford food, they are more likely to delay or cut medication or rely on emergency care for chronic conditions. A multitude of researchers in population health have found similar patterns. It’s impossible to raise healthy children if food is a core problem.”

Population health research drove the American Academy of Pediatrics to recommend that pediatricians screen every family for food insecurity. Population health data has powered system-based interventions such as follow-up texts or calls to post-surgical patients from clinicians, ensuring there’s a continuum of care, as well as patient intake questionnaires that now include questions on mental health, alcohol and drug use, and access to firearms.

Data shows that the PHM approach improves patient health and well-being. According to the Centers for Disease Control and the Cleveland Clinic Journal of Medicine, PHM has demonstrably improved care coordination to achieve a 21% lower risk of 30-day hospital readmissions and an up to 54% reduction, through targeted programs, in emergency-room visits. It has also successfully managed infection control to lower the number of HAIs. That all adds up to significant cost savings, lower burdens of care and healthier people.

“We have to turn our communities to understand what people are actually dealing with. That Builds trust. Trust improves health and healthcare.”

Behind such improvements are policy changes that redefined accountability for community health. Rules instituted under the Affordable Care Act, which Dr. Becerra calls “population health coming to fruition,” mandate that nonprofit health systems work with their communities to understand their needs.

“Standard practice has been to tell patients, ‘You need to exercise 30 minutes a day, and eat five servings of fruits and vegetables,’” Dr. Becerra says. “The PHM mindset asks: Where are they going to go buy the food if there’s no real grocery stores? Where are they going to exercise if there’s no sidewalk or if there’s heavy air pollution? We have to turn to our communities to understand what people are actually dealing with. That builds trust. That improves health and health care.”

PHM changes the day-to-day work of clinicians and administrators. Not everyone needs to become an epidemiologist, but every health professional needs to collaborate across disciplines, use data to guide decisions, and think beyond the clinic.

“It takes a team to look at and really care for the health of a population,” Dr. Rheault says. “It takes clinicians, public health, insurers, quality experts, statisticians, data scientists and the patient at the center of the team. The patient needs to understand their condition and participate in their treatment decisions, so that the care they receive is specific to their needs, whether that’s transportation to appointments or living the last six months of their life enjoying quality time with their kids or grandkids.

“We’re really thinking about the whole patient and the life they’re living, not just their medical condition. It requires a willingness to see the patient as part of a broader story shaped by community forces.”

As PHM defines health care in the 21st century, health professions educators and learners need to understand not just clinical practice, but the broader systems, data and partnerships that shape health.

“We can’t deliver PHM without a workforce trained to think about systems,” says Dr. Becerra, who instills in her students the importance of the “teach-back” method in patient–provider communication: asking the person to explain information in their own words to be sure they truly understand it. Communication is essential for PHM, especially the ability to listen.

“If we’re not truly hearing our patients, our communities and our partners across disciplines, we can’t change systems,” Dr. Becerra says. “The same goes for analysis. Data only matters if it leads to meaningful action. We have to ask: Are we interpreting information in ways that drive real interventions? Are our policies actually improving health? PHM is about fixing the small broken gears so the whole system works better. That requires a commitment to change that actually matters.”

Taking        the    long view        on health

Renewed Optimism for PMH

By Dr. Lee Sacks, MD

THE IDEA BEHIND POPULATION HEALTH management (PHM) is simple: Invest in people early so fewer become sick later. But the health system we’ve built rewards intervention, not prevention. Population health asks us to take the long view, even though our financial, political and cultural structures are wired for the short term. It is a vision that moves faster than the institutions meant to carry it.

When I was a young family physician in the 1980s, Lutheran General Hospital and others in the Chicago region formed physician–hospital organizations. There were staff-model HMOs nearby, and we needed a way to remain competitive. In hindsight, what we were experimenting with was what we now call “value-based care”: a fixed amount of money to care for a defined group of people. The lesson came quickly. The best way to care for that population was to do things traditional insurance simply did not cover. Help a patient in a food desert access fresh produce. Support seniors who needed human connection as much as medication. Pay attention to environmental triggers. Prevent the problem before the problem arrives, and you reduce the cost of care.

The PHM model began to shift my thinking. It freed us from the constraints of classic insurance reimbursement and allowed us to focus on the social drivers of health. It changed the question behind every diagnostic test. Not “Can I order this?” but “Will this change what I do?” PHM demands thoughtfulness, not reflex.

“Population health has always been about that kind of steady, unglamorous, vigilance.”

During the past decade, there have been moments that renewed my optimism. The Affordable Care Act expanded coverage to millions and created the Center for Medicare and Medicaid Innovation, which has seeded countless value-based models. At Advocate, we joined one of the early Medicare Shared Savings programs. More than a decade later, that work has saved more than a billion dollars. But the more important story is the healthier communities behind those numbers: immunizations that prevented illness, screenings that caught cancers early enough to cure, care teams that reached out to patients who rarely walked through clinic doors. Population health has always been about that kind of steady, unglamorous vigilance.

Yet we are still swimming in the old current. Most of our system is fee-based, fragmented and complex by design. Interoperability — the seamless, secure exchange and use of patient data across different health systems — remains elusive. Each stakeholder protects their piece of the puzzle. Patients, too often, get lost in the maze.

The long view is where I remain convinced. Data has changed what we are capable of seeing. When we tracked outcomes across Chicago, we found that disparities could be narrowed, but only when we adapted our approach to fit the needs of our populations. Community health workers proved that trust and shared experience can outperform any pamphlet. Pharmacists managing patients in need of anticoagulation therapy outperformed the physicians themselves. The data showed us what was true before we were ready to believe it.

Population health management has never been about perfection. It is about progress that compounds slowly. It is the belief that health is something we build together, long before anyone steps into an exam room.