populations of colorfully illustrated people, arranged as upward arrows on white background, representing population health definition

The Jefferson College of Population Health (JCPH) celebrated its 10th anniversary last week – Congratulations!! That means that the concept of Population Health is now well established, not the novelty and the experiment that it was a decade ago.

But, in my travels and meetings with healthcare providers and health IT firms in the Pop Health space, I notice that there’s a lot of variation in what people mean by the term Population Health – and this variation results in fuzzy projects, unclear deliverables, confusing metrics – all of which can lead to poorly focused goals. JCPH 1 – the academic organization laying the groundwork for Population Health – gives this definition (shortened by me): “A system that creates conditions to promote health, improve outcomes and prevent adverse events.” (You can view the full JCPH Population Health definition here.) It then lists the following key elements:

  • Healthcare delivery, focused on wellness and prevention, to a specific population
  • Developing policies to address socio-economic factors that impact a population’s health
  • Using data analysis to design new models of health-care delivery that stress coordination and ease of access
I encourage and advocate for an even tighter, narrower definition – but in line with the JCPH framework…

Population Health is…

  • A model for Healthcare Delivery, focused on a defined population (enrollees, patients in your practice, patients in a geographic area…)
  • …supported by a model for Reimbursement, aligning the incentives with the Care Delivery model to maximize health and minimize cost and utilization. This Reimbursement model often will shift financial risk from the payer to the provider…
  • …supported by a Data Infrastructure, necessary to manage, target and track Care Delivery and to optimize Reimbursement.
To me, that’s Population Health, and that’s also Value-Based Care – these two go hand-in-hand. People often confuse Population Health with Public Health, and I admit that it’s a fine line and a grey zone. Many books and papers with “Population Health” in the title end up describing Public Health. Public Health is an activity, mostly by government (federal, state or local) to study, analyze, and track the health of a population and turn the analysis into policy initiatives. It’s not a payment or reimbursement model, and it’s not a care-delivery model. But Population Health often depends and relies on Public Health findings.

And one more way to say the same thing…

Under previous Fee-For-Service reimbursement, the care-delivery model was: whoever comes to my practice, that’s who I see and that’s to whom I deliver care. In the new and current Population Health care-delivery model, a practice delivers care to a group of patients whether they make an appointment or not, pro-actively monitoring needs and managing wellness and healthcare. This requires a data system to guide it. And it requires the Reimbursement Model to encourage the population-based incentives.

Adopting a Population-Health approach requires an alignment of financial and clinical incentives, and the underpinning of data which we just mentioned. I refer to the excellent resources at the Health Care Payment Learning and Action Network to help guide this transition – and I’ll come back to that in a future post.

Looking forward to your thoughts and reactions – thank you!

[1] I am Adjunct Faculty at the Jefferson College of Population Health, teaching Health Informatics and Population Health Analytics.


  • Avatar michael kobernick says:

    Harm,
    I would add something to “defined population (enrollees, patients in your practice, patients in a geographic area…)” that calls out the importance of understanding the social determinants of health influencing that individual within the defined population. We can use our data infrastructure to inform us as well. Michael

    • Avatar Harm Scherpbier says:

      Absolutely agree, Michael. Please see our newly posted October 2018 blog for more on social determinants—we review a Health Affairs paper suggesting ways to improve them, not just measure them.

  • Avatar Sara Turner says:

    I liked your article about the definition of Populstion Health.
    Looking forward to more of your insight.
    Sara T. Turner, RN,MSN,PHN

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