A Blueprint for
In order to deliver true value, payers must take a more expansive approach that builds on the foundation of population health management and expands beyond typical approaches to delivering care. In this section, we’ll provide a blueprint for doing just that using the advanced primary care (APC) model.
The Population Health Management Foundation
In any given population, about 75% of people are considered generally healthy (i.e., they haven’t generated a claim). The vast majority of costs are driven by the other 25% of the population, which is broken into two segments: polychronic (the costliest 5% of the population) and at-risk (the 20% that can benefit most from primary care). A data-driven population health management approach will prioritize the at-risk population segment while engaging the largest part of the population to reveal hidden at-risk patients.
Segment 1: Polychronic — 5% of the population, 45% of the cost
The small percentage of the population that is polychronic (multiple chronic conditions) accounts for 45% of the costs for a typical population. These costs come from high ER visits, numerous extended hospital visits, complex care needs, and nonadherence to care recommended by providers.
Patients in this segment are dealing with serious health issues like cancer, congestive heart failure, and more. It is highly unlikely that a patient in this segment will move down to a lower segment and the focus should be on supporting them with the absolute best primary care possible (including coordination for specialty care).
Segment 2: At-risk — 20% of the population, 35% of the cost
This segment is dealing with underlying conditions and drives 35% of the cost for a typical population. Primary care drivers in this segment are infections, complications, and rehospitalizations.
At-risk patients are the sweet spot for APC because this is where rigorous primary care can have the most impact by treating the underlying conditions, empowering patients to make positive behavior changes, and moving them back into the health segment of the population.
Segment 3: Apparently healthy — 75% of the population, 20% of the cost
The final segment of the population are those people who have not yet generated a major claim. This segment makes up the vast majority of the population but only incurs a fifth of the cost.
Within this segment are people who are actually part of segment 2. They may even feel unhealthy but have not pursued care because they are on an HDHP (high deductible health plan) that makes seeking care expensive. This population needs high-quality preventive care to identify those who belong in segment 2 so that they can receive care early before becoming part of segment 1.