Population Health and Diabetes: A Public Health Concern


The aim of this paper is to discuss the definition of population health and healthcare systems approaches to improve the quality of care for patients with diabetes. To date, value-based care is an emerging solution for people to get the appropriate care needed at an affordable rate. Integrated delivery systems as such as patient-centered medical homes and accountable care organizations are at the forefront of managing chronic diseases. The intent of all of these programs is to pay for quality and ensure coordination of care.  There are risk stratification tools and care coordination tools that help the Care Management Team coordinate care and intervene for higher risk patients. There are also patient engagement tools that can be leveraged such as the Patient Health Records, chatbots, and campaign tools.  In addition, to improve the health of populations utilization of decision support tools, physician feedback, primary care teams with health professionals from various disciplines, electronic health records and disease registries are all used identify patients that are at risk. There is a chance for healthcare experts, public health specialists, and policymakers to collaborate in efforts to improve diabetes care.


The term population health was introduced in 2003 by David Kindig and Greg Stoddart they defined it as “the health outcome of a group of individuals, including the distribution of such outcomes within the group” (“What is Population Health? | Population Health Training in Place Program (PH-TIPP) | CDC”, 2018). Population health is a field of study that focuses on the health status and healthcare utilization of a defined group of people. The main goal is to improve health outcomes of an entire group while reducing health disparities and inequalities. One might consider people with diabetes, people with diabetes are often included in health programs and are a focus of many population health initiatives. To date, population health programs have been set up by health care facilities, and insurers to reduce costs and effectively manage the chronic disease of diabetes (Ryan, 2018).

Within the United States, diabetes is one of the leading causes of death. To successfully prevent complications that may develop over time persistent medical management and patient self-management is required. To ensure patients are receiving the best care new care delivery and payment models are being implemented. In fact, there has been a lack of care for the total care of patients, to include the outcomes of their treatment and the effectiveness with which health resources are used.

Primarily health care services are paid on a fee for services basis which has contributed to the lack of care from health care providers. An emerging solution as such as value-based care is reducing health care costs, clinical inefficiency and duplication of services. This is making it easier for patients to get the appropriate care they need. The federal government is continuously implementing various payment models to achieve the best health outcomes at an affordable cost, in addition to commercial insurers are partnering with health care providers that also seek to reward value rather than volume of services. The Patient-Centered Medical Home and the Accountable Care Organization are two popular models of delivery system reform.  Providers must be able to forecast when a patient is most likely to become a high-risk patient. With the assistance of data analytics which is an integral part of population health management, the quality of care and a patient’s health can be effectively monitored. The gathered data can then be sent to payers and other outside entities.   Care management aims to manage the overall health of a population of high risked patients. Another goal is to ensure a patient receives care at the right time, and place.   In addition, care managers utilize care management systems to facilitate transitions of care by using automated systems to effectively manage high-risk patients.   For example, the risk of progression from glucose intolerance to diabetes mellitus can be influenced by diet and exercise. Individuals within this “rising risk” population are at different stages of readiness to change and consequently at different stages of modifiable risk. Having this insight enables providers to offer services at the appropriate level and time (AHRQ, 2015)

Population Health Programs: Value-Based Payment Programs

Within the United States, it is accounted that diabetes is one of the United States rapidly growing economic burdens.  Currently, diabetes is at a $245 billion annual cost. The cost is solely related to how well the disease is managed. Diabetes is often poorly managed and treatment is complex because it requires drug therapy and behavioral modifications. Consistent poor diabetes management typically results in additional complications. Those additional complications lead to increased inpatient stays, outpatient visits, and additional medical costs.  To reduce high costs, insurance providers have begun to penetrate the health care market with new risk-adjusted incentive payment models. They require physicians to meet and report quality measures for patients with chronic diseases, including diabetes.    The payment requirement has penetrated accountable care organizations that are comprised of primary care entities and individual providers (Hodorowicz, 2016).

Accountable Care Organizations consists of groups of doctors, hospitals and other health care providers that voluntarily come together to provide quality care to patients. They provide coordinated help and care to patients with a chronic illness. Their goal is to ensure that the right care at the right time is provided to avoid duplication in services and prevent medical errors. Accountable Care Organizations aren’t solely just responsible for the quality of care that a patient receives but the overall cost of the care the patient receives. To ensure that Accountable Care Organizations remain in compliance they are supervised by government agencies to ensure that the treatment plans are being properly coordinated and high quality of care is being provided. In addition, Accountable Care Organizations are required to file governmental documentation showing how much money they were able to save the Medicare system. Accountable Care Organizations receive incentives of shared savings bonuses equal to a percentage of the money they saved (“Accountable Care Organizations (ACOs) – Centers for Medicare & Medicaid Services”, 2018).

When mentioning Accountable Care Organizations one might consider the Medicare Shared Savings Program.  The Medicare Shared Savings Program is a payment model whereas healthcare providers and hospitals receive an incentive for achieving better health. This in terms also leads to better population health and lowers healthcare costs. In order for a health care provider to be a part of the Medicare Shared Savings Program, the provider must be a part of the Accountable Care Organization. The Medicare Shared Savings Program requires Accountable Care Organizations to promote evidence-based medicine, engage beneficiaries, report internally on quality and cost metrics, and provide coordinated care across and among primary care physicians, specialists, and acute and post-acute providers. To date, The Medicare Shared Savings Program is quickly growing and being adopted by healthcare providers because of the awareness of the revenue-generating opportunities in Accountable Care Organizations as well as avoidance of penalties under the Merit-based Incentive Payment System (“What is the Medicare Shared Savings Program (MSSP)? | Continuum”, n.d.). Other Accountable Care Organization models would The Next Generation Model offers financial arrangements closely related to the Medicare Shared Savings Program but with the difference of higher levels of risk and rewards. In addition, the Next Generation Model offers telehealth, 3-day skilled nursing facility, post-discharge home visit waivers with the option to participate in populated based payments. (“ACO’S & the Medicare Shared Savings Program (MSSP): How They Strategize Together Towards Value”, n.d.).

Accountable Care Organizations do not only focus on an individual’s health but also seek to improve the health of the entire population for whom they are accountable for.  This is better known as population health management. To date, many physicians haven’t adopted prevention-oriented population health in their current model of healthcare delivery. Most physicians have only treated patients with acute problems. The physician is then consumed with managing the patient’s acute problem rather than addressing preventive chronic care needs.

Accountable Care Organizations are utilizing risk stratifications for better population health management. Risk stratification is the process of assigning a risk status to a patient and using the obtained health information to provide direct care and improve the patients’ overall health. Risk stratification is practiced by top performing population health-focused organizations. A patient’s assigned risk category is determined at the first point of contact. The patients are separated into the categories of high, medium and low-risk groups. To further assist with the categorizing of patients, the following outline is being used by healthcare facilities: STEP 1 Compile a list of health center patients STEP 2 Sort patients by condition STEP 3 Stratify patients to segment the population into target groups based on the number of conditions per patient STEP 4 Design care models and target interventions for each risk group (“Value Transformation Framework Action Guide”, 2017).

Risk Scores: Hierarchical Condition Categories

Hierarchical Condition Categories were created in 1997 by the Centers for Medicare and Medicaid Services. Hierarchical Condition Categories are risk adjustment models that utilize patients diagnoses and demographic information to foresee medical costs.   The Hierarchical Condition Category coding identifies patients that have been diagnosed with a chronic health issue. The diagnoses are classified using the International Classification of Diseases-10. The International Classification of Diseases-10 is matched with the 79 Hierarchical Condition Category codes kept in the Centers for Medicare and Medicaid Services risk adjustment model. In addition to the coding for the diagnoses, other factors as such as age, and gender are also used to give members a risk factor score, the score is used to help determine Medicare reimbursements. Recently, the Centers for Medicare and Medicaid Services began scoring physicians and practices on their performance in the four areas of quality, cost, improvement activities and advancing care information (“Understanding Hierarchical Condition Categories (HCC)”, 2018).

To keep communities healthy, it requires assessing, monitoring and prioritizing risk factors that impact health outcomes. Public health has the ability to control its proficiency in population health metrics to help Accountable Care Organizations understand the epidemiology of patient population. Accountable Care Organizations managing high-risk patients leads to the lowering of Medicare spending, more effective management and optimized use of health care services, improved care management and preventative screenings for chronic illnesses. Understanding what works and what does not is key to ensuring reimbursements, controlling costs and most importantly, providing the best care for patients (Glaser, 2012).

Use of Technology and Analytics

To date, health care facilities are implementing strategies to bring awareness to patients that have a chronic disease, specifically diabetes.  Healthcare facilities are educating patients about their condition and including them in treatment decisions. Eating healthy and physical activities are of importance when it comes to managing diabetes. To remain productive, diabetes self-management skills and behavior change are essential to effectively gaining glycemic control. Self-management would include glucose monitoring, healthy eating, and daily physical activities.  In addition, physicians are assigning patients wellness coaches and conducting motivational interviewing to lead to behavioral changes in diet and exercise and increased self-management. Physicians conducting the motivational interviews encourage patients to reach their health goals. This is done by reviewing the patients previous and current A1C levels and other health records. Once the A1C level is reviewed the physician helps the patient set a goal to meet and monitor their progress.  Other organizations are utilizing motivational interviewing to inform patients about diabetic medications, ways to get reminders to fill their prescriptions and given detailed information about taking the medication properly.  This is an indication that electronic health records are a useful tool in managing patient care. The care team is able to quickly identify tests and routine preventive care that is needed. Studies have shown that patients are becoming eager to use technology for disease management. Telehealth is also being used to capture and monitor data from patients at home. Examples include monitoring patient blood sugar levels through glucometers attached to cell phones.  There are various apps designed for those with diabetes and physicians that treat diabetes. Many patients are using connected health. Connected health is a technology-enabled, integrated care delivery that allows for remote communication, diagnosis, treatment, and monitoring. Its goal is to provide improve digital connectivity between providers and patients to allow individuals to access the care they need anytime and anywhere (Copeland, 2018). Another benefit to the Connected Health patients will l diabetes will be to track their numbers, manage risk factors and utilize the reminder feature. However, before the Connected Health can be fully adopted the barrier of payment has hindered its full acceptance. This is because physicians that are still within the fee for service model are unable to bill the patient unless the patient visits the office, which means taking full advantage of telehealth may be a challenge. Physicians are also utilizing social media to assist patients with effectively managing their diabetes. Social media sites as such as Facebook, Twitter, and YouTube allow providers to communicate with patients and share information about new clinical offerings, links to self-management tools and invitations to chronic care management programs. Also, automated messaging tools are utilized to help patients schedule necessary appointments, fill prescriptions and comply with discharge orders. This is done via texted-mail or phone.


In conclusion, Accountable Care Organizations must continuously take steps to work collaboratively with public health agencies, communities and healthcare organizations to improve the health of the population.  As the health care industry transitions, physicians must consider what new relationships, processes, and information technology assets and skills will be needed to succeed.  Most importantly, the success of Accountable Care Organizations will stem from health care providers engaging patients in managing their care and overall health.