Identifying Health Equity Gaps with Population Health Management

We live in remarkable times. Medical breakthroughs occur almost daily. Our knowledge of how to lead long, healthy lives is greater than at any time in history. But significant numbers of people are still getting sick, and gaps in health equity still exist.

Both the problem and the solution start with the question, “Why?” 

Doing a Deep Dive

To start, let’s define the term “health equity.”  Healthy People 2030, an initiative managed by the HHS Office of Disease Prevention and Health Promotion, defines health equity as “the attainment of the highest level of health for all people.” A gap in health equity, then, is an instance when health outcomes are influenced by socioeconomic status, race, ethnicity or some other factor.

Gaps in health equity can only be resolved by questioning the status quo. For instance, a significant number of people with diabetes are not managing the disease well. Why? Perhaps the data shows they are not taking their insulin. Why? It turns out they haven’t refilled their prescriptions. Why? They can’t afford them.

Drilling down into the data will eventually answer the final “why.” Only then can we begin to find answers to “what” and “how” to close specific gaps in health equity. In this instance, the answer might be to connect those in need with community health centers or pharmaceutical assistance programs. The right answer will always depend on the specific population and their unique needs.

Establishing Priorities

The requirements for achieving health equity, according to Healthy People, are to value everyone equally, address avoidable inequalities and historical and contemporary injustices, and eliminate disparities in health and healthcare.

That’s a lot to unpack. And it also highlights the complexity of the issue and the many, varied factors that must be addressed. Look at gaps in health equity from a health perspective.  View them from a social perspective. And, of course, there’s no ignoring the economic perspective as well. Simply put, health inequities are costly.

Medicaid — with its directive to provide health coverage to people with low incomes — has an opportunity to tackle this problem. To that end, it receives massive funding and has become one of the largest payers for healthcare in the United States. So, it’s understandable when state Medicaid programs look at current outcomes and think, “Why are we paying so much money when we still see populations struggling?”

The federal government has also redoubled its efforts to improve Medicaid. The Centers for Medicare and Medicaid Services (CMS) is putting pressure on states to both control costs and improve outcomes. States are in turn setting quality standards for their managed care organizations (MCOs). Identifying and closing gaps in health equity is now a shared goal between states and MCOs.

But where do states even start? Using current resources, how can they make the biggest impact? The key to identifying priorities is to maximize the integration and insightfulness of data through the use of population health management (PHM).

Basing Interventions on Evidence

PHM is a proactive approach to healthcare that improves health outcomes of a defined population or patient group by addressing their risk factors and health needs. To do this, PHM considers the wide-ranging factors influencing a person’s wellbeing, including social determinants of health — the conditions in which people live, learn, work and play.

PHM is a strategy built firmly on a foundation of data and can help states highlight those areas needing improvement. It can also help states target their interventions — interventions that are now based on evidence.

Using data analytics, states can determine which subpopulations to work with first. Perhaps a state wants to improve a particular health metric and has implemented an educational campaign. But despite its efforts, the health initiatives aren’t taking hold in certain groups. Why? Drilling into its data, the state might find that its diverse population speaks a diversity of languages. The “why” is not a resistance to educational outreach; it’s actually a language barrier. Now, by making resources available in more languages, the state should see better health literacy, which will lead to better health outcomes.

Painting a Picture

A robust PHM program requires comprehensive data. States need to maximize their own data, but it's equally important to ingest data from additional, varied sources. States and MCOs must find efficient ways to share information. Publicly available data — particularly data on social determinants of health — must also be integrated.

Too often, today’s data is locked away in separate systems with separate databases. But when organizations collaborate and break down the silos, a more holistic view of a population's health begins to emerge. And when this combined data is made easily accessible, care management teams can better prepare for the future and ensure people receive continuous care as they move between counties, encounter new healthcare challenges or transition through life stages. 

Partnering for Success

For PHM to truly work, myriad data sources and the systems in which they reside need integration. States can tackle establishing a PHM program themselves, but more often the effort will require bringing in a partner. And the question then becomes, “Who?”

A vendor must have strengths in data management and analytics as well as the systems integration expertise to bring it all together. Many vendors achieve true PHM by piecing together best-in-class solutions. In this manner, the state benefits from a diversity of best practices and new ideas but must manage only one vendor relationship.

When integration is complete, the state can more clearly see gaps in health equity, and then prioritize its interventions to improve outcomes for all. As states look to strengthen their PHM efforts, the only question left to ask is, “When?” And the answer to that is, “Now.”