How to Truly 'Score' Your Population Health Program: Clinical, Financial, and Humanistic Metrics

The Score Step of the PopHealth Sycle

So now you’re running your program, working with your members/patients and network seeking to improve the health of individuals. What do you measure? What’s the Score?

Well, there are two key types of measurements, process and outcomes. It's important to understand both and recognize when they are relevant. Additionally, as we've gotten better at data analysis and particularly the input available from AI we have moved along a continuum from descriptive analytics to predictive analytics to prescriptive analytics. I need to acknowledge that that description came from Qlik Analytics and was frequently featured in a slide they had describing the move to Big Data and some of the other tools. Thinking this approach through, as the analysis improves one can begin Predicting next year’s higher risk patients as well as Prescribe the specific interventions needed to improve their health.

Most programs report Process measures. These are the easiest to gather and have some value. Early in the program one needs to understand certain processes and how they are going such as how is our enrollment going? How many people have completed a visit or an HRA or some other data gathering? How many individuals have been contacted and declined enrollment? How many people haven't been contacted. All of these are process measures. There are a myriad of process measures that should be reported on at least weekly to understand how your program is doing and what it is doing. These measures are important for operations as well as reporting to your client.

But at the end of the day, one needs to show Outcomes.

There are numerous outcome measure depending upon the program. These include:

• Clinical Outcomes – Clinical measures can include lab values, test scores, imaging results, adherence measures, reductions in clinical utilization like ER visits, and any more

• Financial Outcomes – Including return on Investment, reductions in specific areas of cost. But be careful here, if the program also shows reductions in primary care utilization, that’s usually a sign of a problem.

• Humanistic Outcomes - Such as Quality-of-Life Measures, changes in Health Risk Appraisals as compared to Dee Edington’s Natural Flow, Satisfaction Surveys, etc.

To show outcomes, it's important to understand leading and lagging indicators. Leading indicators are those that can be measured early such as enrollment. Lagging indicators are those that take time to achieve and appropriately report on the measure for example it's good to have initial hemoglobin A1C levels for those living with diabetes, but expecting a change in the first month is not feasible. It takes a while to move these numbers in a population, that is a lagging indicator. Can you show changes in three months, six months, a year, multiple years.

I have seen errors in this type of reporting, for example companies claiming changes in a period that was so short that it makes no sense, as during that time period they really hadn't contacted anybody. Seems funny but it's real, taking credit for something for which their program didn't do. Oh well, chalk them off your list of vendors.

In other cases, in their score step, vendors only report on those who had stayed in the program for say a period of 12 months and did not identify or had many individuals drop out. Can you really trust the data? It's clearly biased. There are better statistical approaches to use such as Intent to Treat, having someone with a statistical background can keep you from making mistakes that many vendors are making..

There are many other examples of data elements one should be tracking, when one should be reporting on it and what those numbers mean in the score step. Clearly this step goes well beyond one blog post to explain.

What’s Your Program’s True Score?

Measuring population health isn't just about counting how many people signed up this week; it’s about proving long-term clinical and financial impact while keeping human well-being at the center. If you are only looking at descriptive, week-to-week process metrics, you are missing the bigger picture and the opportunity to predict and prescribe better care.

Are you ready to elevate your reporting from basic process tracking to predictive analytics? Contact our team today for a data strategy consultation, and let’s build a scoring framework that proves the true value of your program.