Population Health and the Primary Care Practitioner

If you are a primary care physician, nurse practitioner, or physician assistant, you have a frontline view of the difference that you can make in your community, one life at a time.

While you care for individuals, you have a role to play in moving the needle toward better population health. You can contribute your expertise and knowledge of your specific patient population toward a larger goal that involves many other healthcare providers and community partners.

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Public health vs. population health

Population health is related to, but not the same as, public health. Public health promotes health and wellness in our society through research, education, and the encouragement of healthy behaviors, according to the American Public Health Association.

Meanwhile, population health is an opportunity for different stakeholders to come together and collaborate to improve health outcomes in a community, according to the Centers for Disease Control and Prevention (CDC). The CDC defines population health as “an interdisciplinary, customizable approach that allows health departments to connect practice to policy for change to happen locally…(utilizing) non-traditional partnerships among different sectors of the community – public health, industry, academia, health care, local government entities, etc. – to achieve positive health outcomes.”

As an example of these cross-sector partnerships, pulmonologist and population health sciences researcher Jerry Krishnan, MD, Ph.D., describes how dozens of healthcare systems and organizations in Cook County, Illinois, were conducting community health needs assessments (CHNA), as spelled out by the Patient Protection and Affordable Care Act. They decided to collaborate and together they formed a new consortium called the Alliance for Health Equity, one of the largest hospital–community partnerships in the nation.

This kind of partnership can create relationships that lead to better care coordination, which is a challenge familiar to many, Krishnan noted.

A numbers challenge

Shortages in the primary care workforce have created an ongoing challenge that affects the health of various populations. Since primary care physicians and other providers on the front lines of care have such a direct impact on patients, the supply of these healthcare professionals is critical to population health.

A study published in JAMA Internal Medicine in February 2019 explored the supply of primary care providers and the impact on life expectancy. “Greater primary care physician supply was associated with lower population mortality, suggesting that observed decreases in primary care physician supply may have important consequences for population health,” wrote the authors.

However, the authors noted, “persistent payment disparities between primary care and procedural specialties continue to erode the U.S. primary care physician workforce.”

Due to unmet demand, family medicine physicians have been the most widely recruited medical specialists for the last 13 years, according to Merritt Hawkins’ 2019 Review of Physician and Advanced Practitioners Recruiting Incentives.

Inequity among populations

Rural communities are often the ones that suffer the most in terms of overall health, due in part to the lower percentage of primary care providers and other health services in these communities. Yet population health does not just depend on access to primary care. Social determinants of health can also play a part, such as socioeconomic, cultural, and other differences between populations.

The World Health Organization defines social determinants as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”

What can you do?

As a clinician, you have the opportunity to improve population health in your community.

“Physicians need to be leading population health efforts, and they need to be engaged,” said Krishnan, who leads the new Institute for Healthcare Delivery Design at the University of Illinois at Chicago. “So, the first thing is to get involved, to volunteer, and to ask for opportunities to participate in your organization as initiatives for population health are being designed and planned. Because I think the physician's voice is critical.”

If you feel especially drawn to the collaborative care approach, consider becoming a champion for initiatives in your healthcare organization or in your community. Encourage your healthcare organization to collaborate, if it’s not already doing so.

“We think that family physicians are already an important part of addressing social determinants of health and disparities and health equity issues,” said Kevin Kovach, DrPH, MSc, manager of population health for the American Academy of Family Physicians (AAFP).

Family medicine physicians are well-suited to collaborating because they already take a team-based approach to care, Kovach noted. So, when a group collaborates to compile data and design approaches, a family medicine physician’s perspective can be very valuable.

“Collaborating, you fill in (holes) and build that out to address problems more innovatively and successfully,” he said.

Population health resources

Want to learn more about population health and how you can help address health inequities in your community? Consider these resources:

  • The EveryONE Project toolkit. This AAFP program created a comprehensive toolkit to help physicians address health inequities and social determinants of health in practices and communities.
  • The Practical Playbook II: Building Multisector Partnerships That Work. This manual, published by Oxford University Press and authored by a team of population health experts, is designed to help organizations form partnerships across sectors to address population health and reduce healthcare costs. 
  • Neighborhood Navigator. This interactive online tool from AAFP allows clinicians (and patients) to search their communities for resources that are relevant to helping the local patient population.
  • Population Health Resources, a variety of resources and tools from the Healthcare Information and Management Systems Society (HIMSS).

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