The evolution of care management: From population to precision

As regulatory and market forces hold payers and providers increasingly accountable for the quality and value of health care, the goals of the Triple Aim – sustainable costs, better health outcomes, and improved patient experience – are more critical than ever. 1,2 These goals are also core tenets of population health management programs, which seek to improve care coordination, access to care, appropriateness of care, and utilization of patient data.3 On the other hand, precision medicine is a potentially competing concept that also seeks to improve value in health care, but with prevention and treatment plans developed and implemented at the patient level. At the intersection of population health and precision care there is potential to set a new standard for improving costs, outcomes and patient experience.

Historically, care management services targeting improved population health have zeroed in on five core diseases: asthma, CAD, CHF, COPD, and diabetes. Under this model, interventions are delivered to patients who share a common condition, regardless of their true need for a given resource or service. For those who are already managing their condition well, these interventions are unneeded and excessive, negatively impacting their patient experience. These individuals would be better served by care management programs that intervene only when doing so would make a beneficial impact. As well, the care management program would be more effective in driving improved outcomes and lower costs by focusing resources only on those patients who can be positively impacted by prescribed interventions.

Take two diabetic patients: patients A and B receive routine reminder calls to attend their scheduled check-ups; however, B also suffers from depression and rarely answers the phone or replies to messages. In this way, care plans that are based solely on disease can be ineffective, contribute to resource waste, and fail to deliver appropriate interventions. Moreover, this approach does not differentiate those individuals that are most likely be positively impacted by certain interventions – a critical piece of the cost-reduction puzzle. By taking into account a broader host of factors that impact health — such as medication adherence, visit compliance, mental health, and socioeconomic status — payers can refine care management plans for optimal impactability.

Comprehensive profiles based on multiple nontraditional data sources facilitate more effective patient segmentation. Segmentation zeroes in on clear steps to advance the Triple Aim across a spectrum of clinical conditions, and interventions are delivered with precision to those who need them the most. This is the best of both models: better outcomes at the population level and targeted solutions at the individual level, delivering improved health, lower costs, and a more positive patient experience. 

Care management that defines patients beyond their diseases is critical for closing gaps between the progress that has already been made toward the Triple Aim and what is possible. Programs built around time-tested principles such as care coordination and informed by comprehensive data sets, cutting-edge precision, and sensitive, flexible touchpoints are poised to take payers, providers, and most importantly, patients closer than ever before to realizing truly high-value health care. 

About the author: Ron Geraty, MD, is CEO of AxisPoint Health, a population health management company. Beginning his career as a psychiatrist, Dr. Geraty is known for founding, developing, and transforming multiple healthcare companies while serving in a variety of executive roles.


  1. Berwick, DM et al. The Triple Aim: Care, Health, and Cost. Health Affairs. 2008; 27:759-769. 
  2. Whittington JW et al. Pursuing the Triple Aim: The First 7 Years. The Milbank Quarterly. 2015; 93:263-300. 
  3. Creten N Et Al. Population Health Management Program Development: The Path to the Triple Aim. Accessed Dec. 20, 2016, from http://www.milliman. com/insight/2016/Population-health-management-program-development-The-path-to-the-Triple-Aim/ 
  4. Khoury MJ et al. Will Precision Medicine Improve Population Health? Journal of the American Medical Association. 2016. 316:1357-1358.