Population Health Management for Employers: Prevent, Manage and Measure
Population health management means using your plan’s own data to find the conditions that drive cost and the members at risk, then offering targeted prevention and care management. Start with one or two targets your claims support, follow the wellness program rules, and measure results over more than one year.
Three Parts of a Population Health Strategy
Prevention
Screenings, vaccinations, tobacco cessation and healthy-habit programs that aim to keep members from developing costly conditions.
Care Management
Outreach to members with chronic or complex conditions, such as diabetes or kidney disease, to coordinate care and help them follow treatment.
Measurement
Tracking claims, use of care and participation before and after a program, so you keep what works and drop what does not.
Find Your Targets Before You Buy a Program
Find the Conditions That Drive Cost
Review claims by condition, drug class and site of care to see where spending concentrates. Small groups should use several years of data.
Check What Your Carrier Already Offers
Most carriers include disease management, wellness and virtual care. Use those first and avoid paying twice for the same service.
Pick One or Two Targets
Common choices are diabetes and metabolic risk, musculoskeletal pain and maternity. A narrow focus is easier to run and to measure.
Four Kinds of Program Employers Use
Chronic Condition Management
Coaching and care coordination for members with conditions such as diabetes, asthma or heart disease, delivered through the carrier or a vendor.
Metabolic and Diabetes Prevention
Lifestyle programs for members at risk of type 2 diabetes. The CDC runs a National Diabetes Prevention Program with recognized providers.
Primary Care Medical Home Models
Care teams built around a primary care practice that coordinates referrals and follow-up, often paired with better access to appointments.
Social Needs Support
Screening and referral for non-medical barriers to health, such as transportation, food and housing, which can keep members from following a care plan.
Wellness Program Rules to Follow
Participatory vs. Health-Contingent
A participatory program rewards taking part. A health-contingent program rewards meeting a health goal and must offer a reasonable alternative for members who cannot.
Incentive Limits
Federal rules cap rewards in health-contingent programs as a share of the cost of coverage, with a higher cap for tobacco programs. Check the current limit before you set one.
ADA, GINA and Privacy
Screenings and health questionnaires raise disability and genetic information rules, and vendors handle protected health information.
How to Tell It Worked
Participation
Track enrollment and active use, not just sign-ups. Low participation means the program is not reaching the people it is meant for.
Use of Care
Look for changes in avoidable emergency visits, hospital stays and preventive care among participants.
Time
Give a program at least a full plan year before you judge it, and compare against a similar group when you can.
Common Questions
Is population health management only for self-funded plans?
No. Self-funded and level-funded plans see the most claim detail, but fully insured employers can use carrier programs and the summary reports their carrier provides.
How many programs should an employer run?
Fewer than most employers add. One or two programs tied to documented claims drivers are easier for employees to find and for you to measure.
Do wellness incentives have legal limits?
Yes. HIPAA and ACA rules limit incentives in health-contingent programs, and ADA and GINA rules apply to screenings and questionnaires. Check design with your advisor and counsel.
Will a program lower my renewal?
Not on its own or quickly. Programs can change use of care over time, but a renewal reflects many factors. Set expectations accordingly.
Where These Rules Come From
29 CFR §2590.702 (Nondiscrimination and Wellness Programs in Health Coverage)
Centers for Disease Control and Prevention: National Diabetes Prevention Program
CFH are licensed insurance brokers, not attorneys or tax advisors. This page is general information, so confirm your situation with your benefits attorney or tax advisor.
Related Guides
Employer Health Plan Cost-Control Playbook
Where population health fits among the levers.
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