PCMH Key to Successful Population Health Management

A presentation at the PCMH Congress 2017 highlighted how quality evidence-based care models like the patient-centered medical home model (PCMH) and better policies that support small practices in underserved communities are the keys to achieving successful population health management.

During his presentation entitled “Population Health: Impact on the Medical Home Neighborhood,” Dominic H Mack, MD, MBA, director of the National Center for Primary Care at the Morehouse School of Medicine, outlined how the challenges facing population health management can be alleviated by addressing the needs of providers.

Dr Mack started his presentation by reviewing how current policy in the United States is impacting population health. He explained that CMS’ $31 billion investment in establishing electronic health records (EHRs) throughout the country has had a significant impact on improving the ability to measure how effective care is. 

He noted that in 2017, the implementation of MACRA has also had a significant impact on how care is delivered in the United States. 

However, he explained that MACRA’s mission of improving care quality and provider performance does not always result in care equity—and leaves some patients with health and social disparities in need of better access and care.

“Quality and equity do not always mix—just because you have quality doesn’t mean you have equity,” Dr Mack said during his presentation. “Improving quality for all does not necessarily reduce disparities for racial and ethnic minorities. This is also true for underserved and rural populations.”

He explained that it is vital to influence the development of better policy for underserved patients because this 5% of the population accounts for almost half of total health care expenses. He noted that poverty and poor health are highly associated, making underserved patients more expensive to treat. 

Dr Mack suggested that in order to solve these issues, care models must target social determinants of health. This involved investigating data sources, identifying community resources for patients, prioritizing which patients have the highest need and are most likely to benefit, and to follow through by putting data into practice.

He noted that providers who serve high Medicaid populations, have small practices, or are in rural health settings, are less likely to adopt EHRs. Dr Mack noted that this results in missed opportunities to gather data on the underserved patient populations. 

“Policy gaps result in missed opportunities to advance health equity by recording informative patient demographic data in EHRs,” he said. 

Dr Mack concluded his presentation by emphasizing the need for programs specifically designed with underserved patients in mind.

“We need to develop program specifically for those underserved populations because they have the most chronic disease, the most morbidity and mortality, and the highest cost,” he said. “That is where the most value is for health care in this nation.”

—David Costill