Population health management is a fast-growing capability within health information technology, and managing the country’s growth in overall care expenditures will require providers to expend more efforts taking care of underserved populations.

About 43 million people in the United States live below the poverty level and their care consumes 67 percent of healthcare dollars, according to Arthur Kapoor, president at Health EC, a population health management company.

The needs of this segment of the country have been neglected for a long time, he asserted, and bringing them into the fold and collecting data on their social determinants is the key to population health success.

Vendors in the population heath arena have massive amounts of data that many providers aren’t taking advantage of, Kapoor says. Providers are too busy trying to maximize revenue while being pressed to cut rates, to also massage and analyze population health data.

Kapoor sees a new way to assist burdened providers-- have their vendors bring the data to them.

Also See: Providers ramp up use of IT to empower population health expansion

Social determinant data can help providers better understand underserved populations and the issues they face. Providers often do not know if their patients have access to transportation, food and housing, or if they are socially isolated and have no one to take them to doctor appointments. “No one talks to them,” Kapoor said. “They keep taking medication when they no longer need it because they like it.”

But there is an easy way to reach these patients. Nearly all of them have a smartphone, Kapoor noted, and population health vendors have tools to help providers’ better monitor their patients.

For instance, a hospital or physician practice can give out grocery cards to help patients in poverty buy food. HealthEC can track the purchases and notify a physician or case manager if a patient bought food that is injurious to their health. A phone call can educate the patient and offers an opportunity for a quick assessment of current health and needs, which can determine if the patient should come in for a visit.

Among other issues, population health vendors should offer one electronic health record on a patient covering the entire spectrum of care to help providers execute and see the benefits of keeping patients healthy, and give providers quality reports so they can negotiate better terms with insurers and with other providers when forming an accountable care organization, according to Kapoor.

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