This article suggests ways primary care physicians can institute aspects of population health management without making a significant financial investment.


Primary care physicians are hearing more and more about population health. Often, their first reaction is to focus on the most financially and logistically daunting aspects – complex care management, clinical informatics interoperability, and data analytics. Fortunately, there are some “inexpensive” approaches PCPs can pursue.

Narrow the Target Population to Those Who are Well or Have a Single Chronic Condition

Population Health Management (PHM) broadly views target populations in three categories –

  • Those that are well (who need to be kept well),
  • Those with a single chronic condition (who need to be managed well), and
  • Those that are complex (who would benefit from complex care management).

The third category requires the development of a risk stratification process and care manager(s), so let’s ignore that group for the moment and focus on the first two, more straightforward groups.

Data and experience support emphasizing these target populations. Many studies confirm that keeping well people well leads to lower healthcare costs in the long run. These individuals also tend to be engaged in their own health and wellness and make good allies in their care.

In addition, numerous guidelines (with metrics) exist to “best manage” individuals with a single chronic condition. Don’t try to focus on every chronic condition. Instead, choose several common ones, such as diabetes, hypertension, cardiovascular disease, COPD, and hypothyroidism. Outcomes improve when the primary diagnosis is well controlled. The secondary and tertiary prevention efforts allay disease progression and complications and often thwart, prevent, or control related conditions.

Focus on the Population You See in the Office

PHM adopts a broad view of the population and advocates proactively targeting EVERYONE – especially individuals who don’t regularly seek care. Rather than developing a complicated process of reaching out to “inactive” patients and the “total” population for whom you may provide care, focus on those who do seek care. Utilizing each patient encounter to improve that patient’s overall health is a much more practical initial approach.

Focus on Prevention and Early Detection

One way to keep patients as “well” as possible is to actively focus on preventive and early detection services, such as immunization rates and evidence-based screenings. Maximize your EMR capabilities or create your own, gender-specific scorecards of measures to pursue. Use them during every encounter to stress prevention and early detection. Empower the staff to own this effort by tracking patient status against these scorecards at each visit and by implementing standing orders that can be carried out while the patient is waiting. Make EMR-based preventive services (or scorecard) review part of the pre-visit preparation process and the check-in or rooming process.

Focus on Modifying Health Risks

Another way to keep patients as “well” as possible is to ask about and intervene with the four greatest modifiable health risks:

  • Tobacco use (particularly smoking),
  • Excessive alcohol use (more than one drink per day in women and two drinks per day in men – though “none” is most safe),
  • Eating habits (both for nutritional value and for weight control – consider “appropriate” BMI ranges and interventions if above or below the range), and
  • Physical activity (a minimum of 30 minutes a day 3-4 days per week).

While behavioral change stages (pre-contemplation, contemplation, preparation, action, maintenance, and relapse) certainly impact patient behavior, there is a body of evidence that reinforces the impact that healthcare providers have on patients’ willingness to change. Be willing and able to assist patients with resources to effect these significant behavioral changes. Have a plan for not only asking about but also intervening in these important areas. Once again, empower the staff to be heavily involved.

Measure Your Performance

It’s not enough to plan and implement processes to address these issues. You have to track your progress. For every process, you should measure the practice’s performance, work to improve it and measure your improvement.

Data collection can often be incorporated into the pre-visit preparation process and the results/referral tracking processes.  Involving staff in these performance improvement efforts will empower them and make them more invested in the outcomes. Plus, it proves the practice’s abilities to others – a hallmark trait to attract more patients, to enhance payer revenues, and to prepare for future involvement with clinically integrated networks (CIN).


Terrence R. McWilliams, MD, FAAFP

Chief Clinical Officer and Managing Director, Employed Provider Networks