What Do Population Health Management Solutions Need To Solve?

The great lesson of the last 10 years of health care innovation is simply this: we can’t just throw technology at our biggest problems and expect them to be solved.


The relentless march of innovation has lately been dominated by data collection, enhanced analytics and predictive algorithms. And massive strides have been made.

The result is that healthcare industry payers have gotten a lot better at predicting which patients represent the greatest est risk and potential costs in the coming year.

This phenomenal step forward means we can target the right people and take action before bad (and very costly) things happen to them.

While this is amazing progress, we should keep this innovation in perspective.

Predictive analytics like those BaseHealth and others have pioneered in recent years are not the solution, but they are a powerful tool in the right hands.

Analytics are no more the solution to the chronic disease epidemic than microscopes were the solution to smallpox.

No, in this fight we have to first acknowledge that chronic diseases are not the problem. Human behaviors are the problem.

So in a solution, we need the behavioral equivalents of antibiotics and vaccines - and perhaps the biggest challenge of all - we need to figure out how to get regular people to decide it’s worth it to choose to take them ... over and over and over again.

Solving A Behavioral Epidemic

In other words, now that population health management programs have the tools to identify and target the people who can most benefit from health interventions, and program engagement, what we are left with is a very human problem:

People have adopted behavioral patterns that over time will lead to chronic diseases.

This is a simple fact of modern life. Now we have to be honest with ourselves about the solution.

And the only real solution to this problem is for individuals to change their behaviors… but the rub is that we want to make it happen at massive scale.

This, I admit, sounds hard.

But let’s venture to break it down anyway.

Ask any behavioral scientist worth a salt where lasting behavior change ultimately comes from and their answer will be that it is initiated primarily from within, as in, it’s typically fueled by a deeply personal intrinsic motivation.

This is a crucial bit of knowledge, but it sounds defeating for those of us who desire deeply to effect change in the health of others.

But just because we can’t “make someone change,” or even really “convince someone to change,” doesn’t mean there’s nothing we can do. Far from it.

We need to examine what can be done by outside forces in order to help facilitate each individual’s readiness to change.

In other words, we need to be able to create a path for more people to discover why it is important to them that they change their behavior.

We need to become experts at helping people connect the dots between what’s important to them in life, and why it takes optimal health to get there.

Health Engagement Science

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Facilitating Change

To sum up the core theme of the most researched behavior change theories, people become ready to make a lasting change only once they decide that the benefits of change will outweigh the costs, and that it will therefore be worth their effort to go through each step in the process of change.

Creating a ‘path’ that facilitates this decision is ultimately the role of care management professionals who engage directly with patients.

Doing this work well requires fostering an actual relationship with each patient that continuously frames the change path as the path of least possible resistance, and of most possible benefit and personal meaning to the patient.

In other words, it involves continuously supporting the individual’s perception that they can tackle the next small step towards change, and that it will be worth it, again and again.

Behavioral experts like my friend Dr. Steve Feyrer-Melk (Nudge’s Chief Science Officer) call this “creating a motivational environment.”

So how do we “deploy” personalized motivational environments across large populations?

How do we facilitate change that happens at a personal level, efficiently and effectively at scale?

Figuring that out is the real question.

I think it’s an essential question.

And it cuts to the core of the work we do with our partners who have population health management challenges at Nudge, and why we focus on equipping health and wellness teams to drive participation, engagement and adherence among members and patients in health programs and interventions.