Most population health webinars focus on topics like chronic disease management, closing care gaps, and the role of preventive care. While these are important concerns, we want you to rethink the meaning of population health and why it’s so important right now. After years of saying value-based care is coming, Dr. Will Caldwell, a physician with 19 years of experience and the Senior Vice President for Population Health at Health Catalyst, will make the case that emerging trends are enabling the true shift to population health. In this webinar, Dr. Caldwell will offer the following: •    Create excitement about your role in helping others live healthier lives. •    Raise awareness of the opportunity facing us. •    Help us understand the role private equity is playing. •    Encourage us to rethink how we source and use data. •    Explain the transition from disease management to population health management. •    Discuss the largest unrealized opportunity in managing the total cost of care and driving better outcomes.

1. © 2021 Health Catalyst
© 2021 Health Catalyst
Population Health: People Get Ready
Will Caldwell, MD, MBA
Senior Vice President, Population Health, Health Catalyst
Senior Health Advisor, PIH - Haiti

4. Do You Know Robin?

5. Readmissions
Telemedicine
Chronic disease management
Clinical pathway development
Artificial intelligence and machine learning
Closing care gaps
EMR point of care integration
Role of preventative care
Importance of internal and external reporting
TCOC reduction strategies
Building a data driven culture around pop health management

6. Your Next 40 Minutes…
• Rethink the meaning of population health
• Excite you about your role making a difference
• Answer “Why now?”
• Define “smart” data acquisition and ownership
• Rotate the care management paradigm 90 degrees
• Suggest a large, unrealized opportunity to manage quality and cost
more effectively – what are we not talking about?

8. The identification and management of the drivers of
clinical and financial risk impacting a patient’s health,
agnostic to payer model

9. Population health is a care delivery model,
NOT a payment model…

11. Fierce Urgency of Now…

12. Why Now – What is Different?

13. Opportunity
“Never before in history has
innovation offered promise of so
much to so many in so short a time”
― Bill Gates
Market Driven
Innovation
“The complexity of medicine outruns the
ability of the
expert mind”
― David Eddy MD
Moral Obligation
“We are now faced with the fact that
tomorrow is today. We are
confronted with the fierce urgency of
now.”
― Martin Luther King Jr.

14. Opportunity
“Never before in history
has innovation offered
promise of so much to so
many in so short a time”
― Bill Gates

15. Consequences of skipping steps
in developing health systems?

16. Market Driven Innovation #1

17. Per Capita GDP
• US $56,116
• Haiti $818
• Sierra Leone $6530

18. “All things outpatient”
Bill Frist MD, 2005
Market Driven Innovation
$100B Invested in Healthcare from PE Sources in 2018
A Shifting Target for Investment…
“Behavioral health management,
pharmacy economics, and virtual care
services are what self insured employers
are looking for today”
Brad Wilson, 2021
“Telemedicine is here to stay”
Brent James MD, 2021

19. “The complexity of
medicine outruns
the ability of the
expert mind”
― David Eddy MD
Private equity provides capital to fund
innovation not supported by traditional
players in the healthcare ecosystem
“A private equity firm that invests in a care delivery
organization reimbursed under value-based payment
should be expected to encourage investments and
operational changes that support better health
outcomes and lower costs, even if acting purely out
of financial self-interest”.
JAMA Online (8/11/2021)

20. What Can We Learn From Financial Services?
Shifting Financial Risk Drives Access to Data and Services
Reducing information
asymmetry supports
innovation
(democratize data)
Who owns my
healthcare data?
SECURE Act, 21st
Century Cures Act
Transfer of financial
risk creates market
demand for access
to data
Market Driven Innovation #2

22. Fierce Urgency of Now…

23. Determinants of Health
This diagram
is a model of
all factors
correlated
with health
outcomes for
an individual
7%
Physical Environment
11%
Medical Care
36%
Individual
Behavior
24%
Social Circumstances
22%
Genetics and
Biology

24. Why data
matters
In all low income countries around the world today,
how many girls finish primary school?
20%, 40%, 60%
In the last 20 years, the proportion of the world
population living in extreme poverty has?
Doubled, remained the same, cut in half
What is the average life expectancy of the world
today?
50y, 60y, 70y
How many of the world’s 1 year old children today
have been vaccinated against some diseases?
20%, 50%, 80%
How many people in the world today have access to
electricity?
20%, 50%, 80%
24

26. Smart Data Approach
Start at the End of the Process
Create a
process or
pathway to
address it
Identify data
sources
informing
process
Use analytics
to create
information from
the data useful
in guiding
decisions
Identify a
clinical or
business need
Ingest and
normalize only
needed data

28. Fierce Urgency of Now…

31. 5 Horizontals to Consider in Care Management
Nutrition and Weight Management
Behavioral Health 2.0
Preventative and Palliative Care
Exercise and Physical Therapy
Financial Health

33. Fierce Urgency of Now…

34. What do I think is the largest
untapped clinical and financial
opportunity in population health?

35. Florida Medicare Population
TCOC attributable to chronic disease higher in
Medicare patients with a BH diagnosis? BMC
2020
• 21% of patients with mood disorder
admitted from ER/12% without mood
disorder admitted
• 2.6% of patients with mood disorder
admitted to ICU/1.6% without mood
disorder admitted to ICU
• 1.5x more likely to be readmitted within
30 days if patients have an undiagnosed
or poorly controlled mood disorder
23,000 attributed lives
7130 patients with depression
(31% of Medicare pop in FL)
A Financial Argument
# with
depression
∆TCOC
Avoidable
Spend (27%)
Total
Savings
DM (36%) 2566.8 15,468 4176.36 $ 3,725,313.12
CHF/Heart
condition (75%)
5347.5 13,044 3521.88 $ 6,543,653.04
COPD (30%) 2139 10,800 2916 $ 2,166,588.00
$ 12,435,554.16
Shared
Savings
(75%)
$ 9,326,665.62
Rev. equiv.
(5% margin)
$ 186,533,312.40
CMS website data 2014, Milliman

37. Your Last 40 Minutes…
• Population Health is not a payer model
• A new dawn for population health supported and
funded by new capital sources
• Shift in financial and clinical risk
• More data is not always better –Must pivot from a
vertical, disease specific care management
approach to horizontally integrated programs
across a population.
• Be smart!
• “BH redefined” is largest opportunity – the
missing piece in population health management

38. Jaime Jaramillo “Papa Jaime”

41. Do You Know Any Robins?

42. “We are now faced with the fact that tomorrow is today.
We are confronted with the fierce urgency of now. In this
unfolding conundrum of life and history, there ‘is’ such a
thing as being too late. This is no time for apathy or
complacency. This is a time for vigorous and positive
action.”
― Martin Luther King Jr.

43. Will Caldwell, MD, MBA
will.caldwell@healthcatalyst.com
704-996-9376

44. Questions?

45. Thank you!