Improving patient outcomes: The role of population health managers

Oliver Dittus is director of care solutions at Evernorth, the health services division of The Cigna Group. In his role, he is responsible for a team of clinicians who work with Evernorth clients to gain insights about their members, gaps in care, and any social determinants affecting their health in order to better coordinate care.

These population health managers identify opportunities requiring clinical attention, which enables custom-tailored interventions to the patient’s condition, utilizing their engagement preferences. This work informs proactive, preventive outreach, which leads to better health outcomes and lower costs for clients and members. 

We sat down with Dittus to better understand what population health managers do, the impact they are making, and how they are improving health outcomes across the United States. 

Tell me about yourself and your role at Evernorth.

I’m the director of care solutions at Evernorth, within our coordinated care department. I lead a group of 10 pharmacists and one nurse practitioner – our population health managers – who support our clients that are enrolled in Health Connect 360. I've been with the company for almost 25 years, but I am a pharmacist by trade.

I’ve been in management for a long time, and I feel incredibly lucky to work with this team of population health managers because of how dedicated they are to the work that they do. Their clinical expertise, mixed with their passion for data and improving member outcomes, is driving a lot of success for our clients. They’re digging into the data on a daily basis to understand what is driving patients to behave in certain ways, to find gaps in care, and to identify patients who may be falling through the cracks. 

And they are making a huge impact. In just one year, our population health managers supported 3.2 million clinical interventions that helped clients save an average of $538 per member per year. Their actionable insights and complete view of plan challenges and opportunities produce healthier patients and enable increased savings.

We know these folks have clinical skills. What other skills do they have?

The population health manager role is probably one of the most unique clinician roles we have at Evernorth. They get to wear a lot of different hats. Essentially, they are a trusted consultant for our clients. 

They’re clinicians, but they also have to be really good public speakers. They’re out in front of our clients, meeting with them and talking about what they are seeing in the client’s population data. They also need to be able to turn data into insights. Each client in the Health Connect 360 program has a dashboard – powered by our Care Insights Hub – which is full of data specific to their member population. The Care Insights Hub blends pharmacy, medical, and lab data with social determinants of health and more to give population health managers a full picture of what’s happening with the members within each client’s population. The Care Insights Hub provides a look into how well members are managing their chronic conditions, whether they are adherent with their medication, and more. 

As an example, the American Diabetes Association recommends that people living with diabetes take medication to lower their cholesterol. If they’re not, we’re able to generate a gap-in-care report for the client, as well as why those gaps may be happening (such as social determinants of health factors or lack of access to care), and make recommendations on interventions. 

The team spends a lot of time thinking about how we can improve the health of our clients’ members by making data-informed suggestions on how we could be doing things differently. Our population health managers must be analytical thinkers, and they must be creative in order to come up with ideas around how to engage people differently. 

Can you give some real examples of the clinical gaps closed by population health managers?

One in eight Americans say the high cost of prescription drugs causes them to skip doses or delay refilling prescriptions. This is a big area of focus for our population health managers – as prescription drugs are among the highest drivers in health care costs for plan sponsors. Our population health managers can identify diabetes patients, as an example, who are not adherent to their diabetes medications and really dig into what is happening. As part of Health Connect 360, we offer diabetes patients remote monitoring, and so if a patient is checking and reporting their blood sugar or blood pressure, for example, we can see that data in the Care Insights Hub. For some diabetes patients, our population health managers were able to identify cases where people were under-ordering insulin because they thought they couldn’t afford to order the correct amount. This insight enabled our case managers at Evernorth to reach out and walk patients through ways to lower their costs by switching to generics. 

Another great example is that we recently had a member who was late to fill one of her asthma medications. Our Care Insights Hub indicated that this patient might also be struggling with social determinants of health issues. Our population health managers were able to hand this information over to one of our pharmacists, who was able to confirm that the patient was on multiple medications and was struggling to keep track of them all. She was also having food insecurity issues, which was adding to her stress. The pharmacist then worked with the patient to set up a new regimen to help her get back on track with her medications and connected her with resources that could help her access food and pay her rent. 

The population health managers are digging into data on a daily basis. What kinds of trends are you seeing? What should plan sponsors keep their eye on in 2024?

GLP-1 medications, which treat obesity and diabetes, are a hot topic right now for clients mainly because of the high costs associated with these medications. That’s one area our population health managers will be watching closely in 2024. Women's health is also a priority area for many of our clients and we will be doing a lot of work in that space as well – ensuring that women are empowered to take care of themselves in all stages of their lives.