The United States (U.S.) spends nearly twice the average of other Organization for Economic Co-operation and Development (OECD) countries’ expenditures on health, but has the lowest average life expectancy, performs worse than average on many population health outcomes, and has more outcome-related disparities compared to peer OECD countries (OECD, 2023; Gunja, et al., 2022). An analysis of 2020 Commonwealth Fund International Health Policy Survey data found lower income adults in the U.S. fare relatively worse on affordability and access to primary care and income-related disparities across domains than those in ten other high-income countries (Doty et al., 2020). The 2021 Commonwealth Fund report (Schneider et al., 2021) notes the U.S. has the largest disparities between income groups, except for preventive services and safety of care.

The U.S. and CMS acknowledge the importance of quality measurement and that quality reporting and value-based programs have improved outcomes and how measured entities deliver care. Additionally, population health measurement is critical to improving the nation’s overall health. As such, CMS is committed to four principles for improving population health:

• Establish health equity as a strategic priority
• Empower and enable measured entities and other interested parties to take a data-driven approach to measuring and improving population health
• Leverage state innovation and local leadership through partnerships
• Address all drivers of health including clinical, social, behavioral, and environmental factors.

This document provides a high-level overview and definition of population health. It addresses considerations for population health quality measures with respect to the Measure Lifecycle. As population health measures evolve, so will this document. 

Introduction to Population Health

Population health refers to “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”. (Beck, et. al.) Note that this definition does not delineate how to define the groups themselves. When developing population health measures, clarity of the denominator is critical for measurement. The current approach for commonly published summary measures of population health, such as mortality rates, primarily uses geopolitical areas.

However, other population identifiers may include panels of patients (e.g., persons assigned to a specific measured entity or measured entity team), members of a health plan, or members of a specific social demographic (e.g., women of color). Social determinants/drivers of health (SDOH) (e.g., economic stability, education, social and community context, health and health care, and neighborhood and built environment), and social risk factors (e.g., food and housing insecurity, lack of transportation), also impact population health significantly (Green & Zook, 2019).

CMS defines a population health measure as a broadly applicable indicator reflecting the quality of a group’s overall health and well-being. Examples of measure topics include access to care, clinical outcomes, coordination of care and community services, health behaviors, preventive care and screening, and utilization of health services. Without guidance as to how to define a group, these working definitions reflect important distinctions between population health measures and quality measures. The current intent of quality measures is to assess the quality, cost, or efficiency of services to individuals by health care setting, so there is an attachment of quality measures to services and specific types of measured entities. Population health measures would not necessarily have these restrictions. Population health measures are more expansive in that they include what is happening outside the direct health care system.