In 2016 and 2017, more than 100 visiting healthcare executives gathered at athenahealth for candid roundtable conversations with Harvard Business School professors Amy Edmondson and Nancy Koehn. The topic: population health.

How can healthcare leaders coach their hospitals and physicians across the new playing field of risk-based care? The goal, they agreed, is in clear sight: improve the quality and effectiveness of healthcare while controlling costs for defined groups of patients.

But the playbook is still in rough draft. “Managing population health involves a set of strategies and capabilities that many of us are still wrestling with at this point," said Anil Keswani, M.D., corporate vice president of ambulatory care and population health management at Scripps Health in San Diego.

That said, by openly sharing their successes, failures, and frustrations, these executives could agree on a path toward a viable population health model of care. Here are the top insights from some of the nation's leading healthcare executives on the realities and the promise of population health:

1. The transition to population health is financially precarious

Under pressure from payers to enter risk-based contracts, leaders worry about moving too quickly as they brace for lost revenue from hospitalizations and procedures. They are wary of penalties for failing to meet quality metrics when the targets required by payers don't always capture the kind of care they know drives better outcomes. And, overall, any shift in standards and strategy for the future runs up against bills to be paid and lives to be saved today. Said one leader in the room: “We are driven by the tyranny of the urgent."

2. The transition is a cultural shift – and that can be even more precarious

Moving away from acute, episodic care to sustaining wellness across populations requires everyone on the continuum of care to think differently. As Edmondson told gathered leaders, “You went to medical school to learn to fix broken things. Now you need to reorient to prevent things from getting broken."

While they may support population health efforts, physicians and staff fear an increase in already crushing workloads. What's more, team-based care may not be an easy adjustment for all providers. Partnering with community organizations — churches, the YMCA, or schools — can be an operational challenge for hospital workflows. And a cultural sea change also asks a lot of patients, particularly high-risk "frequent fliers."

As Brian Woods, M.D., chief medical officer of NorthStar Anesthesia of Texas, says, “Until you have the end user buy in and commit to the vision of your culture, you won't generate a result."

3. Actionable, aggregated data is paramount

As organizations aggregate data across their systems and their community, making it actionable is a key concern for healthcare leaders. “Sometimes there's so much information that you can't get any directional signal," says Poonam Alaigh, M.D., an internal consultant for the ACO strategy for Atlantic Health System in New Jersey.

Data that draws a more accurate picture of patients' lives must be added to clinical and claims data. “We need to collect social determinants of health data and see the patient in the context of their life," says Elizabeth Majestic, vice president of population health at Cottage Health in California.

Aggregating clinical, financial, and demographic data in real time will deliver the actionable information in the moment of care — the foundation of population health.

4. Care and access for high-risk, high-cost patients must be prioritized

When data identifies complex, high-cost patients, effective interventions can be developed to address the drivers of those patients' health and identify appropriate forms of access to improve their outcomes.

"If you look at the management of cost, it's about managing the high risk of super-utilizers," says Scott Reiner, the president and CEO of Adventist Health in Roseville, Calif. One solution may be to expand the use of online, mobile, and telemedicine tools to increase access and enable providers to influence patient behaviors outside office-based encounters.

For example, "There are lots of people who want more from their primary care doctor. They want that interaction, they want to be guided, and they want it now. [But] most practices are not set up for that," says consultant Bill Winkenwerder, M.D. "There needs to be a new layer where you can just either call, go onto the web or have an app on your phone, and within 30 to 60 seconds, you're talking to a doctor."

5. Population health is a team sport

Care for targeted groups of patients, whether defined by a region, employee pool, or disease cohort, must be integrated across teams and communities. And all of the actors — providers, payers, patients, and their communities — must be aligned in their approach and incentives.

In integrated systems, community groups — food banks, housing advocates, schools and churches — join the healthcare system, drawing on resources once owned by hospitals and payers to address the root causes of poor health.

“We have to move away from a model that serves self-interest," says Larry Mullins, CEO of Samaritan Health Services of Oregon. “Whether they are hospital interests, or physicians' interests, or ambulatory surgery interests, that doesn't work when you're getting into population health. You're talking about allocating a finite amount of resources for a defined population, and you really can't have one player trying to dominate out of self-interest."

6. The need for a population health workforce is urgent

To deliver effective population health, physicians must be freed from administrative work to focus fully on providing high-quality care for their patients. Research by athenahealth reveals that in organizations where staffers, instead of physicians, assume administrative tasks — data entry, identifying and closing gaps in care, and managing communication with patients — physicians are able to increase quality of care with less risk of clinician burnout.

While “quality" is often defined as meeting sets of individual metrics, Jessica Sweeney-Platt, executive director of physician performance research at athenahealth, says decades of research into service-intensive industries indicate that true quality is a function of "ensuring that providers have what they need to deliver the care that their patients need and expect."

Navigating the transition to population health requires leaders who can communicate a shared vision, build consensus, and reshape cultural priorities to reinvent care delivery. “People are thirsty for leaders and organizations that lift them up," says Koehn, author of Forged in Crisis: The Power of Courageous Leadership in Turbulent Times.

And today, that lift — a healthier population — is as urgent as it is challenging.

Gale Pryor is associate editor of athenaInsight. Artwork by Katherine Streeter.