Special Report

A high-performance network approach to population health really works

Population health trends within an accountable care plan


Embright, Washington's clinically integrated network founded by UW Medicine, MultiCare Health System, and LifePoint Health, is tracking early signs of success in the 2022 benefit year. Prior to 2022, the foundational elements of Embright's philosophy and approach were implemented across UW Medicine Accountable Care Network (ACN). This population included a portion of Washington State Health Care Authority and The Boeing Company employees averaging 40,000 from 2016 through 2019.

From 2016 through 2019, UW Medicine demonstrated that a data-driven approach to population health can deliver better results across a set of defined metrics. Significant improvements were achieved in several quality domains that improved the health of patients and related downstream costs. 

These measures included preventive screenings, diabetes management, and hypertension management. For people with diabetes, the number of patients/members with (HbA1c) control increased by 6% over two years, from 74% to 80%. Blood pressure control also improved by 6% from 66% to 72%, and colorectal screening rates improved by 17%.

Each of these successes is a result of focused, data-informed strategies and tactics that require a high level of communication, coordination, and execution that outside entities are not able to reproduce. These successes reduce adverse health outcomes through prevention, which directly reduce the cost of health care and improve the patients/member’s quality of life. It doesn’t take many prevented heart attacks, strokes, amputations, or colon cancers to add up to an impactful effect on payer benefits, both directly through reduced costs, as well as prevented loss of productivity ─ not to mention grateful employees.

Preventive Screenings

Pneumococcal vaccination rates improved from 75% to 85% over three years (2016 - 2019).

Vaccination and screening improvement over three years 

UW Medicine ACN population health efforts to increase preventive screenings delivered successful results in key areas impacting population health and overall costs.

  • Pneumococcal vaccination rates improved from 75% to 85% over three years.
  • Colorectal cancer screening rates improved from 55% to 72% with assistance from a member outreach campaign which included direct mail FIT kits and individual follow-up on positive results.
  • Cervical cancer screening rates improved from 75% to 78% due to a targeted outreach campaign.

Colorectal cancer screening rates improved from 55% to 72% with assistance from a member outreach campaign which included direct mail (2016 - 2019).

Cervical cancer screening rates improved from 75% to 78% due to a targeted outreach campaign (2016 - 2019).

Diabetes Management

Retinal eye exam screenings improved over two years (2017 - 2019), from 47% to 54%.

Aspects of diabetes management control increased

Diabetes was an identified focus area for UW Medicine's ACN members. Over two years (2017 - 2019), intentional activities were implemented to increase screenings associated with identifying and managing diabetes. This focus led to an improvement in three metrics. 

  • Retinal eye exam screenings improved over two years from 47% to 54%. 
  • A1c control improved over two years from 74% to 80% through a targeted population health effort in select “at-risk lives” cohorts.
  • Blood pressure control improved over two years from 65% to 73% “at-risk lives” cohorts.

A1c control improved over two years (2017 - 2019) from 74% to 80% through a targeted population health effort in select “at risk lives” cohorts.

Blood pressure control improved over two years (2017 - 2019) from 65% to 73% “at risk lives” cohorts.

Hypertension Management

Hypertension control pilot a success

A pilot program was launched during this period (2018 - 2019) with the intention of improving hypertension control throughout the population. UW Medicine ACN population responded positively to the pilot, and health metrics significantly increased. 

  • Blood pressure (BP) control improved from 66% to 72%.
  • The baseline BP recheck rate increased from 23% to 73% at intervention sites by the end of the pilot.

Blood pressure (BP) control improved from 66% to 72% during the pilot program.

The baseline blood pressure (BP) recheck rate increased from 23% to 73% at intervention sites by the end of the pilot.