The authors of a PwC report sat that population-health management efforts must think beyond the usual clinical measures and collaborate with groups outside healthcare.

The report notes that population-health programs usually  rank patients according to the financial risk to the organization  that their  specific conditions represent, at least at first glance.

But, the report says,  socio-economic and environmental needs and pressures must be considered along with their direct medical ones.

The report touts Partners HealthCare’s High Risk Care Management Program.  It uses  both clinical indicators and data from electronic health records about patients’ backgrounds and  other characteristics. So far, the program has been saving more than $2.50 for each dollar it spends.