Like a lot of new concepts, population health seems to be on everyone's lips and there seems to be a lot of excitement to “do” population health. It sure sounds good and yet I am entirely unclear about the specifics and I’m pretty sure that everyone is feeling a different part of the elephant.
Unfortunately, a recent paper published on BMJ Open suggests that these divergent views are common.
We can all understand the goals of the triple aim: better care—higher quality health care with fewer defects; better health—a related but independent goal that the population at large is actually healthier; and lower cost, at least on a per capita basis—reducing total costs of care.
But as an activity, what would population health look like? What would people do on Tuesday if they were doing population health? I don’t know, but I was recently in a meeting that clarified for me the wide variety of things that might fit in this category. We were discussing the training requirements for a health care workforce competent in caring for people with multiple chronic conditions and someone observed that "we have to do ‘panel management’ because we are doing population health now."
As an activity, what would population health look like? What would people do on Tuesday if they were doing population health?
Frankly, I was shocked. Panel management—as described in Ed Wagner’s Chronic Care Model, for example—may be a good way to deliver higher quality care, but it is very hard to understand it as the same thing as measuring and working to improve the health of the population of a city, state, or country.
Panel management, which borrows the managed care framework, assumes that a defined population of member/beneficiaries of a health plan (or perhaps attributed lives in an Accountable Care Organization) are assigned to particular providers who have certain responsibilities to be proactive about offering some care services as opposed to the laissez faire norm in fee-for-service, where the only time any health care professional might think about you is when you are in one of their facilities.
A nice version of team-based panel management is Kaiser's Complete Care approach, described in a recent Wall Street Journal article. Clearly, the outcomes targeted by Complete Care (screening rates, vaccinations, and chronic disease control) are more commonly thought about as part of quality care. So for population health to have meaning, I think it has to be more than proactive, organized, team-based primary care.
To my mind, population health needs to include a variety of activities well beyond the usual health care activities of even the best clinical care and have a much greater public health focus.
To my mind, population health needs to include a variety of activities well beyond the usual health care activities of even the best clinical care and have a much greater public health focus. For population health to be a meaningful concept, it has to address another amorphous interstitial concept: the "social determinants of health."
At the John A. Hartford Foundation, we have been interested in addressing some of the social determinants of health and meeting some of the more immediate needs for health promotion through better organization and quality of social services that help older adults get access to programs like Healthy Moves, Healthy IDEAS, and the Chronic Disease Self Management Program .
Our recent grant to the Partners in Care Foundation and the Elder Services of the Merrimack Valley is designed to ensure that these services get “baked into” the evolving managed care plans taking responsibility for older adults and the high-needs population eligible for both Medicare and Medicaid.
However, even these efforts seem less like some radical shift to "population health" and more like meeting the real quality of care needs of a complexly ill population of older people with substantial rates of chronic disease. So I find myself still perplexed about “population health.”
How does it differ from good comprehensive care on the one hand and from public health on the other?
I remember reading a think piece years ago on the physician of the future. I dimly remember an example of an emergency physician who delivered high-quality, one-on-one clinical care and worked on population health. For part of the day, this physician worked in an ED with decision support and as a member of a high-functioning team (better care). In other parts of the job, this paragon also addressed the health of the population by educating school students about the benefits of seatbelts and testifying to town council about the placement of traffic signals based on tracking of accident reports.
In our aging society, I’m not sure what the equivalents of seatbelts and traffic signals may be. But at 14 percent of the population and rising, I think that older Americans, who also have more chronic health conditions and poorer health status than younger people, could really use some of this population health—whatever it winds up being.
I certainly hope that they won’t be left out of whatever health promotion and prevention efforts eventually are developed.