Population health is the next big thing and every hospital team should be up for the challenge of bringing “wellness” to communities, now! But, population health is not at all new. Governments, employers, and health insurance providers have been engaged in this challenge for a very long time. Health departments require immunizations controlling childhood and other diseases. Case in point, polio was virtually eliminated as a debilitating illness through mandatory vaccination. EPA, FDA and other Federal agencies reduce population health risks by enforcing standards for water, industrial waste, air quality, food safety, significantly reducing population health risk.
Regulatory controls seek to reduce or prevent risky, expensive personal choices: illegal narcotics, heavily taxed substances (tobacco, alcohol), speed limits, helmet laws, the list is endless. Designed to “manage” population health and control societal cost of over indulgence, non-compliance, or addiction, these programs have proved effective. Second hand smoke exposure has been virtually eliminated through location bans. Employer and health insurer incentivized behavior modification programs have been moderately successful. While others have fallen flat, voluntary presidential campaigns to motivate exercise and sound nutrition are two perennial examples.
Let’s analyze these examples. When a health risk is very high (polio) and solution is straight forward (vaccination), government can act effectively. We support and comply because the horror of the disease and simplicity of solution is obvious. If a risk factor is a clear danger, most citizens will support a ban to protect themselves and society–narcotics. If a risk factor is socially acceptable and a personal choice but inherently risky then tax it to curb over indulgence and defray societal cost of being a “user/abuser”. If the risk factor is environmental and sufficiently understood, regulate and hold violators accountable for cleanup and avoidance, especially when scale is large and perpetrators are corporate or governmental bodies. Voluntary initiatives however, unlike successful strategies, are personal appeals and unenforceable. The majority of us being “managed” choose to not comply, resulting in a citizenry living longer, but in poor personal health.
Personal health is dependent on education, options, choices, convenience, genetics, and motivation. Personal choice is influenced by culture, environment, and nutrition options. No single poor choice, by itself, is health threatening. Poor choices over a lifetime almost invariably result in obesity, diabetes, heart, respiratory, and other “conditions” that are treated, and medicated, but not cured.
Healthcare providers: physicians, clinics, hospitals and others excel at dealing with existing medical conditions in one of two ways–repair it or cope with it .Medical approaches to “prevention” are mostly about early detection, when options are many, outcomes are improved and recovery time/cost gets reduced.
Provider system focused Population Health Management is not new. It is a recycled concept from the 80s known then as Managed Care. Remember, Health Maintenance Organizations? or Primary Care Providers? or Capitation and risk pools? These were the ACOs, Medical Centered Homes and outcome based compensation models of their day.
Perhaps these initiatives broadly struggled and failed because they were good ideas, ahead of their time. Certainly much has changed since the 80s in healthcare. We have more sophisticated medical science; evidence based medical practice, clinical data analytics and transparency, broadly available networking, supporting government policy, and an urgent cost of health care economic threat to motivate us. Clearly, times have changed and this time it will work.
However, can we really imagine hospitals organizing medical staff members to share reimbursement and risk for significantly reducing member healthcare utilization, if member behavior does not change? Can hospitals and, more accurately, physicians, get patients to change unhealthy lifestyles? What about the “healthy” young population of future health benefit abusers, happily engaging in irresponsible personal health practices that have not caught up with them just yet? I am not talking about high risk behavior. I am referring to sedentary life styles; overeating (supersize me!), alcohol consumption, smoking, marijuana, sugar (Mayor Bloomberg wasn’t really wrong about Big Gulps!), and one of my personal favorites–carbs! These behaviors will drive continued exponential growth of preventable chronic conditions if left unchecked.
Hospital executives considering an Accountable Care Organization are focused on creating a care delivery network, IT investments in interoperability, data management and analytics, member assignment, compensation and goal negotiations with government, and employer sponsored payment programs. These are significant decisions and challenges, but they are, essentially, mechanical. Vitally important, they do not address necessary wellness initiatives that reduce long term demand for medical services, crucial to successful population health management.
Perhaps before any of these efforts are begun, research should be conducted to learn how other industry players focus on positively impacting individual life style and healthy living choices. Assemble all available internal and external data about the population your ACO will serve. Leverage “big data”, not with clinical informaticists focused on early detection, but with actuaries providing insights into environmental risk factors, expected demand for medical services (volumes and acuity at very granular levels of detail) and insight into specific challenges of healthy lifestyle programming of your membership. Are your members physically fit and health conscious in an outdoors focused locale? Maybe a population where nutrition culture is defined by local dishes, which are really tasty but not so healthy? Are some communities within your population underserved by healthy option food services and groceries? Are some demographic segments heavy smokers or drinkers or sedentary? What programs and strategies have been shown to meaningfully impact personal decisions every day?
Severity and frequency of medical events can be reduced with structured, proactive clinical monitoring, and support for at risk populations: children, seniors, and those of middle years who have acquired a chronic condition or are predisposed to a chronic condition. Emergency room visits can be reduced for patients recently discharged or those suffering from chronic conditions when support is provided for taking medications compliantly, completing prescribed therapies, and medical provider maintenance. Efficiency and medical quality can be improved with decision support for care givers and patients/family members to understand and select the right course of treatment, provided by the most appropriate medical provider and venue.
Social, demographic, and environmental factors must also be addressed, if an ACO is not going to walk the path of HMOs to failure. These are long term drivers of future demand. Many of them can have immediate, positive impact on medical utilization, addressing societal economic challenges. These actions can deliver personal and social benefits, improving individual quality of life versus life lived longer in poor health.
To summarize, apply operational thinking already defining provider-based approaches to outcomes and costs. Utilize tools and practices of payers, employers and public sector to change personal choice, reducing need. Recognize that physicians make poor personal trainers, nutrition counselors, and health coaches. Evaluate environmental factors that make poor choices easy or necessary. Measure everything at levels of detail which make interventions and continuous outcome improvement possible.
Population Health Management is a myth. Health is personal. Healthy lifestyles are largely a choice. Even those of us challenged with genetic predispositions or conditions can make choices and engage in behaviors that maximize quality of living. Maybe we should really focus on Individual Health Management!