Population health: Why the hottest term in healthcare is getting problematic

It's not unreasonable to say ACOs need a new term to describe their work.

As population health emerges as a driving force in healthcare, many hospitals and health systems are trying to define the precise role they should play in this complex paradigm.

Some systems are approaching it narrowly, partnering with physician groups or post-acute care settings and calling it part of their population health strategy. Others are casting a wider net, partnering with community organizations and taking on responsibilities they wouldn't have considered several years ago — all without a defined return on investment.

Those approaches are neither right nor wrong, but the latter is more supportive of population health's goals — many of which extend beyond the small bubble of hospitals and physicians.

Somewhere along the way, the term "population health" took on multiple meanings. The true definition of the term loosened a bit, and people started peppering their conversations with (what has become) healthcare's hottest buzzword. If this persists, healthcare runs the risk of diminishing what was originally a very big, powerful idea.    

May we have the definition, please?
In its truest form, population health refers to the health of an entire population of a geographic location — not so much a defined group of patients assigned to a health system's accountable care organization. The ACO model is relatively new, making most of the language we use to talk about it new to us, as well. It is not uncommon for healthcare professionals to conflate "population health" and use it without precise meaning, or to use it strictly in reference to ACO beneficiaries.   

Jason Dinger, PhD, is CEO of MissionPoint Health Partners in Nashville, the accountable care organization affiliated with Saint Thomas Health. When asked to describe population health, he says to picture a Venn diagram.

In that diagram, health policy makes up the biggest circle, with health improvement strategies falling inside of it. A smaller circle inside that represents healthcare, which contains bubbles for hospitals, physicians, rehabilitation clinics and more — the gamut of healthcare providers. When you look at it this way, it's no wonder some in the hospital industry see population health as daunting: Hospitals represent one circle among many, and one that is dependent on the success and engagement of other participants in the health policy arena.

Lawrence Casalino, MD, MPH, PhD, is a professor of healthcare policy and research at Weill Cornell Medical College in New York City. He has worked with several colleagues to reign in the use of "population health" and remind those in healthcare of its broader meaning.

In addition to medical school, Dr. Casalino was trained as a sociologist. He worked as a community organizer before he earned his medical degree and ran a family medicine practice for 20 years. "I think I have a pretty good sense of what medical care can and can't do," he says. "Certainly, we can do wonderful things with medical care and affect people's health, but there is a lot of research to suggest that social determinants of health are, overall, more important to people's health than medical care."

These determinants include all those things in the health bubble that Dr. Dinger described: income and levels of income disparity, crime and neighborhood safety, housing, education and employment, along with several others. This is where two difficulties come up: The challenge health systems have in finding their niche in this broad context, and the frustrating reality that there is only so much a healthcare provider can do to influence those social determinants.

"Health systems are not the government," says Dr. Casalino. "They do not have the resources, expertise or authority to improve the health of the population in a geographic area on their own. They can't change the public school system. It's hard to think hospitals could affect levels of income disparity. They're busy enough trying to do what they have to be doing to improve care for their patients."

But this doesn't mean hospitals shouldn't or couldn't contribute to the work that can change those social determinants of health. Hospitals are often the largest employers in their communities, and generally, they are highly respected. If they at least make an effort to collaborate with other social institutions or local nonprofits to make nonmedical changes and improve community health, that certainly wouldn't be a bad thing. Unfortunately, the money put toward these efforts will likely remain meager until there's a stronger business case for doing so. There is no direct economic incentive for healthcare providers to think about the health of people who do not yet require medical care.

Historically, hospitals have sent oncologists to the community gym to talk about the system's cancer care or nurses to shopping malls to take shoppers' blood pressure. This has been seen as community benefit. There's no ill will here — that is good and important work, but it doesn't really affect the social determinants of health, experts suggest. And health systems' partnerships or affiliations with nursing homes, urgent care centers or specialty groups aren't the most direct way to influence the health determinants of a population, either. "You're still in that care circle," says Dr. Dinger. "But man, there are a lot of other things going on beyond just caring for people."

Dr. Casalino says his point is not to criticize hospitals, but to get language right. Talk about population health relative to accountable care organizations, meaning the health of assigned beneficiaries to a healthcare provider, slowly deflates the term of its originally intended meaning. If healthcare providers, consultants, speakers at industry conferences and others push the idea that population health is catching on and being taken care of, it's easy to forget much of the work isn't about the health of geographic populations much at all.

When policymakers are led to believe population health is already in the works, it could have especially damning repercussions. If healthcare providers keep touting their population health efforts and using the phrase as much as they like, population health may soon be seen as healthcare jargon rather than a health policy concept. As a result, funding toward public health agencies and nonprofit organizations may remain stagnant or possibly suffer.   

It's not unreasonable to say there needs to be a new term to describe the work ACOs are doing.

"I get emails every day that go to thousands of people, saying 'population heath management conference' this, our organization will help you with population health management," says Dr. Casalino. "Everyone feels very proud because everyone feels it's very important to do population health, but it's a very loose use of the term and probably not the best use of the term. Really we're only talking about medical care for patients attributed to ACOs."  

Where hospitals go wrong
Many health systems are eager to frame new programs as population health endeavors even though the initiative may be no different from a program launched 10 years ago under the traditional fee-for-service payment model. Conversations about population health are progressing to a point where healthcare leaders should be prepared to answer for specifics: What is the precise population you're targeting with this program? Who will bear the real risk for these people and their health? How do you plan to reduce costs? How are you measuring results?

Dr. Dinger thinks a couple of different trends have taken hold of the hospital industry. "One: People are instituting a new set of programs to show they can think differently about health. 'We'll institute a program for how to provide healthcare services for the homeless community or other disenfranchised 'population.' But many would say that is still in the care circle," he says. "Two: I think a lot of institutions are engaging specific populations to show they are actively reaching outside of their traditional walls, which is a good thing, but are still trying to determine how to sustain these programs under their current economic models and in partnership with others."

Take a homeless healthcare program, for instance. No one debates the importance of accessible healthcare for homeless men, women and children. But if launched under the premise of population health, providers must address the costs of care — not just shift them — and determine who will bear the real risks for this population's health. This calls for health system leaders to think creatively and flex muscles that may not have been put to use in traditional strategic planning. "I think we, as healthcare industry personnel, need to start thinking about the costs outside of healthcare to bend the cost curve over time and distribute the shared savings in a way that sustains both our healthcare institutions as well as supporting organizations that aren't traditionally considered as part of the healthcare system," says Dr. Dinger.

Though they need to think more creatively, healthcare leaders should also have a healthy sense of skepticism about population health efforts. What might look like a much-needed intervention on paper, such as a grocery store in a food desert, may only turn out to be one small piece of a multipronged solution. There are no silver bullets, but amid excitement for population health, systems may oversimplify problems and overinvest in solutions only to see the same health outcomes.

For instance, several studies have suggested that opening grocery stores in food deserts can have a limited effect on changing behaviors. "We've worked hard to provide access to fruits and vegetables, [but] we still need to educate around how many healthy foods can be prepared and desirable for the entire family," says Dr. Dinger. "Our experience is that many people are knowledgeable about healthy eating and active living, but have trouble working around the day-to-day barriers [and] then trying to put that knowledge into practice."

Health systems also have to reduce their obsessions with "programs" to succeed in population health. Instead, they must get better at partnering with community organizations and nonprofits. As illustrated by Dr. Dinger's Venn diagram, health systems cannot improve health outcomes by themselves. Yet some still attempt to act as autonomously as they can, ignoring a wealth of expertise and resources.

"When we talk to other population health managers, they have unearthed a number of unique challenges inside their populations, such as domestic violence, elder abuse and other public health crises. Unfortunately, most respond by trying to implement their own unique program to respond to the issue," says Dr. Dinger. "We usually encourage them to first speak with the experts in their community who work on these issues every day. In many cases these are nonprofit organizations that can add great value to the population health effort but often have trouble engaging and integrating with a health system's efforts."

In a viewpoint piece and qualitative study published in the Journal of the American Medical Association and the British Medical Journal this spring, Dr. Casalino and his colleagues suggested that the narrow, ACO-centric definition of population health could lead ACOs to wrongly conclude they are addressing all aspects of population health and therefore do not need to form relationships with public health agencies.

It's true that hospitals today are expected to do more with less, but by working under a narrow understanding of population health, hospitals may perpetuate this expectation more than necessary. Population health does not lie on health systems' shoulders. By partnering with nonprofits, public health agencies and other organizations, health systems can play into their own strengths and benefit from the expertise and contributions of others.

Finding space to innovate
Fee-for-service is still the predominant payment model in healthcare, but some health systems have an easier time pursuing population health under this pay model than others. What sets them apart?

First, population health pioneers have found ways to innovate around traditional reimbursement. MissionPoint's physicians work under a modified capitated agreement, which has left the ACO with more flexibility to experiment with care delivery. Dr. Dinger says MissionPoint empowers pediatric groups to launch a fast-track system that treats patients who do not have appointments, for instance. People and their children can be seen in 30 minutes or less by a nurse practitioner, who also reserves time in the appointment for parent or guardian education.

"When you're getting monthly amounts for patients, your cash flow is smoother, and you can start innovating because you know what cash is coming in next month," says Dr. Dinger. "Many can now afford to do that, but in fee-for-service world they were unable to."

MissionPoint also sees the value in taking on extra upfront costs for patients to reduce their healthcare costs down the line. The ACO doesn't know exactly when or where it will see that ROI, but this is all part of bearing risk. MissionPoint pays for certain memberships to The YMCA, for example. "We know that being able to help people develop healthy active living habits is crucial to some people in our population," says Dr. Dinger. "If we can get them to go to the Y, we'll save money elsewhere to offset the cost of the Y membership. By providing more support services, we're able to improve a member's health status and prevent their costs from escalating."

Aside from the strategic complexity of population health, health systems must also overcome a workforce and staffing problem. Nearly 60 percent of health system and hospital CEOs ranked population health as the "hardest" skill set to find within the broader healthcare field, according to an American Hospital Association survey. Further, 48 percent of executives identified community and population health management as a talent gap within their organizations, making it the second-largest talent gap recorded after experience in leading nontraditional health partnerships, which is closely related (54 percent).
ACOs are still in their early days, and now is the time for health system leaders to move their organizations in the right direction by clarifying their ACOs' responsibilities, defining their role in improving health for the greater community and establishing a willingness to partner with organizations that fall outside of the healthcare bubble.

For as much as we hear it and read about it, population health is not a healthcare-specific concept. It is something to be shared between public health agencies, social institutions and policymakers. Hospitals fit in there somewhere. We shouldn't expect too much too soon, but hospital leaders need to start defining what their organizations can do in the broader picture of population health and explore opportunities that have, for years, gone untouched.


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