3 questions about population health with no easy answers

'Population health' is a term used begrudgingly by most healthcare professionals. It's not that anyone opposes the idea of keeping populations healthy — it's that the fine print of how to do so makes for an endless conversation. 

Certain questions commonly come up in talks about population health — three, specifically, surfaced during an April 20 panel at the Becker's Hospital Review 8th Annual Meeting in Chicago. 

The discussion, moderated by David Jarrard, president and CEO of communications firm Jarrard, Phillips, Cate & Hancock, touched on the definition(s) of population health, financial models to support the health of large groups of people and the need for physician education and involvement in the cause. 

Throughout the discussion, panel participants acknowledged certain questions they grapple with themselves or see other healthcare providers struggle to solve, and how they attempt to answer them. Here they are: 

1. What's the definition of population health? A Google search of What is population health? yields this primary return: "It is an approach to health that aims to improve the health of an entire human population." It is safe to say that leaves room for interpretation. 

"If you asked five people for a definition of 'population health,' you'd get 10 different definitions," George Whetsell, co-founder and managing partner at Chicago-based Prism Healthcare Partners, said to his nodding co-panelists. 

Mr. Whetsell has encountered different versions of the phrase in his work with hospitals and health systems of all sizes across the U.S. He said some use it to describe public or preventive health activities, such as wellness visits and free mammograms. Others use it to refer to alternative payment models or provider-sponsored health plans, whereas some see population health through a provider-specific lens — i.e. referrals, patient handoffs and guiding a patient through medical settings during an episode of care.  

The fact that population health carries multiple meanings is itself a challenge. Before entering a conversation on the matter, one must explicitly state their working definition to compare apples to apples. Assuming population health means the same thing to a colleague guarantees an apples-to-oranges exchange. 

2. How will my hospital influence someone's transportation, literacy or dietary habits? Stonish Pierce, regional chief ambulatory, ancillary and business development officer for the mid-city region of Chicago-based Presence Health, defines population health as taking accountability for the outcomes of a population. 

Presence has secured a nutrition grant and opened a farmer's market for low-income patients. It launched a three-week healthy lifestyle summer camp for children and a mobile care van that travels throughout Chicago, both of which are funded via philanthropy. The system partnered with the YMCA to offer temporary memberships, is considering further investments in fitness centers and has partnered with transportation companies to ensure patients have the means to arrive at appointments on time. 

Although Mr. Pierce has a definition of population health — and a record of actions his system has taken to support it — that doesn't necessarily make buy-in a sure thing in the physician community. Given the cost pressures hospitals face nationwide and growing concern for the wellbeing of physicians and caregivers, organizations are unsure of how they can or will meaningfully move the needle on economic and sociological conditions outside of their direct control.  

"We will have to find a way for patients, caregivers and communities to really work in concert with one another," said Cheryl Sadro, executive vice president and chief business and finance officer for University of Texas Medical Branch at Galveston. "The biggest obstacle we see is 80 percent of the issues around population health are completely out of our control — socioeconomic issues and the very things people make choices about every day." 

3. Who or what will pay for population health improvements? "Money drives everything," says Mr. Whetsell. "Reimbursement has driven every decision in healthcare for the last 40 years."

The majority of health systems still make the bulk of their revenue under fee-for-service payments. In fact, only 3 percent of health systems provide more than 50 percent of all care under value-based contracts, according to a 2016 report from Deloitte. For health systems to take accountability for the outcomes of a population, they need a payment model that supports the preventive and social services that entails — not one that reimburses based on the number of tests, procedures and treatments provided. 

The coming months or years will either bring the repeal and replacement of the ACA or ongoing policy uncertainty. Either way, hospitals and health systems will feel margin pressure. As resources tighten and cost-controlling initiatives intensify, many hospital and health system leaders feel strapped and are scrupulously analyzing investment decisions. Given this context, one can see why the idea of bearing more expenses for activities that are not guaranteed to improve health outcomes — and may divert patients when hospitals are still largely reimbursed on fee-for-service with DRGs — is unfathomable. 

"I have a concern that we can't be halfway," says Mr. Whetsell. "There can't be middle ground, where we are 80 percent fee-for-service and 20 or less percent capitation. We either have to bite the bullet and move to a full capitation model, or we are stuck with a fee-for-service, volume-driven system that continues to work the way it has."

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