Buzzwords often “jump the shark.” And, when they do, many in the healthcare industry tend to discard the concepts behind the trendy nomenclature altogether. Psychologists refer to this as semantic satiation, when the repetition of a word causes the listener to perceive the speech as repeated meaningless sounds. Words such as “paradigm,” “rightsizing” and even the phrase “do more with less” come to mind.
My fear: “Population health” may soon fall into that bucket as well. And, that’s truly unfortunate as population health could help to dramatically improve the quality of care received and outcomes realized by patients. Instead of discarding the concept, however, it’s important for healthcare professionals to understand the true meaning of population health, why it has surfaced as an important goal and what we as an industry can actually do to move population health efforts forward.
Beyond the ivory tower
So what exactly is “Population health?” Dr. David Nash, Dean of Jefferson School of Population Health, states that population health focuses on outcomes distribution within a population, health determinants within that population and policies and interventions that impact the determinants.
This definition provides a great foundational understanding of the concept – and one that my graduate students at the University of Southern California fully grasped. So, when I asked them to write a paper that answered the following question: “What would YOU do to improve the health of our population?” — they reacted quite happily, thinking they could quickly master the assignment.
However, they soon realized that population health is not as easy as it looks. In fact, upon deeper analysis and as they attempted to move from the academic to the practical, they realized that many questions need to be asked and answered such as:
• How are we specifically defining the population?
• What are the determinants specific to the population?
• What are the interventions we are proposing?
• What are the outcomes that we are measuring?
Answering these questions turned out to be much more complicated than any of the students originally imagined. For example, the students realized that there are many ways to define a specific population. It may be by age or disease, geography or covered lives, or patients within a practice by risk, age and disease. These all represent certain types of populations, none greater than the other.
Exactly how the population is defined, however, depends on what you want to accomplish. Identifying the key determinants will lead us to solutions to make a difference. And, after selecting populations such as parolees from prison, Medicare transgender patients and elementary school students, the graduate scholars realized that there are many ways to define a population.
And, therein lies the challenge. When you define your population, it becomes a frame of reference, a perspective or a new lens. The challenge always is to change this perspective and to make it real. For example, many organizations have seen unnecessary readmissions as a hospital problem. Financially it may well be. However, the solution for unnecessary readmissions lies in defining and redefining the population that we are addressing and then making changes in the community. Turning our eyes 180 degrees changes our perspective and will change the solution.
In essence, Dr. Nash’s definition contains the right components but identifying the components for the population health challenge at hand and making a difference become the real challenges.
Beyond yesterday’s solutions
In fact, the need to make a difference is more pressing than ever before for a variety of reasons. First off, healthcare researchers and actuaries have demonstrated that our population is not as healthy as it could and should be, especially when we compare ourselves to spending and health in other developed nations. Over the past century, life expectancy has increased and maternal and infant mortality have plummeted but, at the same time, obesity and type 2 diabetes have increased with increasing secondary complications in both morbidity and mortality.
Second, addressing today’s health issues requires a much different approach than it used to. It’s become increasingly apparent that in contrast to the 20th century where many of the determinants of health were infectious, the determinants in the 21st century are behavioral. Inactivity and a sedentary lifestyle, over-processed food and fast food and, as hard as it may be to believe, smoking still affects approximately 20% of the population.
So, whereas vaccines, clean water, car seats and seat belts were the solutions of the past, behavioral and environmental determinants are the solutions for the future. And, that makes a huge difference in population health efforts.
Consider the following: Once vaccines are developed in the lab, they can have a rapid effect on a population. Heamophilus Influenza (HiB) vaccine, released for children in 1987 and infants in 1990, saw a rapid decline in associated disease, the most severe being meningitis. Before the introduction of HiB vaccine, HiB was the leading cause of bacterial meningitis among children younger than five years of age in the United States. Every year about 20,000 children younger than five years of age developed severe HiB disease and about 1,000 children died. More than half of the children who developed severe HiB disease were younger than one year of age. Due to the use of HiB vaccine, by 2012, less than 50 cases of HiB disease occurred annually in children younger than age five years.
In contrast to a vaccine, however, implementing behavioral changes takes considerably more time and effort with patient populations. For example, smoking, identified as a behavioral determinant, still accounts for the majority of lung cancer and kills more than 150,000 people per year even though the original definitive research about the dangers of smoking was published in the early 1960s.
Toward new habits
Even though traditional science will help determine the key factors and their impact on health, the social scientists have a much more difficult challenge. Changing behavioral determinants of health requires a different set of principles. Both disciplines are based in science and require great insight into the human biome. However, social sciences require greater dependence on individual behaviors, motivation and patience.
Behavioral scientists tell us that a change in habit, good or bad, occurs in stages rather than at one point in time. Indeed, to change a habit, individuals need to:
• Acknowledge that there is a habit;
• Understand that you want to break the habit;
• Plan what to do to break the habit;
• Implement the change; and
• Maintain the change.
Popular self-help gurus claim that it will take 21 days to form a new healthy habit – or break a bad one. The truth is, there is no magical timeframe for making lasting changes. Some people can pick up a new habit, like eating more veggies, in just a few days. Moving these principles to a population requires even more time and effort.
Reinforcement of behavioral change is an integral component that will yield sustainable results. Rewards for maintaining glucose within a specific range on a daily basis will ultimately change eating habits and an improvement in HgBA1c. In the beginning, frequent acknowledgement of success will reinforce the new behavior. As the behavior becomes a habit, fewer rewards are required. Just as individuals will need to change their behaviors, provider organizations that are interested in population health will need to change their practice behaviors. Newer ways of communicating with patients is required. Innovative ongoing support for patients in making behavioral changes will increase sustainability. As incentives for individual patients promotes change, provider organizations will require incentives to promote and sustain change. Reimbursement and recognition are very powerful incentives for physicians and practices to continue to change.
Beyond the healthcare provider
What’s more, as it formerly took a vaccine to improve the health of a population – now it takes a village. To get an entire population to adopt a healthy lifestyle requires a wide range of participation. Solutions need to include city planners to develop parks and bikeways so activity can be encouraged and safe. The food industry needs to be part of the solution for eliminating food deserts while the politicians will need to respond with policies and regulation. The healthcare delivery system needs to look at how it delivers care and promote health. The annual physical requires a more comprehensive approach to activity, flexibility, nutrition and prevention and not just a set of labs to treat. Health will literally take a village to move behavioral change.
Toward a technology-enabled population health plan
While technology – in and of itself – is not the only population health answer, it is a key component of success. From simple every day tools to new complex innovations, technology needs to be included as part of any comprehensive initiative aimed at managing population health. Secure communication technologies such as e-mail, text messaging and even the telephone can be very powerful tools to help practices engage with individuals in the behavior change process.
The Institute for Health Technology Transformation notes that implementing electronic health records is the first step in gathering data elements for population health management. Subsequently, healthcare organizations must then utilize and analyze the information that is housed in these systems. Sharing information from multiple sources along with identifying additional sources for individual health data through personal devices and remote monitoring equipment will add to the ability of organizations to fully understand individuals and populations.
Predictive analytics tools will take the information we have and allow us to find new relationships between various data points. These relationships will, in turn, provide deeper insight into things we may have never thought existed. More sophisticated analytics tools that help stratify risk within a practice or community will help direct resources to people who need them the most. The human mind is great but just as “machines” are not perfect, neither is the human brain. The human brain cannot manage the plethora of data, let alone do it without bias, that a machine can. Machine learning, on the other hand, only analyzes what information it is given. Therefore, marrying humans with unbiased data analytics tools will produce the most effective outcomes. This partnership will bring new clinical and business information to the forefront so that we, as organizational leaders, can make better decisions for our patients, our communities, and our business.
Organizations will only receive the brass ring, however, when they are able to leverage the information collected and predict the future. Ultimately they will be able to improve population health by asking and answering the following: Where are individuals or populations at risk and what can be done to interrupt or prevent poor outcomes and life-threatening events and improve health and wellbeing?
Conclusion
While moving toward better population health outcomes might seem like a significant challenge, it is important to start somewhere. That may sound simplistic but starting at the beginning with the goal in sight will eventually lead to success. A “mosaic” is a picture made with many small pieces. Put together your mosaic to provide the vision of your future and take time to understand the pieces you have and the pieces you will need. Building your roadmap and collaborating with other professionals and community leaders will get your best results. Set your population health goals, develop metrics and move forward. That will get you where you want to be!
Dr. Wesp currently serves as Executive Clinical Strategist for Jacobus Consulting, a leading healthcare consulting firm, based in Irvine, CA. and adjunct professor at USC Sol Price School of Public Policy. Dr. Wesp is dedicated to improving the quality and safety of patient care through clinical decision support, evidence-based medicine, and the transformation of operational processes. Dr. Wesp graduated from Rutgers University-NJ Medical School, completed residency at Children’s Hospital Los Angeles, holds a Master’s degree in Organizational Management, and is a lifetime member of the American Association for Physician Leadership. For more information on Jacobus Consulting, go to: www.jacobusconsulting.com.
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