The triple aim promoted by former Centers for Medicare and Medicaid Administrator Donald Berwick—lowering per-capita costs, improving the patient experience and improving population health—is taken as an article of faith.
The vaguest of these three is population health. What exactly does it mean?
In a widely cited Journal of the American Medical Association article, Douglas Noble and Lawrence Casalino wrote that accountable care organizations were interpreting population health in medical terms, or “as a responsibility to provide preventive care for all of their patients and care management for their patients with serious chronic disease.”
“Population health,” they wrote, “depends not only on medical care, but also on social services, the public health system, and, crucially, on socioeconomic factors (e.g., housing, education, poverty, and nutrition).” They argued that focusing population health only on patients “may divert attention from social and public health services and from socioeconomic factors critical to health.”
Most Dallas-Fort Worth healthcare executives beg to differ. Population health, they say, really should be plural: populations defined by specific demographics or conditions to allow their organizations to treat them specifically and properly.
Texas Health Resources chief operating officer Barclay Berdan said, “A population is not just a community. It can be an employer and its employees. Or a patient panel. The term ‘population health’ can throw people off. It’s too big to have an influence.”
Population health is a societal definition and a geography, added THR chief clinical officer Daniel Varga, MD. Hospitals need to identify resource needs, he said, and have accountability for specific populations, like coronary artery bypass grafting and looking at their care for 120 days after surgery. A health system could manage specific procedures “spectacularly” using that approach, he believes.
“If you look at [treatment of] congestive heart failure at any of our facilities, you will find equally good outcomes regardless of race. If you go out in the community, you will find huge disparities. You need a different set of tactics for that.”
Sharon Phillips, Parkland Health System executive vice president, said, “When you address population health that broadly, it is hard to do it well. It is evolving toward more specific definitions of specific definitions of population health management.”
Baylor Health Care System is using predictive analytics to focus on its patients who are likeliest to rack up large healthcare bills. Those patients are stratified based on the top 1 percent, 5 percent and 20 percent, based on health status.
Cliff Fullerton, MD, Baylor Quality Alliance chief medical officer, said each group commands a specific set of care-management resources. He said the top 1 percent receive home visits by nurse practitioners.
Christine Snead, Baylor community care coordinator, said the 1115 Medicaid waiver would allow the system to serve uninsured and underinsured patients at its seven community clinics better.
THR relies on the big-data capabilities of its joint-venture partner Healthways to risk stratify its Texas Health Physicians Group patients. Berdan said those patients are put into three categories: high risk for high costs; those with gaps in care; and healthy patients who may need specific interventions to keep them that way. The last category of care will be introduced next month, he said, based on Healthways’ well-being index and included analysis of socioeconomic factors, and connection to family, community and spirituality.
The proposed Blue Zones project in Fort Worth, spearheaded by THR and Healthways and which is designed to improve community health, comes closer to the broader definition of population health.
“If we are able to help nudge people to be active and eat better, that can contribute to the health of our patients,” Berdan said.
Consultant PwC expects more partnerships such as this in 2013 as companies “build their population health infrastructure to include shared responsibility for patient outcomes and satisfaction, data collection and analysis, member education and engagement, and a focus on at-risk populations.”
An American Hospital Association survey of hospital chief executive officers in late 2011 found that 98 percent agreed that hospitals should investigate and implement population-health management strategies, although executives of larger hospitals were more likely to identify them as necessary to guarantee their future institutional success.
Phillips said Parkland was the first U.S. health system to incorporate the social determinants of health in providing care.
“There might be social determinants that get in the way no matter how well we do medically,” she said. “They may be jobless, or have drug or alcohol issues. We try to stabilize them in their home environment. That’s a more granular definition of population health.”
Parkland studies the health of neighborhoods surrounding its 12 primary-care health clinics and staffs them accordingly. Parkland also has a mobile clinic that visits 28 Dallas-area homeless shelters.
Steve Jacob is editor at large of D Healthcare Daily and author of the book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at firstname.lastname@example.org.