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Why Is Improving Population Health So Difficult?

Why Is Improving Population Health So Difficult?

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PHILADELPHIA — Barriers still exist to improving population health overall, but there is room for optimism, Mark Smith, MD, said here Tuesday at Thomas Jefferson University’s annual Population Health Colloquium.

For one thing, “Political leaders increasingly ‘get it'” regarding the need to improve population health. “Health is, as they say, too important to be left to the health department,” said Smith, co-chair of the Guiding Committee on Health Care Payment Learning and Action Network at the Centers for Medicare & Medicaid Services.

The movement toward improving population health and the social determinants of health actually is not new, he asserted, noting that decades ago, public health physician H. Jack Geiger, MD, prescribed food as medicine. And the “Whitehall study” of British government workers, which has gone on for more than 25 years in the U.K., has found that the higher people climb on the government’s administrative ladder, the longer they live, even after controlling for factors such as weight and smoking status.

So why is it coming into prominence now? Because “healthcare costs so damn much,” he said. “[We want to prevent] it from appropriating every dollar the U.S. economy has.”

Back in the 1970s, Smith continued, President Richard M. Nixon, a Republican, proposed universal health coverage in America, paid for with an employer mandate. At the time of Nixon’s proposal, “the cost of a high-end Blue Cross Blue Shield plan was 15% of the minimum wage; by 2009 it was 115% of the minimum wage … We priced ourselves out of reach of the [average family].”

The other reason population health is coming to the fore is the change from reimbursement for volume to reimbursement for value. “We used to pay for visits …. If factories make widgets, doctors make visits,” said Smith. “We pay for inpatient days, procedures performed, units sold.”

Instead, “we would like to pay for outcomes, both clinical — such as lack of infection — and patient reported, such as freedom from pain,” he said. “We would like to pay for quality-linked processes, patient satisfaction, and peer/co-worker ratings.”

While trying to transition from one payment method to the other, “hospitals and doctors have one foot on the canoe and one foot on the dock,” said Smith. “If you’re a hospital, everything you do to improve your finances in a volume-based world hurts your finances in the value-based world. If you’re a doctor, it’s pretty much the same thing … That’s why hospitals are thinking about housing, transportation — things that are unnatural for them to be thinking about.”

This type of change presents several challenges, he said:

  • Complexity of disease prevention. “Compared to isolating a bacillus, if you think about preventing diabetes in America, wagging our fingers and telling patients to [eat better] is not getting the job done … The fixes are enormously complicated and go way beyond health policy to other areas.”
  • Short-term outlook of payers and insurance markets. “If we would like to financially incentivize actions which prevent diseases 20 years from now, [in cases] where the people we are trying to incentivize are not going to have financial responsibility for those diseases, we shouldn’t be particularly surprised if they’re not enthusiastic about doing so,” said Smith. “In some ways, the greatest argument for single-payer is you may finally unify the short-term and long-term consequences in health. This is not a moral judgment, just a statement of fact … Many things that will save money in the long run will require investments of money in the short run by people who won’t save money in the long run.”
  • Rigid departmental silos in government. It’s easy to say you want to unify social services, housing, and corrections around a health-related goal, “but very hard to do,” he said. “To the extent that expenditures in the healthcare system reflect failures of other governmental action, the capacity to get above those silos requires political leadership and a new view of the healthcare sector and other adjacent social services, where these things are quite rigid and are on short budget years … The people doing the integrating have their own FTEs [full-time equivalents] and head counts and contracts to think about.”
  • Power and expense of healthcare stakeholders. “Imagine putting hospitals in charge of social services — first, [costs] will go up 30% off the bat, and second … people doing housing and job training for generations will immediately get pushed aside because we think we understand all this,” he said.
  • Difficulty in scaling up innovations. “Every one of you has a wonderful example of great stuff they did in your hospital, your community and you ask, ‘Why aren’t they doing this all over? — and it’s a difficult thing,” Smith told the audience. “We haven’t developed very good mechanisms to take small innovations to scale.”

And yet, there is reason for optimism, he added. In addition to politicians taking notice, “we have new tools and new science; healthcare has largely been digitized. We have the capacity to have large data sets that can help us with a population health approach that we didn’t have even a decade ago,” he said. “We have greater understanding of pathophysiology and risk factors, digital medical records, and big data, and we have behavioral economics — increasingly being applied both to patient behavior and health professions behavior — and we have a sophisticated workforce.”

But this is still uncharted territory, “and there will be twists and turns, unexpected breakthroughs, and setbacks along the way. So we need lots of PDSA [plan, do, study, act] cycles, because much of this — at least at scale — is theoretical.”

1969-12-31T19:00:00-0500

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