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Which Populations? Whose Health?

By Emily Friedman. First published in Hospitals & Health Networks Daily on June 4, 2013

The success of population health improvement initiatives will depend not on payment policy or inspirational models, but on the hearts and minds of those who work in our hospitals, medical groups, community health centers and other sites of care

Emily Friedman

Buzzwords flit around health care with the same energy — and sometimes the same result — as heat-loving insects flit around a flame. Much of the time, they come, they go, only to be replaced by another of their ilk. But how often do these buzzwords and the concepts they represent actually make a difference? How many of them change attitudes or, even more important, practice?

These thoughts came to me as I contemplated the new enthusiasm for population health management (I prefer the term population health improvement), a concept with great promise for healthier patients and communities, as well as significant cost savings for providers and payers. Definitely one of those win-win things. On the other hand, I was reminded of the "healthy communities" movement of years ago, which involved many of the same buzzwords and concepts and pretty much petered out in most places.

Mounting Pressures

It isn't as if there is no interest in improving the health of populations. Accountable care organizations are charged with bettering the care and health of defined groups of Medicare or other patients. The Affordable Care Act requires that nonprofit hospitals conduct community health needs assessments and attempt to address unanswered needs (and to explain which ones are not being so addressed, and why); proposed regulations for this activity were released by the Internal Revenue Service in April. Insurers, obviously, can save a mint if their policyholders are healthier. And oh, by the way, preventing disease that doesn't have to happen, and mitigating the effects of disease that does happen, are good and moral things to do.

Yet, a recent survey by the Health Research & Educational Trust, an affiliate of the American Hospital Association, found that of 10 priorities for health care organizations seeking to move to an outcomes- and value-based based model, population health improvement ranked 10th, outranked by everything from clinical alignment to integrated information systems to partnering with payers.

Large, truly integrated health systems certainly have the potential to improve the health of their communities, but whether they actually have the chops — and the will — is another question altogether.

The same potential exists, on a more limited basis, for ACOs. But in a widely publicized article ("Can Accountable Care Organizations Improve Population Health? Should They Try?" by Douglas J. Noble and Lawrence P. Casalino, Journal of the American Medical Association, vol. 309, no. 11, pp. 1119-1120, March 20, 2013), the authors point out that "many ACOs appear to interpret their responsibility for population health in medical terms — that is, as a responsibility to provide preventive care for all their patients and care management for their patients with serious chronic disease." Although the authors concede that this is an improvement over the traditional model — "which has been to focus on whatever patients appear in the physician's office" — it hardly constitutes taking responsibility for the health of everyone in a given community or area.

"Population health," they go on to write, "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)." Therefore, they say, to claim that ACOs are focusing on population health improvement when they are really only providing care to a selected patient group muddies the waters and "may divert attention away from social and public health services and from socioeconomic factors critical to health."

If a health care alliance or system of any kind announces that it is taking on the task of protecting the health of a population, I'm afraid that some cynical questions should be asked: What are you in this for? The putative fiscal rewards down the line that the ACA promises? Or true community health improvement? Will this be a new model or, rather, a replay of the early 1990s, when insurers (many of whom are forming ACOs) figured they could make a fortune by severely restricting access to providers through tight managed care? That didn't work out too well. Are you prepared to face the challenges of a general, random population, or will this be one more exercise in cherry-picking the younger, healthier and better insured? As any student of health care history can tell you, there are myriad ways of avoiding difficult or unhealthy patient populations, no matter how "random" the selection is supposed to be.

If You Really Mean It . . .

Furthermore, a true commitment to population health improvement means going beyond both the individual and the clinical perspective — not a comfortable prospect for most providers. Yet that's the difference between window dressing and making a real difference.

In a January report titled "U.S. Health in International Perspective: Shorter Lives, Poorer Health", the Committee on Population of the National Research Council found that the United States ranked 17th among developed countries in terms of health status and longevity. Although the committee found the usual problems within the health care environment — lack of insurance, spotty availability of primary care, insufficient attention to prevention, poor health habits — it concluded that, in the words of its chairman, Steven Woolf, M.D., professor of family medicine at Virginia Commonwealth University, "Much of our health disadvantage comes from factors outside of the clinical system and outside of what doctors and hospitals can do." Or, at least, can or will do at present.

The authors noted that the United States suffers from "a unique weakness of its social safety nets, the magnitude of social inequalities, and the harshness of its poverty," as well as factors as diverse as too many traffic accidents and the widespread availability of firearms.

Woolf also wrote, "Research is important, but we should not wait for more data before taking action, because we already know what to do."

And we do, in many ways, if we have the intestinal fortitude. Physicians can be empowered (which includes making it worth their time, and seeing that they have the time) to talk about improving health behaviors with patients. Hospitals and systems can cast their nets wider, so that everyone in the community is included, instead of leaving out those most in need.

Social workers, community health aides, volunteers and others can be trained to go into the most neglected parts of town and talk to ministers and deacons and members of religious orders, barbers and hair stylists, teachers and principals, police and fire department representatives, those involved in criminal justice, and others who every day see the results of strict adherence to the medical model: seniors living alone in unsafe housing, tripping over wiring, suffering smoke inhalation from fires or debilitation because of malnutrition; obese children victimized by a combination of dietary ignorance, busy parents and a lack of available healthy food; a street gang culture that follows Al Capone's well-known advice to "live fast, die young, and leave a good-looking corpse"; widespread, uncontrolled anger that leads to domestic abuse and murder; the hopelessness of long-term unemployment and poverty; and the often-unseen epidemic of depression.

These plagues are more difficult to address than childhood immunization. Who wants to take on the National Rifle Association? Who can be convinced to open a supermarket or a full-service restaurant (preferably one with healthy offerings) in a high-crime area? Who will protect the produce from community gardens? (I have lived in the inner city most of my life, and I have grown herbs and vegetables whenever I could and, for several years, I had to live with constant poaching of green beans and zucchini from my all-too-accessible garden by persons unknown.) Who will pay health care providers, stuck in their medical-model silos, to inspect patients' homes for dangerous wiring or gas connections? Who will employ ex-offenders, or provide anger management classes for abusers, or go into the prisons to improve care?

The fact is that American hospitals and systems have done all of this and more. Learn from the winners of the Foster G. McGaw Prize and the Premier Cares Award and marvel at their creativity: Mount Sinai Hospital in Chicago starting a beekeeping program for ex-offenders (it's great honey; I buy it at the farmers market); Baystate Medical Center in Massachusetts, transforming a county jail; St. Mary's in Lewiston, Maine, building housing for low-income families; Henry Ford Health System in Detroit launching the African-American Men's Health Initiative to serve all of southeastern Michigan; and many, many more innovative and successful programs.

It can be done, but committed providers need to know where to look for both need and inspiration. Community needs assessments cannot be superficial. In the annual United Health Foundation health rankings for 2012, for example, Vermont ranked as our healthiest state (an almost all-white population, many of them affluent and living in college towns), whereas Louisiana and Mississippi tied for last (large African-American populations, many of them very low-income). Yet, there are pockets of poverty in Vermont and of significant wealth in Louisiana and Mississippi.

Hawaii, with the highest percentage of Asian-Americans in the United States, ranked second — it's an expensive place to live, so it attracts the wealthy, and it offers year-round opportunities for exercise, plus plenty of fresh fish to eat. New Mexico — which has the highest percentage of Latino residents in our country — ranked 32nd; Alaska, with the highest percentage of Native American residents, was 28th.

But look again; drill down. Many Native Hawaiians suffer from extremely poor health and premature death. There's a big difference between the health status of people in Los Alamos, N.M. — one of the wealthiest counties in the United States — and the low-income, poor-health border counties. Virginia ranked 21st overall, but five of the nation's 10 wealthiest counties are located there. Conversely, South Dakota overall ranked 27th, but five of our nation's poorest counties are there, along with two in Texas, and one each in Alaska, Arizona and North Dakota.

Drill down deeper. Take my town of Chicago. I imagine, if I spent some time with the Chicago and Cook County departments of health, I would find enormous differences between the health status of people living in ZIP code 60611, home of million-dollar condo towers and our previous mayor, and ZIP codes 60621 and 60636, where in some neighborhoods the life expectancy for an African-American man is about 20. The causes for these disparities lie largely outside the medical model.

The Partnership Imperative

Speaking of public health, those providers that are serious about population health improvement should spend some quality time with their city, county and state health departments. These agencies are the wellspring of population health improvement; that's what they do for a living. They are underfunded, unsung and often plagued by politics, but they have much to teach the rest of us.

As Thomas Frieden, M.D., M.P.H., director of the Centers for Disease Control and Prevention, wrote in the May 16 issue of The New England Journal of Medicine, one of public health's major roles is "to protect and promote health through populationwide action. Governmental action is often a more effective and efficient means of protecting public health than the actions of individuals. Immunization mandates, fluoridation of water, iodization of salt, and micronutrient fortification of flour are all classic examples of this type of action; many were controversial initially, but are widely accepted today because they save money and reduce illness, disability, and death." He goes on to write that some initiatives, such as bicycle paths and limits on the number of liquor stores in a neighborhood, "serve entire communities, and individuals cannot feasibly implement them on their own."

Neither can individual providers. Partnerships are critical — with public health, other providers, community organizations, activists, the police, the fire department and anyone else who realizes that reinventing the wheel will doom efforts to improve health, all that will be accomplished is needless competition, bickering and the usual suspects falling through the cracks.

And I wouldn't worry about such partnerships being scrutinized by the Federal Trade Commission for anti-competitive behavior; no one is going to get rich off any of this.

Unanswered Questions

Obviously, there are many questions about how well real community health improvement efforts will work. One is whether payment will follow policy. If money is indeed saved, will those who produced the savings see any of it? One reason some of the emerging ACOs make me nervous is that everyone involved seems to think that his or her organization will garner the riches, and that is not how it is likely going to work.

Another issue is that those who talk the talk are going to have to walk the walk, and that has torpedoed many allegedly high-minded efforts in the past. Recently some of the Pioneer Medicare ACOs threatened to leave the program because, rather than just reporting on what they were doing, they would now be required to demonstrate that they have achieved what they promised. Well, gee.

A third issue, as health care consultant and health information technology expert Maria Friedman (no relation) has pointed out, is that although "using HIT to improve population health is essential," the fact is that "electronic health records are not designed to support it." They need to change, she writes in the March 20, 2013, issue of HIT Perspectives, from being "transaction-based to being intelligence-based. They need improved capabilities for disease registries, large-scale data collection, decision suppor and predictive analysis." She adds — and this is a critically important point — that "physician panels, especially for primary care providers in ACOs, will likely be very different from what they are today and will require practice change."

There is also what I call the public health conundrum — the fact that the most successful public health efforts are conspicuous by their low profile. No one is poisoned by bad salami at the deli, there is no measles epidemic, illness caused by that tainted pharmaceutical was nipped in the bud. There is no fanfare; there are no headlines. And, more likely than not, the public health budget is cut, despite the fact that these nonevents are the product of very hard work on the part of many health care professionals.

Fourth, how will success in population health improvement be measured? How will it be rewarded — if it is rewarded at all? The dismal history of societal neglect of our public health departments, unless and until there is some cataclysmic event, does not exactly inspire optimism.

Finally, there is a deep cultural and psychological issue. Mitch Greenlick, an Oregon state representative and longtime advocate of population health improvement, wrote in JAMA many years ago that health care, and medicine especially, is overwhelmingly geared toward the individual — practitioner and patient alike. It's the patient in front of me who matters, and what's in it for me if some kid I never heard of gets measles?

In epidemiological parlance, the symbol for a population is n. Greenlick's question was "Can providers learn to love n?" It's a stretch, and it will likely require a major re-do of medical education (which Greenlick, a pharmacist, also has attempted) and nursing education and the culture of health care itself. Public health can teach us much here, as can military health care, if we are willing to listen and learn. But stemming the rampantly individualistic tide of our health care culture will not be easy.

Do It for the Right Reason

In the end, the success or failure of population health improvement initiatives will depend not on payment policy or provider attitudes or even inspirational models, but rather on the hearts and minds of those who oversee and work in our hospitals, medical groups, community health centers and other sites of care.

As the Rev. John G. Simmons, a hospital administrator (among many other roles) who spent his entire adult life addressing the social causes of ill health, wrote in his memoir, A Sacred Rage: "You have to be involved with the community if you're going to be a community hospital. The health of the community includes more than the physical health of its people. It includes political, economic, educational, mental, social and religious health.

"Social wounds do not always bleed before our eyes. They are often internal injuries of spirit and of mind. But they will out. The prejudice, hostility, hate, envy and fear we have for our fellow men who differ in any way from us is a cancer . The healing community of the hospital must move toward the healing of the social sicknesses in the community with a commitment to seek to prevent social sickness and not merely to cure or to be content with curing superficially. The whole man — body, mind, and spirit — must be made whole again. If not, we shall be torn apart, man set against his fellow man. [We must be guided by] the creating and sharing of a common unity of purpose."

The Rev. Simmons died in April, his dream yet unfulfilled. I hope that someday we can make it a reality, for all of our sakes.

This article is dedicated, with love and respect, to the memory of the Rev. John G. Simmons, 1917-2013.


Copyright 2013 by Emily Friedman. All rights reserved.

Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Daily and a member of Speakers Express. The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.


First published in Hospitals & Health Networks Daily on June 4, 2013

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