Redefining Population Health to Deliver Health+Care at the N of 1: Part 1

Editor’s note: This is the first part of an abbreviated three-part series.

Experts consider population health the next revolution in healthcare, but before data, analytics, and statistical patterns give up the secrets that will improve patient outcomes, the industry must create a framework of standards, guidelines, and measures that focus on individual impacts to health.

Any conversation about population health starts with definitions: what is health; what are suitable patient groups; what treatments do we measure; do we measure episodes or illness; what is the unit of measurement; what are the expectations. These initial steps will allow healthcare organisations and systems develop and personalise the revolutionary prevention, diagnosis, and treatment programs that will allow for improved patient care and help prevent further cost explosion.

A results-based population health model is a first step to reforming treatment and payer models, and incorporates new variables such as community and environmental factors, and social determinants. It also sets the premise that by using digital technologies and expanded data sets to stratify, follow, treat, and engage sub-populations, providers will be able to influence improved patient health outcomes and achieve a high value-for- cost ratio at the N of 1.

Populations and Sub-Populations
At its heart, population health reflects the goal of every form of medicine, starting with the Hippocratic Oath: “First do no harm.” Yet its larger scope also means medicine should improve a person’s health status, and ideally, offer a better quality of life through prevention, early intervention, and precision treatments, while providing the best value for cost.

We need to let go of conventional assumptions about healthcare cost inflation, and examine the data with a new prism.

For example, 40 percent of human death derives from an individual’s behavior [1]. Another 30 percent stems from an individual’s genetic risk; and 20 percent relates to environmental and public health issues. Only 10 percent of human deaths link to illnesses or injuries that fall within the treatment lens of the traditional healthcare delivery system [1].

The typical patient profile for the U.S., by example, shows they die younger than other high-income countries; consume more calories; have higher drug abuse rates; use seat belts less often; are involved in more vehicle accidents involving alcohol; and use firearms violently than the citizens of other industrialised nations [1].

This collection of habits and behaviours give the U.S. more obesity, injuries, homicides, adolescent pregnancies, sexually transmitted diseases, HIV and AIDS cases, and drug related deaths than other industrialised countries. Moreover, approximately 20 percent of every dollar goes not to healthcare — but to profit and administration, among others [2].

Within this ailing framework, we see that rising healthcare costs also reflect healthcare inequality, socioeconomic factors, cultural norms, lack of education, lack of access to care, and poor health behaviours. So the traditional medical model — treating patients after they become ill — gives us no path for reducing or controlling healthcare costs [1].

As long as healthcare rewards institutions via a reimbursement-for-service system, they cannot realistically be expected to focus on wellness. After all, well patients provide far less revenue than chronically ill ones under the existing medical model. Yet that short-term view overlooks the exponentially increasing long-term costs for the chronically ill as their health spirals downward from often-preventable conditions.

Moreover, from a strictly humanitarian perspective, it is immoral to emphasise illness as a revenue generator, rather than rewarding institutions and patients for their good health. Healthcare reform in more progressive countries attempts to acknowledge that. It also institutes channels for health education as a component of healthcare, via the penalties for readmission, among others.

Until we have robust reimbursement channels for prevention — that is, payer systems that incentivise us to reach people (especially youth) when they are healthy, before they develop behaviours, much less illnesses, that will become acute — we are missing the optimal platform for controlling medical costs.

In addition to those missed prevention steps, our current system reimburses based on diagnosis and treatment via the traditional medical model, that is, performed on someone who is already sick. Every test, biopsy, scan, blood test, or other diagnostic step is rewarded.

Indeed, a system that earns more for sicker patients is destined to keep spiralling out of control. The sickest patients account for the most costs, and a disproportionate share results from treating people with multiple, chronic illnesses, often accompanied by mental and behavioural health problems, and compounded by economic disadvantages. More than a quarter of costs (29 percent) result from 1 percent of patients [1].

One perspective supports stratifying subpopulations into these groups:

• The currently healthy, who need few services;
• The currently healthy with risk factors;
• Acute-care patients;
• Chronically ill patients [3].

This stratification supports the types of measures that more institutions and third-party payers are adopting to focus on prevention. Indeed, their attention on preventive steps comes largely in response to the demands of the governmental efforts, but reflect what doctors and other providers have been saying for decades. Rather than treat acute symptoms when the patient is already sick, we need to keep people healthy, and catch disease or illness early.

By the end of the 20th century, medicine had delivered tremendous improvements to life expectancy for people 65 and older. These improvements resulted from smoking reductions, improved hypertension control, and better heart disease and cancer treatments. With this broad range of diagnostic tests and therapies, medicine focused on individuals. The resulting insurance models based their reimbursements on the need to pay for this technology explosion, along with the proliferation of costly new diagnostics and interventions.

While life expectancy was increasing for people more than 65, a concurrent trend noted with more clarity the relationship between actual causes of death, and risk factors — primarily tobacco and alcohol use, physical activity, and nutrition. That contrasted with the traditional medical model that ascribed death to a disease, illness, or trauma only. Acknowledging the underlying reasons allowed a new model that reframed quality of life and the value of positive health behaviours [4]. And these factors clearly related to the way we live — our social structures, behaviours, education, and influences [4].

With the relationship among physical activity, obesity, and diabetes established, decisions affecting health spread far beyond hospital walls into the public sector. Sidewalks and recreation centres may lead to more physical activity that reduces obesity, diabetes, and likely, cardiovascular disease. Without analytics to measure these actions, however, it is difficult to know how– or if — they result in better health outcomes or reduced health care costs.

Decision makers also need to know what works for whom in what context given the wide variations in communities and populations [5]. A connection with social structures, a person’s friends, family, behaviours, education, and habits, has a direct relationship to health in many cases. Researchers find a clear connection between emergency department visits and a person’s social support network. This population health analysis, while simple, generates meaningful, authentic responses that are also cost-effective.

For example, a patient with a history of admissions related to alcohol can receive referral information for community organisations, treatment programs, friends, or family. Non-medical responses have a great effect with people who have complex, chronic medical conditions, such as post-discharge home care; home-health care; even meal delivery services.

References
[1] D. C. Pate, “The problem to be solved,” Becker’s Hospital Review, 25 November 2014.
[2] D. Thompson, “Why Is American Health Care So Ridiculously Expensive?,” The Atlantic, 27 March 2013. [Online]. Available: http://www.theatlantic.com/business/archive/2013/03/why-is-american-health-care-so-ridiculously-expensive/274425/. [Accessed 2016].
[3] D. C. Pate, “Population Health: It’s About the Subpopulations,” St. Luke’s Health System, 12 May 2015. [Online]. Available: https://www.stlukesonline.org/blogs/st-lukes/news-and-community/2015/may/population-health-its-about-the-subpopulations. [Accessed 2015].
[4] L. Breslow, J. E. Fielding and S. Teutsch, “A Framework for Public Health in the United States,” Public Health Reviews, vol. 32, no. 1, pp. 174–189 , 2010.
[5] M. A. Stoto, “Population Health in the Affordable Care Act Era,” AcademyHealth, Washington, DC, 2013.