A health care lobbyist discusses population health

Recently, I attended a dinner and lecture at the local dining venue where they served huge hunks of prime rib and sauteed snow peas from some far away place where it’s spring, and chocolate mousse and wild rice. Global warming increased just slightly due to our excess consumption, but my portion would have been wasted had I stayed home. Beside the food, I was curious to see what the health care lobbyist who spoke had to say about where health care reform is headed. I was surprised to find that he was almost entirely positive about what was going on and that in general he said things that I agreed with.

How could this be? Health care lobbyists generally want the industry they represent to get as much money as possible. I generally want the health care industry to reign in its excesses and be more conscientious and efficient. Clearly there is some agenda here that I don’t understand. Either that or efficiency and reigning in excesses is beginning to align itself with the success of the health care industry.

The speech

Paul Lee, the speaker, bravely faced an audience that included many doctors and administrators who believe that health care is going rapidly to the dogs and that the Affordable Care Act (or Obamacare as they prefer to call it) is the end of all that is good. His message was quite succinct and described a scenario in which the growth in health care expenditures would continue to slow and populations would become healthier and more people would be insured and access care in an environment that would include more non-physician caregivers and less specialists.

His visit and presentations were paid for by the CEOs of the three local hospitals who seemed to approve of his message. He showed graphs of trends and briefly touched on the specific issues of rural hospitals, which all three of the local hospitals are. He talked about how new requirements for hospitals to curb complications would lead to a safer environment for patients and fewer unplanned readmissions.

Population health

He also used a couple of terms that had the feel of buzzwords, but which were actually very interesting. He spoke of the inevitability of focusing on “population health.” We presently do fee for service medicine, though not entirely (there are health care coops and other pre-paid models and quite a few physicians are salaried.) This means that we get paid when patients are sick. We are moving in the direction of being paid for how well we take care of patients, otherwise known as pay for performance.

According to Mr. Lee we are heading toward a goal of population health which he explained meant taking responsibility for the health of the entire community in which we practice, rather than just taking care of patients when they get sick. There is an article in the Journal of the American Medical Association this month which looks at exactly this. Emma Eggleston MD and Jonathan Finkelstein MD write about how population health could be attractive to the stakeholders who pay lots of money when people get sick, but might be less attractive to entities which make their money only through treating sick people.

Also, if we focus on making everyone healthy there may be a dynamic of requiring people to do certain things that interfere with their individual rights, such as exercising and stopping unhealthy habits. This may not be universally acceptable to Americans.

How it works

I know that in our small community there could be some non-hospital interventions which might significantly reduce hospitalizations.

If physicians or midlevel caregivers would see patients on an emergency basis in nursing homes and maintain good continuity of care with those patients and their families we would see fewer emergency room visits and hospitalizations. If there were a community crisis center that was robust and effective, we would have less emergency mental health visits. If acupuncture and massage were easily available and covered under insurance, we would likely have fewer pain medication prescriptions and fewer hospitalizations for complications of these medications. If our hospital was paid a certain amount of money per year to take care of the patients in the community regardless of whether they were admitted to the hospital, low cost ways to reduce hospitalizations would be very attractive, and the hospital would likely invest in them. If the hospital made money only when patients were admitted, they would not be inclined to do so.

Mental health hospitalizations and emergency room visit are almost always a drain on hospital resources since we don’t have a psychiatrist or mental health capabilities and can’t hospitalize these patients. Traditionally these patients have also been poorly insured or uninsured as well, so there was no hope of reasonable reimbursement for the hours of care (however that may be defined) that they received in the emergency room. Hospitals such as ours might well save money by funding a community crisis center if it actually kept patients out of the emergency room.

A nearly viral piece of news recently was the fact that Utah has drastically reduced homelessness by giving the homeless homes. There is an initiative in Utah, begun 8 years ago, to reduce homelessness and poverty, which has several strategies for reducing costs related to chronic destitution. It costs a significant amount of money to treat the homeless in emergency rooms and intermittently put them in jail, and there is less of that if they live in apartments rather than on the street.

Utah does not provide housing for free, but does make it very affordable, charging about 30% of government funded income. Utah also has programs to prevent homelessness including interventions to keep people in their homes at risk of losing them. President Obama’s 2009 American Recovery and Reinvestment Act (the much derided “stimulus package”) has been partly responsible for funding these projects. This is an excellent example of population health. Not only does it reduce emergency room related costs, but the no-longer-homeless are much more likely to get and hold jobs than if they were on the streets.

Compressed morbidity

The other term that our speaker, Mr. Lee, used at the end of his talk was “compressed morbidity.” He explained that this was the overall goal of a good health care system. Most people, he asserted (and I agree) would like to be sick for the least amount of time possible, and die when they are not yet miserable or have only been so for a short time. The concept of compressed morbidity was first introduced by Dr. James F. Fries, now an emeritus professor of rheumatology at Stanford University, in 1980. He wrote a more comprehensive article on it in 2005. Dr. Fries noticed that almost everyone dies by the age of 110 and most people by the age of 85. As we get better at maintaining health, more people live to be older, but the true maximum age of a human doesn’t increase much.

With better prevention of disease, be it vaccination or quitting smoking, people live to ages that are closer to the maximum age and spend less of their lives sick and requiring medical care. He suggests active encouragement of all of the behaviors that we know make us stronger and smarter, including such revolutionary ideas as providing alternatives to nursing homes as people age. Although we will live longer if we do those things which slow disease and decline, we will overall use less medical resources. This goal is the end result of a population health approach.

I am mostly but not entirely excited about all of this. I personally would like to live healthy and then drop dead, or get eaten by a bear or something, while I remain mostly independent. But I still do respect the rights of people with different values to practice them. That sounds pretty good until I think about the rights of people to become addicted to injectable drugs, get HIV and multiple abscesses all over their body, spend years in the hospital and nursing homes lingering with their stroke related brain damage and chronic pain and eventually die after costing the system multiple millions of dollars.

I suspect that it is not really up to me and does not rest on my sensibilities whether the US moves in the direction of population health and achieves progressive compression of morbidity. It will most likely be determined by how much money we are willing to spend on health care and what kind of overall outcomes we are willing to accept as being adequate for our money.

Janice Boughton is a physician who blogs at Why is American health care so expensive?

Comments are moderated before they are published. Please read the comment policy.

  • Dr. Drake Ramoray

    Of course the lobbyist has nothing but good things to say and the hospital CEO’s. They are the ones that will make the money under the new system.. The hospitals and insurance companies are all in on it and have the best lobbyists. Healthcare costs are going to be squeezed, and they are going to be squeezed out of doctors and turned into bonuses for administrators and insurance companies. The government will be happy because healthcare (in theory) will cost less and the insurance companies and hospitals will make more money (Please tell me you don’t think that hospitals and insurance companies are working against their own interests.) What I can’t understand is why doctor’s like this author insist on working against their own interests (and patient’s for that matter unless you really think this big box Walmartification of medicine is really going to help people). One of the things that resists more centralized medicine in this country is independent doctors (not very well anymore I might add). Does the doctor employed by the hospital have the patient’s best interest or his employer’s best interests in mind?

    ==================================================

    According to Mr. Lee we are heading toward a goal of population health which he explained meant taking responsibility for the health of the entire community in which we practice, rather than just taking care of patients when they get sick.

    ===============================================

    This is an interesting phrasing. Particularly the entire community in which I practice part. Is this suggesting that I am responsible for the diabetes care of patient’s I have never even seen before, or who refuse to come see me? As you relate it you state it as the community in which we practice which would make that the case?

    ==============================================

    “According to Mr. Lee we are heading toward a goal of population health which he explained meant taking responsibility for the health of the entire community in which we practice, rather than just taking care of patients when they get sick.”

    ==========================================

    There is that community in where we practice again.

    ===============================================

    But I still do respect the rights of people with different values to practice them.

    ============================================

    is contradictory to

    ===========================================

    if we focus on making everyone healthy there may be a dynamic of requiring people to do certain things that interfere with their individual rights, such as exercising and stopping unhealthy habits. This may not be universally acceptable to Americans.
    =============================================

    The day I’m judged on the health of my “community” is the day I stop being a doctor. The day I”m “required” to exercise and stop “unhealthy” habits is the day I move to another country. This piece reads like a crony capitalism/ totalitarian state that I have no interest in. I’m first generation native born immigrant. My parents fled less intrusive government than this. Still have connections in some, until recently this has been a better place to practice medicine.

    • southerndoc1

      “meant taking responsibility for the health of the entire community”

      Change “taking responsibility for” to “being blamed for,” and everything is much clearer.

    • FEDUP MD

      I must have missed the part of the Hippocratic Oath where I was supposed to be a party to subverting people’s individual rights under the guise of the greater good of the community. In fact, I’m fairly certain I missed where that was noted in our Constitution too. And of course, every experiment where people are forced to give up their individual rights for “the greater good” has always turned out swimmingly.

      It appears the author can be bought with some good food and then with a straight face can endorse stomping all over rights for which people have fought and died. Do you want to know why these restrictions are unacceptable to most Americans? Because they violate the deepest tenets of our country’s values.

  • http://hautuconsulting.com/ Shane Irving

    I think we need more doctors like Dr. Boughton willing to look at and think about a possible new world of healthcare in America. After all more of the same will just keep digging the hole deeper. And really Obamacare is likely to only be the first step of many…. If Vermonts experiment is successful who knows how quickly things could change.

    Yes, there are going to have to be huge changes in Healthcare but it doesn’t necessarily mean we end up with a huge US Health Inc. Yes, there are problems with Hospitals, Insurance Companies and Big Pharma but we still need to start with a vision….

    • Dr. Drake Ramoray

      The speaker at that dinner is peddling totalitarian/crony capitalism nightmares with nice sounding words and good food.

      Single payer is better than what is described in this article. I am in the camp that suspects that is the actual point of ACA from the beginning. As some other doctors here have posted I will support single payer the day I am allowed to collectively bargain. I am well aware in my above post of practicing in another country ( I looked at Australia and New Zealand at one time in my career) that I will be moving to a less “private” or “market driven” healthcare system in the eyes of the general public.

      Just about anything is better than what is described in this article. I will not be a slave as a “healthcare provider” to some mid management corporate frat boy who had a C average in medical business administration

      http://www.frederick.edu/courses_and_programs/degree_business_administration.aspx

      so that the ultimate goal is that these guys can make more money.

      http://www.kaiserhealthnews.org/stories/2013/june/06/hospital-ceo-compensation-chart.aspx

      • http://hautuconsulting.com/ Shane Irving

        1) I totally agree that CEO and Senior Administration salaries are ridiculous (at Hospitals and Insurance Companies).

        2) I also agree with you that the ACA may be the first step towards a Single payer system. (At least #2 may fix #1…)

        • Dr. Drake Ramoray

          I believe you missed my point. This author’s vision is horrible, and has no merits whatsoever. She is a pawn, a dupe, to insurance companies and hospitals, and is completely oblivious. She does not understand that she is in a room full of people who will make lots of money off of her hard work. She did not deserve the praise you have bestowed upon her.

          ACA being the first step to single payer is also not a good thing. It will completely trash (read be worse) than what we previously had in order to get us to this liberal perceived utopia of single healthcare. You are happy with the ends, I am focusing on the means to that end.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I don’t understand this sentence:

    “That sounds pretty good until I think about the rights of people to
    become addicted to injectable drugs, get HIV and multiple abscesses all
    over their body, spend years in the hospital and nursing homes lingering
    with their stroke related brain damage and chronic pain and eventually
    die after costing the system multiple millions of dollars.”

    Anybody care to clarify?

    • Dr. Drake Ramoray

      We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are HIV, multiple abscesses, and lingering in a nursing homes.

      I believe the simple answer is that the author doesn’t know what a right is in the first place. This will inevitably lead to healthcare is not a right argument, which I don’t really want to have, but I just couldn’t help being snarky and illustrating the ridiculousness of the author’s statement.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        OK, thanks, I feel better now, since it seems we both don’t understand it…. :-)

    • guest

      I would be interested to know the author’s thoughts on any possible relationship that might exist between the right she describes above, and some other rights, such as the right to drive a motorcycle without a helmet, the right to smoke, the right to eat unhealthy food, the right to follow a sedentary lifestyle, etc, etc.

  • PoliticallyIncorrectMD

    Politicians take care of populations, Physicians should stick to taking care of individuals.

  • Joe

    We hear a bit about how health care policy is executed in other countries. For example, there seem to be plenty of stories about draconian cost control measures in Japan, long lines in Canada and England, and so forth. Is the “population health” strategy that is getting so much publicity here in America something that other nations have used (successfully)?
    This is not a rhetorical question. I don’t know and would like to have a better idea of how this alleged panacea has worked elsewhere.