A population health approach to wellness

FACT: Four determinants of health account for 40% of all deaths in the U.S. – smoking, unhealthy diet, physical inactivity, and alcohol use.

FACT: A mere 3% of Americans do all of the relatively “simple” things they should to stay healthy – i.e., exercise for 20 minutes 3 times a week, don’t smoke, eat fruits and vegetables regularly, wear seat belts regularly, and remain at their appropriate BMI.

FACT: According to the Institute of Medicine, missed prevention opportunities cost us $55 billion per year and inefficiently delivered services cost us another $130 million.

Combined, these facts clearly indicate that ours is a pretty sick society.

On April 17, 2012, I was asked by Humana to lead a webinar session for their Thought Leadership Series, a program that provides in-depth analysis of a variety of healthcare issues with a focus on the latest trends in health plan design, benefits delivery, and broadening capabilities.

My topic was “Reinventing Healthcare: A Population Health Approach to Wellness,” and I thought that readers of this column might be interested in the nutshell version.

Exactly what falls under the broad umbrella of population health?

In essence, population health encompasses the distribution of health outcomes within a population, the determinants that influence this distribution, and the policies and interventions that impact these determinants.

That being said, a population health perspective is considerably more than the sum of individual parts or a cross-sectional view. It takes into account more health determinants than traditional public health models and recognizes that responsibility for health is diffuse.

It isn’t coincidental that key concepts for population health – the Chronic Care Model, Disease Management, Demand Management, Patient Engagement, Clinical Decision Making and Self Care – are also part and parcel of many healthcare reform initiatives.

The Chronic Care Model, a well-established organizational framework for chronic care management and clinical practice improvement, takes a comprehensive, multisystem approach that is especially well suited to working with vulnerable populations.

Disease Management, a system of coordinated healthcare interventions and communications for populations with conditions in which self-care efforts are significant, supports physician-patient relationships, emphasizes prevention of complications through evidence-based medicine and patient empowerment, and evaluates clinical, humanistic, and economic outcomes.

Demand Management strategies include health risk management, symptomatic and urgent care controls, elective treatment choices, acute condition management, and end-of-life planning.

Patient Engagement refers to patients playing more active roles in their care and advocating for themselves. It seeks to improve the areas of health literacy, clinical decision-making, self-care, and patient safety.

For patients to be engaged in Clinical Decision-Making, there must be patient decision aids, training in communication skills for clinicians, coaching and question prompts for patients (now available from the American Center for Patient Decision Making and the Foundation for Informed Medical Decision Making).

The necessary ingredients for the Self-Care piece are self-management education, self-monitoring and self-administered treatment, self-help groups and peer support, patient access to personal medical information, and patient-centered tele-med and e-health.

One important way that health reform is driving population health is through Accountable Care Organizations (ACOs), a new type of delivery and payment that links health provider reimbursements to quality metrics and reductions in the total cost of care for a specific population of patients.

Under this model, the ACO (a group of coordinated healthcare providers) is accountable to its patients and to its third party payers for the quality, appropriateness, and efficiency of the care they provide.

What does all this mean for the future?

The three major themes as we move forward will be: 1) transparency, 2) accountability, and 3) no outcome, no income.

The best — although not the easiest — way to attain a healthier population is to change the culture of medicine; i.e., practice based on the evidence, reduce unexplained variation, reduce our slavish adherence to professional autonomy, continuously measure what we do and close the feedback loop, and engage with patients across the continuum of care.

At the 30,000-foot level, we need to continue building on several immovable cornerstones:

  • Create value by improving patient outcomes and satisfaction while decreasing medical errors, cost and waste
  • Coordinate care across people, functions, locations, and time to increase value while ensuring that patients participate in the process
  • Reform the payment system and begin paying providers for the quality rather than the quantity of care they deliver
  • Guarantee portable health insurance for all citizens, giving them choice, control, and peace of mind

There are a number of good sources for finding more information on Population Health.

For starters, there are a few good books (Population Health: Creating a Culture of Wellness, edited by me and my team) and a bimonthly journal (Population Health Management).

Annual population health rankings by U.S. county, available from the University of Wisconsin’s Population Health Institute, enable comparisons of health and health determinants (e.g., obesity rates, quality of healthcare services, high school graduation rates) with other counties.

I will close by sharing Nash’s immutable rule: High-quality care costs less.

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

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