Population Health in Times of Crisis
These are serious and sobering times. Beyond the staggering attacks on our democracy and the accelerating pace of global warming unleashing waves of destruction on our planet, the COVID-19 pandemic is illuminating cracks in our health care system. Population health can help us understand the issues and challenges created by the COVID-19 crisis, and energize communities.
What is population health? My definition of population health is a holistic approach to health that encompasses social determinants and is built on public health, chronic care management, and case management principals to address low risk/healthy patients, rising risk patients, and high risk patients respectively.
How does population health address low risk or healthy patients? If you are healthy, we want to keep you that way. The best way to stay healthy is to focus on two things; diet and exercise. The most efficient way to deliver messages about diet and exercise is through radio, TV, and social media that can reach hundreds and thousands at a time, rather than relying on individual visits to your health care provider. We also use preventive screenings and immunizations to keep people healthy, but many of these functions as well could be more efficiently delivered in public health settings rather than individual doctor offices.
How does population health address rising risk patients? The holy grail for population health is to identify who will be your next patient to be sick, so that you can intervene before they need an expensive hospitalization. However, we already know who the next patient to be admitted is, it is our patient with chronic conditions such as diabetes, hypertension, chronic heart failure, and emphysema. Team-based strategies focused on chronic care management will help our rising risk patients and their clinicians better manage their chronic diseases.
How does population health address high risk patients? You can purchase complicated algorithms to identify your high-risk patients, but again we know who are our high risk patients. They are our sickest patients, including those who require hospitalization. Patients with complex needs such as those with disabilities or who are receiving care in multiple settings are also very difficult to manage. Case management and navigation services are needed for transitions of care and to support these high risk patients and their caregivers.
Public health is the original population health, because of its emphasis on the “public” rather than on individual patient care services, as well as its mission to promote and protect the health of people and communities. We are getting a crash course in public health as it has been thrust into prominence by the COVID-19 crisis.
We have witnessed the array of public health functions during the during the COVID-19 pandemic. The daily tallies of COVID-19 cases and deaths represent the epidemiology and tracking functions of public health. We have heard the health education messages on masking and social distancing, and we have seen hopeful signs of planning and coordination between hospital systems facilitated by public health to accommodate surges in hospitalizations and ICU beds. At the same time, we have witnessed struggles to provide personal protective equipment, and develop coherent testing strategies.
The response to COVID-19 involves medical care as well as public health. Testing and screening overlap both. The silos around medical care and public health have inhibited coordination. Medical offices, urgent cares, and emergency rooms can and should be expected to test patients with COVID-19 symptoms, while public health is the natural choice to direct screening and surveillance of asymptomatic individuals.
The COVID-19 crisis is not occurring in a vacuum. There are three intertwined megatrends impacting our health care system; the growth of value-based care where organizations are responsible for cost as well as quality, the availability of digital solutions to improve access, and the emergence of population health.
The focus of this discussion is population health and the prominent role that public health is playing in our response to the corona virus, but we have also seen a dramatic, almost overnight upsurge in adoption of digital solutions with video and telephone calls replacing office visits. Multiple factors have contributed to the explosion in telehealth including COVID concerns, but enhanced payments and relaxation of privacy requirements have played a major role. I suspect the telehealth genie is out of the bottle, driven by efficiencies for both patients and providers.
Value based care has not played a major role to date in the COVID-19 response. Before thinking about why this may be, lets take a step back and think about what is value in health care. Don Berwick, former head of the Centers for Medicare and Medicaid Services, defined the triple aim of health care as; improving the health of the individual, improving the health of the populations, and reducing cost per capita. However, when we look at how managed care companies are compared, the vast majority of metrics are clustered in the individual health domain, where quality is defined by HEDIS measures and patient satisfaction surveys.
Not surprisingly, managed care companies pour energy and resources into improving the individual quality scores that are used to calculate star ratings, which, like Yelp, are the most visible markers we have of managed care performance. However, HEDIS metrics only cover a narrow range of patient care, patient satisfaction does not correlate with high quality care, and neither HEDIS scores nor patient satisfaction seem particularly relevant during the COVID-19 pandemic. At the same time, there is precious little data to compare managed care companies on population level metrics such as emergency room visits as a measure of access to primary care, or admission and readmission rates as measures of disease control.
Value based care has also been slower to move on the potentially even more dramatic changes that can occur when you organize health care delivery to increase efficiency and reduce costs. Steps we can take to improve efficiency include: focusing on transitions of care and coordination of care, and using more team based approaches to care. It would also include the adoption of strategies we have reviewed including digital solutions to improve access, and population health approaches to keeping people healthy, as opposed to caring for them when they are sick.
To help understand these dynamics, lets look at who participates in value based care, and the role of each during the COVID-19 crisis. Clinicians, particularly primary care clinicians are points of first contact for patients, identifying who needs a higher level of care and providing advice and counseling in the office and by phone. Specialists, who normally drive the lions share of cost and health care services, have played a lesser role, particularly as elective cases are deferred.
Hospitals and emergency rooms have become the focal point in our battle to save lives. Vertically integrated health care systems are in the best position to respond because they can allocate resources and services between different parts of their system. At the same time, managed care companies have played less of a role as we see government and public health working directly with health care providers. We shouldn’t draw too many parallels between the response to this pandemic compared to the job of providing health care during more normal times, but the story of COVID-19 does highlight who is actually providing care, what organizations are best positioned to respond to health care needs, and which organizations are largely intermediaries.
Lets return to the population health framework to think through a COVID-19 plan. For low risk, healthy patients, we again want them to stay that way. This is accomplished by education and public health measures that support wearing masks and social distancingthat is most efficiently delivered by public health. Rising risk patients include those who are at risk from exposure to COVID-19 positive patients through travel, work or home. This rising risk population is best identified by contact tracing which is a traditional public health function. At-risk patients include those with symptoms such as cough and fever. These can be identified by screening which has both a public health and individual health component. High risk patients need to be in hospitals with access to intensive care. Preserving availability of ICU beds requires planning for surges that also has both a public health and an individual health care, working separately, and together.
Another category of risk are those who are confronted by the social determinants of health. Social determinants are defined the World Health Organizations as the conditions in which we are born and live that are shaped by money, power, and resources. For example, according to the Federal Reserve if you are an average white family, you have seven times as much wealth as an average black family. Imagine how your life would be different if your family had seven times as much wealth as you have now.
You can recognize the impact of social determinants when you identify health disparities. According to the CDC, health disparities are preventable difference in the burden of disease experienced by socially disadvantaged populations. We have a terrible example of health disparities as we speak, with differences in COVID-19 mortality between blacks and whites approaching 4 to 1, and similar disparities between latinos and whites driven by increased exposure to COVID-19 experienced by essential workers in low wage jobs. Sadly, racial disparities are not new. Black infant mortality has been double the rate for whites for decades.
How do social determinants impact health? Not surprisingly, studies show that those with the lowest incomes and least educated were the least healthy. Can we impact social determinants? Other studies show that countries with greater social expenditures have better health outcomes, suggesting the answer to this question is yes.
However, have we had as much success in addressing social determinants as we might like? The answer to this question is probably no. Before thinking about how to address social determinants, let’s first identify who has a stake in social determinants. The list includes:
Physicians, who are expected to be patient advocates
Hospitals, most of whom are non-profit. Their noprofit status is dependent on doing community needs assessments and addressing identified needs.
Healthcare organizations need to cover required services mandated by regulatory bodies which may include social determinant functions
Community based organizations receive funding to provide social services, and
Government is obligated to uphold laws covering health and human services.
With so many entities involved, its easy to see why change is so difficult.
What then should we do to address social determinants? A key step is channeling the efforts of all these afore-mentioned entities. When we think about the doctors, hospitals, and services that we rely on, there is a local flavor to the challenges we face that are best addressed at a community level. CDC defines community health as, “Interventions that work for the greatest impact on health and well-being for all”, which resonates with the Triple Aim we discussed earlier. As the CDC points out, the key ingredient is, “establishing and maintaining effective collaboration” which has been a continuing theme in our discussion of population health, public health, and individual health care services.
What would a community health strategy look like? Actually, very attractive. It would include the creation of a healthy living environment, with a focus on access in all neighborhoods to healthy foods, physical activity, and safe walking trails to aid physical, emotional, and community well-being. It would involve an investment in public health- but as we watch trillions of dollars being poured into our economy, perhaps now is the time. An investment in public health would pay dividends in several ways. Health promotion and disease prevention education can help reduce rates for conditions such as obesity and diabetes. Public health can support coordination across a range of health care services. A sustainable public health infrastructure that links individuals and medical offices with social services could dramatically improve communication and coordination for individuals and organizations.
There are opportunities to think outside the box about the intersection between public health and individual health. For example, there is a strong case for shifting wellness activities for school aged children and adolescents, and working age adults away from individual clinical services and towards school and work-based sites. Communities could envision pooling resources to most efficiently offer clinical services, such as support for an addiction medicine specialist, or telemedicine for a service such as wound care that was otherwise not available. Promoting data exchange to reduce duplication and waste and improve access to care would be another admirable aim. At the same time, we will want to identify savings for our health care system that are related to improvements in community health, to help offset the costs of these investments.
Based on what we have discussed, we can be confident that the steps needed to emerge from the COVID-19 pandemic will depend on a strong, energized public health infrastructure working closely with the actual providers of health care, clinicians, emergency rooms, and hospitals. This is a recipe for success now and in the future as we tackle other pressing health care issues including the social determinants of health.
We are at a tipping point, driven by the growth of value based care, availability of digital solutions, and the emergence of population health. There will be immense opportunities for improved efficiencies in the near future. If history is any guide, this will lead to a few wealthy individuals and corporations realizing immense windfall profits, while the rest of us remain little better off. The alternative is a vibrant integrated health care delivery system that works for patients, providers, and communities. Lets work together to tip health care in the right direction.
Dr John Zweifler is a family physician with years of patient care, medical education, and medical administration experience. He currently works as a physician consultant with the Fresno County Dept of Public Health, and consultant with the Terry Group with a focus on population health. He is the author of the e-books, “Tipping Health Care in the Right Direction”, and “Pop Health.”
