“Population health” and the evolving role of healthcare organizations to improve it
By Thilina Bandara
It is becoming increasingly clear to health professionals, researchers and decision-makers that the health and well-being of populations depend on more than just access to healthcare. Considering peoples’ non-medical circumstances — like income, education, race and employment status, for example — reveal multiple barriers to living a healthy life. Broadly speaking, this is understood as a “population health approach” to conceptualizing health.
There is still, however, work to be done to apply population health concepts into the way health systems work.
Firstly, it seems, there needs to be a common understanding of what “population health” means.
Health for who?
The most often cited definition of population health amongst researchers originates from Kindig and Stoddard (2003) where they state that population health refers to “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Implicit in this definition is recognition that some groups are not as healthy as others, and that efforts must be mobilized to understand and rectify these inequalities.
In 2015, Kindig revisited this topic to assess where “population health” stands since his 2003 definition. Here he concludes that recently, population health has been operationalized to often focus on improving the overall health outcomes of a particular population — often a patient population — with less relative focus on reducing the gaps in health outcomes between groups.
Kindig argues his original definition was meant to focus attention on the total population and the disparities within sub-populations. He asserts that the new clinical incarnation of population health is better described as population health management or population medicine.
Using a population health management/medicine approach risks missing those who are not insured, or have other social and physical barriers to receiving care. A total population approach, on the other hand, orients decision-makers towards implementing programs that can alleviate non-clinical barriers to health for everyone — mobilizing healthcare resources in non-traditional ways to reach marginalized groups and to improve the conditions for health. This would involve creating a healthcare system that stretches beyond the hospital, to provide more value to more people.
The Institute of Healthcare Improvement echoes a similar sentiment around this definitional divergence. As a vanguard of popularizing of the phrase “population health” within healthcare circles through their “Triple Aim” initiatives, they see overcoming this distinction between the definitions as a primary project of healthcare organizations in the future.
Why the confusion?
The confusion may lie in a fundamental misunderstanding between population health advocates and decision-makers in healthcare organizations about what a health system ought to be good for.
The tension may be summarized by the following question: Should non-clinical needs even be in the purview of healthcare organizations?
While advocates say yes (absolutely), healthcare administration may see it as outside their mandate.
And who could blame them?
Since the inception of modern technological medical age, healthcare has been an enterprise built on the foundation of the biomedical model; that is, healthcare is where one goes to fix the biological phenomenon of illness. All the financial incentives are built around the deployments of biologically-based treatments and technologies; “billing” for these is the flywheel of the operation.
Thankfully for population health advocates, folks are working on changing Medicaid payment models in the United States, for example, to allow healthcare organizations to get creative on what services they provide.
The way forward
Two proposed solutions — risk-adjustment and pay-for-performance models of payment (explained in detail here) — can work to incentivize managed care organizations (MCO’s) to both collect social determinants of health data at the patient level, and to mobilize social interventions outside of the hospital setting to improve the health and well-being of target populations.
With risk-adjustment, states can work with MCO’s to screen patients for social barriers to health and get reimbursed accordingly to provide more comprehensive services, while also enabling the state to better understanding their Medicare population. Pairing this with a pay-for-performance model that utilize social determinants of health-related metrics as performance indicators can help states identify programs that reduce disparities in a given community, further incentivize their implementation, and work to scale them in the future.
Again, while technically interventions at the MCO-level should capture the majority of under-served populations, there is still a risk of missing people who fall through the cracks of the current system.
From here, it will then require a full-on community-development sized effort to ensure healthcare organizations, in collaboration with local governments and community-based organizations, create solutions that reach everyone in a community. Equalizing opportunities for education, social mobility, income security, and adequate housing is a collective effort that healthcare organizations have to be at the forefront of.
Continuing to embolden healthcare professionals towards feeling like they have a place in this fight will help move the population health agenda forward. Emerging payments models may help do this. It will also take the clear and consistent articulation that population health is for everybody — the total population — and not just for those who have the good fortune to be regularly treated.
So what’s next?
The truth is: No health systems in North America has truly figured this out yet because we still have a few questions yet to figure out.
- Who is left to convince in healthcare that non-clinical determinants are important and worthwhile targets for healthcare organizations to tackle?
- Will new payment schemes be the key to changing our mental model of what a health system ought to be good for?
- Is perhaps better and more health and social status data the answer?
- Are we even sure people are using data when planning services?
- What are the barriers to combining efforts across health and social care organizations?
These and other questions get us into the actual tactics of making population health a priority within health systems.
And with every new insight we glean from organizations being bold and experimenting, we might see systems as a whole iterating their mandates, hopefully pushing them towards an integrated health and social care future for everyone.
Thilina Bandara is a population health researcher based in Canada. His research interests include health systems and service research, health equity, and One Health.
