Population Health Management

Introduction The concept of population health management refers to understanding and managing health outcomes at the population, rather than the individual level. Cousins et al (2002) highlight that risk levels for different ailments and conditions can vary by populations, so breaking down a population demographically can help to understand how risk varies. Their study showed that predictive modeling can be used to identify risk levels for different conditions among different populations. This underlying logic is the basis for the concept of population health management.

If risk levels vary by population, then it can be easier to understand underlying causal or contributing factors. From there, tactics can be developed to help deal with those risk factors, addressing them and therefore reducing the risk of that condition among that particular population. Population health management is, therefore, a powerful tool to improve health outcomes, because it leads to more preventative approaches, rather than treating a condition once it is already occurring.

The Underlying Logic of Population Health Management Kapp, Oliver and Simoes (2010) explore the concept of population health management in their study. They surveyed women in Missouri to understand some of the underlying lifestyle factors for cancer. Their study showed, among other things, that certain segments of the population were less aware of lifestyle factors that contributed to cancer than other segments.

First, they were able to do this by targeting a fairly narrow segment of the population – women in a certain part of Missouri between the ages of 35-49 who had not had a personal history of cancer. Their study then gathered some demographic information, including education level. From this, they were able to determine that education level in particular has an influence on the degree of knowledge that the respondents had regarding lifestyle influences on cancer.

Lifestyle factors are by no means the only contributing factors to whether a women gets breast cancer, but there are lifestyle factors that contribute. The underlying logic of the Kapp study is that some lifestyle factors are preventable. Where there is higher awareness of lifestyle factors that a person can control, they are more likely to do so, and this can explain why some conditions occur more in certain segments of the population.

The United States has relatively poor health outcomes for a developed nation, and while there are any number of reasons for this, lifestyle habits among the nation's poor and undereducated are definitely a contributing factor – obesity is in particular a driver of poor health outcomes, and is almost entirely controllable for most people. Cramm and Nieboer (2016) further explore the issue of population health management. They argue emphatically that disease management is not the solution to public health issues.

By tackling disease on the level of the individual, that person already has the disease. First, when looking at statistics, outcomes don't change much once a person has something, other than when treatment is improved. Advances in treatment, however, are typically diffused across the developed world quickly, so the United States cannot gain much advantage statistically by innovating treatments.

The only true way to improve health outcomes on a broad level, they argue, is by tackling behaviors and knowledge at the population level, to reduce the incidence of disease in the first place. The Challenges of Population Health Management One of the first and most obvious challenges in population health management is that it doesn't work on its own. It must work in conjunction with traditional disease management because once somebody gets sick, they still need to be treated.

Population health management therefore needs to be implemented in a broader, preventative manner, but as a piece of the overall health care puzzle, rather than a replacement for treatment-based cared. Inkelas and McPherson (2015) argue that the US healthcare system, as presently designed, is ill-equipped to adopt population health management. First, it is primarily a for-profit health system, so there is incentive to run a disease treatment model – healthier populations are less profitable.

Second, there is relatively little incentive for population health management when different health care providers operate in the same region, competing against each other for business. None has any incentive to engage in population health management. It is much easier to see the logic of population health management in a country like Canada, or the UK, where the government provides health care. The taxpayer-paid systems have an incentive to reduce illness, as it saves the entire system money.

Furthermore, without competition, the health care authorities have no concerns about introducing broad-based education programs, and even training programs. People will still get sick, so doctors will still have jobs, but an entire branch of such a system can easily be set up to improve education about preventable contributing factors to illness. To further this thought, a government-run system can turn to other branches of government for environmental laws, or rules governing other activities, if those support health care objectives.

It is difficult to conceive of how such a thing would work in the United States – the trade-offs are entirely different. So Inkelas and McPherson are right to suggest that the US is not in a good position to fully embrace population health management. Kizer (2015) explores this concept further, looking at how to build clinical integration into a population health management strategy. He notes that care is often fragmented, as a lot of the population suffers from multiple conditions and sees multiple physicians to treat them.

This fragmentation of care obfuscates the information that, if possessed, would allow for a higher degree of clarity about each patient individually, but also patients as an aggregate body. He argues that if clinical services were better integrated, outcomes would improve , healthcare would be cheaper, and that such a structure would provide for an opportunity to deliver more preventative care as well. The logic of this is the current structure focuses on one physician dealing with a patient on one condition; and another physician on a different condition.

That approach means that each physician is specifically oriented towards dealing with conditions individually, rather than taking overall patient health as a holistic matter. Restructuring the clinical health delivery model, he argues, provides that opportunity. A physician can take an interest in a patient's overall health, and in doing so has more of an opportunity to educate the patient, and coach the patient on better lifestyle choices.

The Role of Education Education is a core component of population health management, and there are many different means of delivering education on health care matters. The research such as Kizer (2015) focuses on the role that the physician, or the health care system in general, plays in education.

One of the issues with that argument is that for something like obesity, which is a precursor to a lot of potential health problems, the path to becoming obese starts at a much younger age than when the patient finally presents in the health care setting with some sort of ailment. Typically, the path to obesity starts in early adulthood, and sometimes even before that. What this points to is more of what Kapp et al (2010) discussed.

They talked about the differences in health care awareness between people of different education levels – that college education was correlated with a much higher understanding of lifestyle factors that contribute to health outcomes. It is not that people who go to college all study medicine, by no means, but rather than when people go to college they increase their awareness and ability to conceptualize how different things link together. They learn more about the complexities of the world.

They learn how to think things through at a higher level, and that puts them on a stronger footing to understand concepts like how environmental factors contribute to health outcomes, or how you want to avoid becoming obese in the first place because of how difficult it is to undo obesity later in life when it becomes apparent that it is causing a diminished quality of life.

People with a college education also tend to earn more, and when higher earning capacity is combined with stronger ability to think critically, to understand complex linkages, and to see further into the future, it makes for a population that is more likely to make better choices for their health throughout their lives.

Any one individual with a college education can completely miss the mark, and lack of a college education doesn't mean that a person is condemned to make poor choices, not at all, but on the aggregate level it has been shown in multiple studies that education is correlated with superior health outcomes. Towards Population Health Management Bridging the education gap is definitely a challenge, but this is exactly why population health management is so important.

When a population health management system is adopted, there is opportunity for the people who are instituting it to think through these challenges. Yes, they might wish to engage at the clinical level as Kizer (2015) suggests, but they might also see that approach is being just one piece of the puzzle for population health management. They might look at populations that are more vulnerable to poor health choices, and focus their energies on figuring out how to reach those people more effectively. There are ways.

Maybe it is a matter of building it into the public education system. Maybe greater levels of exposure in media, social media, or wherever the more vulnerable population is best reached. But just committing to the idea of population health management will set in motion attempts to figure out the best way to preach the gospel about preventative health care, and the link between lifestyle choices and certain health outcomes. Without this approach, we are stuck with the current disease management system.

Improvements there can definitely help improve health outcomes, but there are limits to what can be accomplished, unless there is more of a pivot towards population-based health management strategies. Financing Population Health Management There are few healthcare organizations that serve the entire populace in the American healthcare delivery model. Thus, population health management would need to be financed at the governmental level, and possibly delivered at that level as well.

Given that the government is the payer under Medicaid, Medicare and the VA, there is a case to be made that the government can and should play this role. Otherwise, population health management efforts will be inherently fragmented. Some populations might be reached effectively, but many others will not be reached under a system.