National Public Health Week 2013 Perspective: Population Health and Return on Investment

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By: Karen Hacker, MD, MPH, ICH Executive Director

Today, as part of health care reform, new strategies such as Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs) are being developed to enhance quality, efficiency and control costs. Achieving these goals necessarily requires managing a “population” of patients, and shifting the focus of care from illness to wellness. The Triple Aim initiative of the Institute for HealthCare Improvement provides a roadmap for transformation, emphasizing the importance of improving: 1) the patient experience of care, 2) population health, and 3) reducing the cost of healthcare. While the aims of cost and patient experience are self-explanatory, the population health aim still remains unclear.

So what is population health?

Today, the phrase “population health” has many meanings. For some health care providers, it is simply about the panel of patients they serve. For larger integrated systems and health care insurers, it’s often their entire enrolled population. While both of these definitions move us from the individual patient to a group perspective, they don’t include larger geographic populations. Thus, controversy about the precise definition of population health continues. And that definition matters – especially considering how it impacts the ways in which systems allocate resources for and measure changes in broader health. To improve overall health, the definition of population health must extend beyond the delivery system to consider the many social determinants of health that fall outside of the medical system’s purview.

However, expanding this definition comes with challenges. Is it realistic to expect the health delivery system to influence the health of the geographic community that it serves? If so, how will this new direction be paid for? In a recent issue of the Journal of the American Medical Association, Drs. Noble and Casalino commented on this by asking “should ACOs be given incentives to improve the health of the population in their geographic area?” Further, how can the delivery system leverage community benefits to support the public health system – both governmental and community-based?

The Affordable Care Act offers enormous opportunity for collaboration across sectors to achieve overall population health. Both the delivery system and the public health system are important players in this endeavor and can improve health and reduce costs if they work together. In order to achieve a return on investment for future health and more immediate cost savings, these partnerships must utilize evidence-based preventive strategies which span policy and clinical strategies and range from screening and vaccinations, to no-smoking policies and access to fresh fruits and vegetables.

But how do we get there from here? As delivery systems identify their populations and the opportunities for improvement, so too public health systems are trying to understand how their historic work intersects with today’s focus on care delivery. These two areas tend to think very differently, but we need them to start thinking together. We also need to ensure that the focus on care delivery doesn’t sacrifice our public health system but rather builds the appropriate bridges to create a continuum of care for communities. In the face of the massive delivery system transformation that is occurring nationwide, this is a challenge. As these two systems begin to clearly articulate their roles and responsibilities, one jurisdiction at a time, and as new models emerge and are tested, we should hopefully see whether collaboration creates the efficiency and improvement that is needed. There is much to do in population health, and the opportunity is now.

For more information on ACOs and population health see Drs. Hacker & Walker’s forthcoming article in the American Journal of Public Health: Hacker K, Klein-Walker D. Achieving Population Health in Accountable Care Organizations, In Press, American Journal of Public Health 2013