Population Health Isn’t Working Out Quite the Way They Said It Would. What’s Going On?

I hate shots.  Every year when flu season rolls around, I think, “what’s in it for me?” The answer is, “it isn’t for me. It’s for the herd.” I am young and healthy enough that I am unlikely to die of the flu but I have children, older people and vulnerable patients I care about it, so I get a flu shot every year.

This is true population health. I get a flu shot for the benefit of others. Population health has been extended to a much larger set of activities that have no communal benefit. One patient with diabetes doesn’t benefit from another getting a foot exam. (Mammograms, colonoscopies, no communal benefit. STD screening, on the other hand, fits in the category of true population health.)

This distinction matters. Here’s why:

  1. People are keenly aware of being told to do things that aren’t for their personal benefit.
  2. People reject recommendations that don’t match their health needs.
  3. People are much more likely to follow recommendations from people they trust.  Points 1 & 2 above undermine trust.

Lively discussion with my fellow panelists at upcoming HIMSS17 panel on consumer engagement highlighted my own misgivings about the absence of the patient’s individuality and voice in population health efforts. We all want better health in the population, but are we going about it in the right way?

Population health puts people into categories by conditions (diabetes, hypertension, depression), age, lab results and medical billing data. These categories presume their own importance. When in fact, psychosocial, behavioral and environmental factors determine individual health far more.  Patient goals, preferences and barriers to care tell us what stands between that patient and better health. Without this data, population health efforts are undermined.

Here’s an example from my own practice as a psychologist. I learned that “depression” wasn’t a useful category except when I needed to bill with a diagnostic code to get paid. A person in mourning, a postpartum mom with catastrophic feelings, a socially isolated geriatric patient, a mid-career professional struggling with unmet ambitions, a sad teenager having a first psychotic episode or a disabled veteran unable to sustain relationships have almost nothing in common but all could be labeled as “depressed.” Standard recommendations for depression, especially medication, are useless in treatment planning as the root cause of ‘depression’ is rarely something medicine can treat. Depression, the symptom, risked distracting me from the root cause. Diabetes, hypertension and depression can all be looked at as symptoms that do not necessarily share root causes. Population health groups people by these conditions and risks prioritizing those groupings over other (more important) diagnostic and therapeutic models.

Population health efforts are actually making us dumb, blind and deaf to the patient’s true health needs.

In a 15-minute visit, it’s a zero sum game. When the provider is pummeled with gaps in care alerts and practice guidelines, the more the provider attends to the EHR, the less they attend to, look at, listen to and learn from the patient. When the population health need gets attention, is it at the expense of the individual’s need? Care plans driven by population health diagnostic categories are more formulaic, symptom-focused and may ignore root causes. As such, they are less likely to be successful. Then, when patients fail in flawed care plans, we indulge in blaming and name-calling: “non-compliant” or “non-adherent.”

‘Non-compliance’ is an appropriate act of patient resistance to an inappropriate care plan. Resistance is an act of self-affirmation, a rejection of a care plan that doesn’t match true health needs. Vive La Resistance! We don’t need compliance, we need collaboration.

When 50% of patients don’t adhere to medications or guidelines for screening tests, the “standard recommendations” are failing, not the patients.  Resistance is the consumer voice telling us medications cost too much or that they secretly wonder if the medication is working. Resistance communicates the individual’s fear of quit smoking because they will gain weight. Resistance is a form of communication that needs to be welcome. Standard recommendations need to adjust. Then, our patients are co-conspirators, plotting their journey to health, working against all the forces that will undermine them. We need to stop blaming patients for non-compliance and stop pressuring providers to be enforcers.

What if we turn the standard approach inside out and start by asking patients:  “what are your health goals?”   “What is your biggest health concern?”

If we allow people to build Pathways to Health, to choose their own adventure, at their own pace, we can prioritize steps to health at an achievable pace. (By the way, mammograms, flu shots, colonoscopies, foot exams, and eye exams, medications can all be offered as steps on a Pathway to Health. Population health services like pharmacists, nutritionists, social workers and care managers can all be offered in response to patient needs.)

Technology can support this beautifully and take an enormous workload off providers. Through our work at Vital Score, we have directly observed hundreds of primary care visits. We use Motivational Indexing to capture and categorize people’s goals, needs and barriers to health and we responsively offer patient-driven Pathways to Health. Our results show that when people self-identify needs and self-refer to services, their participation rate increases up to 20x. People own their choices because their choices are personally driven for their own benefit. It’s not only better for workflow, it’s better for outcomes.

I have come to the conclusion that population health will not succeed until it is driven from the ground up from patient needs. The top down approach is a Herculean effort without yet enough reward.

Hilary Hatch is the Founder and CEO of Vital Score

Categories: Uncategorized

7 replies »

  1. Remember BiDil? I can’t help but wonder …

    They would have been better off developing a targeted drug for South Koreans (certain cancers) or Indians (diabetes, related) …

    Targeting populations while ignoring populations, strange!

  2. You can’t deny that we already know that people of different ethnic backgrounds respond differently to different antihypertensives. So standardization could hurt some minorities. You would probably also agree that reaching a target blood pressure in a frail elderly diabetic woman who then falls and breaks her hip is not as good as it might look on your NCQA diabetes scorecard. And speaking of NCQA, I temporarily lost my cert. when I started following the 2013 lipid guidelines. They took a year and a half to change their metrics. So much for evidence based care. And efficiency in healthcare can’t be a top priority when practices’ cost burdens keep piling up and the middlemen are raking in profits on the backs of exhausted and distracted providers.

  3. The fact of the matter is that we all, as taxpayers, do benefit from that diabetic patient getting her annual foot exam. Let’s say our patient is over 65. When that sore progresses into a festering osteomyelitis and eventually leads to a below the knee amputation, guess who’s getting the bill? That’s right – we all are. Public health encompasses far more than communicable disease – it’s about utilizing our resources at every level in order to maximize the health benefit to our population as a whole.

    Standardization of recommendations to care providers is intended to create a uniform set of metrics to determine how we are doing and whether our interventions are resulting in improvement. While it’s true they are generally process measures and not outcome measures, I believe most to be evidence-based and well chosen. Like a runner without a watch, without the ability to measure, we cannot gauge improvement. Standardization is key to taking waste out of our system.

    Putting the issue of improvement aside, moving away from standardized care recommendations toward customized recommendations would cause a tremendous drop in efficiency in healthcare. It’s only in the (appropriate) standardization of care processes that we can make efficiency gains. It’s the same reason a suit made just for you by Enzo the tailor costs a lot more than one you get from Men’s Wearhouse. No healthcare provider wants to feel like a factory worker. But efficiency matters, particularly in Medicaid and Medicare patients because this care is being paid for by taxpayers. Most taxpayers, myself included, want to make sure tax revenue is spent wisely. We are being asked to care for more and sicker patients every day, with many systems at the breaking point. We need to design our healthcare system for the world we have, not the one we want.

  4. Thanks for post; a population’s “health” has nothing to do with medical care. Health is personal responsibility. Second, a population’s “medical care” is best when individual’s choose based on knowledge of the best scientific comparisons of outcomes, and, then, their preferences for those outcomes, and then each best individual choice is summed to a population. Averaging out is not only bad medicine, it is a useless prophecy. Last, public health has nothing to do with medical care; when the outcomes of my choice affect yours, that is public health and not my choice. I hope we begin to realize that the entire process and philosophy of medicine has been on a down hill course; only individuals matter; only a cottage industry matters, and the money makers planning against that reality can go jump in the lake. Hope you get a chance to read my book; http://www.uncpress.unc.edu/browse/book_detail?title_id=3788

  5. Spot on. I think PHM can be added to good patient care, but it has essentially replaced patient care with obsession over metrics and documentation. Right now, data mining is prioritized over everything, including listening to a patients acute concerns.

  6. Beautiful music to my ears!

    I’ve been meaning to write a post on the same topic. You beat me to it.

    In Sweden, where I trained and first worked, childhood immunizations, developmental screenings and basic anticipatory guidance were handled at free nurse-run clinics with a physician available for on-the-spot consultations. Each child’s chart was returned to the parents after completion of the visit documentation.

    People still had pediatricians or family practitioners they brought their families to for sick visits and the personal physician would review the clinic notes from the Barnavårdscentral (BVC).

    This system seemed to me the antithesis of the idea of family practice to me back then, when I wanted to be everything to each one of my patients.

    But now, with the top-down, heavy handed American view of for example immunization compliance, which, as you so eloquently point out, benefits the herd more than the individual, I find myself not enjoying being rated on my performance on the metrics that have become substitutes for quality today.

    Physicians have cared for individual patients for thousands of years. And yes, we didn’t always have the best understanding of disease processes or the best tools at our disposal. But we are now entering an era of “precision medicine”, “personalized medicine”, “patient centered care” and “accountable care” (and I think that should be accountability to our patients). So now is not the time to burden us or to clutter up our precious fifteen minutes with work that amounts to nothing more than being an instrument for political or public health ambitions that sometimes actually harm some of our individual patients.

    Public health is perhaps best done by professionals that are less focused on individual patient relationships and more responsible to the larger community. Doctors sometimes have to be like lawyers, defending the rights of those who go against the norms of society. You can’t always be both those things at the same time with your patients.

    Especially not in fifteen minutes.

    Perhaps we should consider the Swedish model for childhood immunizations?

  7. “What if we turn the standard approach inside out and start by asking patients: “what are your health goals?” “What is your biggest health concern?”

    My dear Ms. Hatch – you are singing my song. Alas, a physician used to be able to do this. However, nowadays if someone comes in for a flu shot and wants to discuss their health goals and I dare to speak with them about something else — well I get audited (happened this week.) The insurance company found nothing (except actual patient care occurring.) But they are of course angry that they could not “find” more money for their CEO by taking it back from me.

    Healthcare in the US is no longer about patients or physicians. It is about CEO’s, administrators, and pharmaceutical company profits. Many of us are interested in the patients biggest health concern, but this is falling on deaf ears. Keep spreading your message. It is a good one. I am listening… every good movement has to start somewhere.