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To Achieve Its Goals, Population Health Needs More Specialists

I attended a Population Health conference this summer where a number of representatives from large health systems and physician organizations convened to discuss common challenges. Many of my healthcare colleagues assume that anything that carries the label “Population Health” must relate to health disparities and food deserts. While we do address these topics, the vast majority of sessions and conversations had one underlying theme: lowering the total cost of care.

In rebuttal to any charges that our group is far too corporate to be considered a fair example of Population Health advocates, even the Institute for Healthcare Improvement addresses the importance of managing costs with the third part of the Triple Aim stated as “reducing the per capita cost of health care”.

Whether it is from Medicare or commercial ACOs, the Efficiency metric in CMS’s Value-Based Purchasing program, or the continued push from commercial payors for bundled payment programs, health systems and provider groups are beset by demands regarding cost. Unfortunately, at this conference, and in most groups trying to meet the demands of Population Health, one key stakeholder group is often absent: Specialists.

If cardiologists, spine surgeons, and hospitalists cannot become engaged with Population Health principles, moving the cost needle will be very challenging, if not impossible. I believe there are ways, however, to engage specialists in providing efficient care.

Access to Data: Commercial insurance payors have provided Primary Care Physicians with cost data for their attributed patients for years. Moreover, most primary care physicians are enrolled in risk contracts with penalties and potential bonuses with quality and cost-of-care tied in. Specialists, unfortunately (or fortunately, depending on whom you ask), have been immune to the cost of the care they provide. While groups like Propublica have released Medicare payment data, what would be valuable to specialists is how their quality and costs compare to their peer groups who manage the same conditions. For example, what is the average cost between two gastroenterologists for a patient with inflammatory bowel disease. Sharing this data with specialists can lead to some tough questions about best practices, clinical variation, and, appropriateness criteria.

The need to develop appropriateness criteria: When talking to several orthopedic surgeons about a new bundled payment program for joint replacements, one senior surgeon opined, “Well, this is all well and good, but what do we do about the 82-year-old woman with a bad heart and severe arthritis?” His comment has stuck with me because it points to the lack of guidance many practitioners have when it comes to deciding which patients should receive treatment and which patients should not. Defined by Brooks and colleagues at the RAND corporation, a procedure or treatment is considered appropriate if the expected health benefit of the treatment exceeds the expected adverse consequences by a wide enough margin that the intervention is worth doing.

Unlike clinical guidelines, which may recommend a therapy for certain pathology (joint replacement for severe arthritis), appropriateness criteria incorporate patient-specific variables (diabetes, heart disease, obesity, etc.) and the “appropriateness” is defined by an expert panel. Specialty societies and colleges should endeavor to establish appropriateness criteria for their members to help curtail care that may both be wasteful and potentially harmful to their patients.

Teaching the residents: When I was a surgical intern (during the first term of the George W. Bush administration), I recall my first day on the Trauma service. I was given a list of patients by the graduating intern and the order to do the discharges first—especially the one going to the SNF, as it would require the most paperwork. I did as I was told and sent the patient to this magical place called ‘SNF.’ It took me a couple of months to muster up the courage to inquire what the acronym stood for. I have become well acquainted with Skilled Nursing Facilities in my short career in Population Health as I have looked at reducing post-acute care expenditures, but, sadly, the interns whom I speak to now have just as foggy of a notion of why it is important to know where our patients go after they leave the hospital. Most teaching institutions are tertiary- and quaternary-facilities that focus on developing new therapies and techniques in addition to training residents on what constitutes standard of care. It may be easy to forgive academic physicians for not having the time, quite frankly, to educate on Population Health. Unfortunately, if training programs do not start stressing this aspect of medicine, specialists will remain in the dark.

I will be admonished by some for spending an inordinate amount of time on medical costs in an essay about Population Health, and I would be the first to state that quality of care should never be sacrificed when accounting for the cost of care. However, as patients continue to face increasing out-of-pocket costs for the care they receive, it is one more reason to make sure that their dollars are being used judiciously. ​

Vikram Reddy, MD is an Associate Director of Population Health for the Henry Ford Health System.

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  8. Unfortunately, the Paralysis afflicting our nation’s healthcare industry is so entrenched that it is unable to accept that it needs help from outside their DOMAIN. Any attempt at innovation for these issues is met by marginalizing resistance.

  9. I think the job of physicians and health care providers should be taking care of individual patients and their families. I believe you are correct in that the social determinants of poor health should be addressed, but not by the health care system.

  10. The fundamental causes of inadequate Social Capital and Poverty are really not amenable for correction by healthcare. However, an effort to improve the attributes of Social Capital and Poverty for certain population groups is likely to reduce the health spending that is required to mitigate their adverse effects for certain groups.

  11. By including population health as a goal of the U.S. health care system, we put a lot more people on the gravy train….so if one of the goals of population health is to bring down prices, its inclusion as a goal is doing just the opposite.

  12. Taxation is the taking of work effort-equivalent by one citizen and giving that to the pool of effort contributed by all citizens. Why isn’t social capital the same thing? …capital meaning a setting aside of resources now, for a future return later?

    Why doesn’t a community-that-taxes-itself-more have more social capital (than other less taxed communities.)? …as long as that money is a tool for future returns?

    My point is that if you simply used the word ‘tax’ you would express your ideas more laconically.

  13. Here is what Population HEALTH could offer for a truly neglected quality attribute of our nation’s healthcare industry: its worsening maternal mortality ratio for 25 years (the only OECD nation with a worsening MMR). There are three data sets that, historically and recently, can be rank-ordered for the 50 states by their MMR: 1987-1996; 2001-06; and 2005-14. Listing each data set by lowest to highest MMR, each list can be divided into 6 clusters. There are several observations that can easily be made. First, there are only two states that ranked in the lowest (Best) cluster of all three data sets: Alaska and Massachusetts. Among many contributing factors, I suggest that these two States have the lowest MMR consistently over a long period of time based on how well they maintain their State’s level of SOCIAL CAPITAL.
    .
    Secondly, there are three States that were in the worst cluster of the first MMR data set and subsequently were in the first or second clusters of the third, most recent, data set. They are: Alabama, Vermont and California.
    .
    Finally, there are five states that were in the best MMR cluster of the first data set (1987-96) and worsened to the third or fourth clusters for both the second (2001-6) and third (2005-14) data sets. You can’t attribute this to reporting irregularities. I suspect that this is related to the change from the predominant use of volunteer faculty prior to 1980 to employed faculty after 1980 by the Medical Schools of these states. I would certainly be open to plausible alternatives.
    .
    Even though there have been attempts to improve each State’s MMR reporting accuracy, the character of clustering is remarkably stable from data set to data set. The Pearson correlations among the three data sets are all >0.9000, for both the mean of each cluster and the standard deviations of these clusters. Its quite remarkable. The pattern of cluster standard deviations reflect a Gaussian Distribution for each data set.
    .
    I suspect that the underlying character of the data sets is the level of Social Capital and Poverty among the States. This might be seen by the hurricane, recovery resilience of Texas versus Puerto Rico. These factors are beyond the purview of the healthcare industry. Its no wonder that all the efforts of many segments of the healthcare industry have had little effect on controlling our Nation’s worsening maternal mortality ratio. I have estimated that nearly 700 women die annually in the United States solely because they lived in the wrong Nation prior to the onset of their pregnancy. Its a staggering observation.
    .
    SOCIAL CAPITAL may be defined as the expression of trust, cooperation and reciprocity by the citizens of a community that is more likely to occur for resolving the ‘social dilemmas’ they encounter daily within their community’s civil life when the attributes of a caring relationship increasingly characterize the enduring networks of the community’s citizens, especially the neighborhood network of each citizen’s ‘family’.
    .
    If you would like a copy of the three data sets, leave a message at 402-810-0479 before 11-817. pjn

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