A few years back when the ACO concept was starting to gain traction as a result of the Affordable Care Act’s Shared Savings Program, Mark Smith, MD of the California Healthcare Foundation remarked that, "the accountable care organization is like a unicorn, a fantastic creature that is vested with mythical powers. But no one has actually seen one." I am starting to wonder, as are many others, whether that analogy might even more adeptly describe population health and the tidal wave of efforts now being directed toward managing same.
In a post today on the Health Affairs Blog David Kindig argues that in light of the definitional challenges that have led to confusion of what population health is – or is not – what’s now required are “multiple definitions.” Counterintuitive as that may seem, Mr. Kindig explains how the term is today being increasingly applied to populations characterized by disease state and/or chronic condition (i.e., a clinical perspective) rather than the traditional understanding of populations defined primarily by geographic origin.
The latter’s focus is rooted in public health officials’ efforts to observe, quantify, assess and understand a multitude of personal and environmental considerations that impact the health of individuals – and how that impact is manifested in health characteristics of a defined population over time. The former is a growing focus of new delivery and payment models that aim to lower costs by decreasing demand – while assumedly concurrently not affecting safety, quality or having a negative impact on outcomes.
More importantly, population health in the clinical sense is being touted as a primary means of assessing the success of those models – and in turn, providing financial reward for that success. And further, in contrast, it is being used as a disincentive to pursue activities that are not proven to improve population health.
And there’s the rub, isn’t it. One of the two obstacles that currently prevent us from being able to leverage value in healthcare as Porter, et al have envisioned as the market mechanism that will curb costs and increase performance is the ambiguity surrounding how to define a patient outcome (the other being 19th century cost accounting practices still in place in healthcare). If we haven’t yet been able to adequately define and agree upon the comparative merits of individual patient outcomes, then how the hell can we suppose to find benefit from applying that shortcoming exponentially?