Chasing Population Health

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?

  ~ Sparky

Moving Away From Sick Care

There is a saying that goes, “America doesn’t have a healthcare system – we have a sick-care system.” I don’t know whether that quote is attributable to an individual or not, but the connotation is that what for decades has served as a healthcare delivery system belies the underlying premise that the individuals benefitting from that system’s value proposition are, indeed, healthy.

Of course, they are not – at least at the time service is required.  They are sick, ill or afflicted by a myriad of chronic diseases and conditions. Whatever we want to call it, a system that addresses the needs of these individuals is critically important. But the study in ironic contrast serves to raise awareness of the need to address population health as the best hope of reigning in the unabated march of healthcare’s gobbling up the nation’s GDP.

Last week a new Health Policy Brief, The Relative Contribution of Multiple Determinants of Health, was released by Health Affairs and the Robert Wood Johnson Foundation that looks at factors and considerations impacting individual and population health. These are commonly referred to as health determinants and can be summarized into five major categories: genetics, behavior, social circumstances, environmental and physical influences and medical care.

Researching and understanding how specific factors and considerations within these categories impact individual and population health is very challenging because of complex, interdependent, bidirectional relationships – and because the timeframe over which meaningful measurement must take place can often be decades. But if the US delivery system is to make a paradigm shift away from having a sick care system, efforts must continue to understand whether and how health policy interventions and choices, as well as the efficient use of limited resources, can achieve better outcomes.

This, in turn, requires the adoption of a more holistic understanding of health: the roles social and environmental (i.e., nonclinical) determinants play in impacting individual health. Human behavior, for example – a primary concern in understanding poor health outcomes – must be understood and assessed, “according to multiple dimensions and at various points of intervention.”

Despite the challenges, progress continues on understanding the role nonclinical determinants play in individual and population health outcomes. The continued advancements in Big Data should accelerate these efforts. The policy brief referenced above provides a nice overview of these efforts with resources that should be noted by healthcare providers wanting to better understand how their competitors are seeking to become strategically aligned with population health management.

There are currently a lot of major healthcare providers touting in the press their foray into population health, as if the opportunity for impact is ripe for harvesting. But having recently become more educated and aware of the myriad issues and complexity of population health, I do have to wonder if their strategies are too narrowly focused on how to creatively redeploy existing assets and resources – rather than making a candid and honest assessment whether either can be productively leveraged in the context of a holistic approach to healthcare.


Population Health Needs A Brand Positioning Strategy

Population Health (PH) is a term that has become ingrained in the Healthcare Reform lexicon over the past decade. It’s one of those politically gravitational conveniences that allow candidates from different parties to embrace a common goal with little risk of being criticized for holding beliefs different than their opponent. And that is precisely because it is difficult, if not impossible, to prove someone believes in something that does not have a consistent and agreed upon definition.

Just What is Population Health?
What PH enjoys in broad political support it lacks in definitional credibility. A good treatise on variations of contemporary definitions can be found in Academy Health’s Population Health in the Affordable Care Act Era by Michael Stoto, Ph.D. Without wanting to deliberately adulterate that work, Stoto highlights conceptual commonalities and differences in definitions from several sources that I will try and very briefly summarize below.

A focus on health outcomes – the subjectivity of which notwithstanding – and the distribution of outcomes (i.e., how do outcomes vary across comparative stratifications, such as geographic residence, ethnicity, age, etc.)

The impetus of achieving healthier outcomes is through encouraging healthier lifestyles, better nutrition, preventative care, avoiding behavioral risks, etc.

Measurement of health status indicators as well as the factors that are correlated with those indicators (e.g., socioeconomic conditions, physical environments, childhood development, etc.)

Utilization of data and analytics to develop a conceptual framework for understanding and explaining differences in population health indicators – and how that knowledge impacts research agendas, resource allocations and public policy.

Often discussed (or confused, depends on your perspective) with public health, though the latter also typically connotes a governmental influence of some type (e.g., a municipal health department).

Policy Perspectives
From a policy perspective, there are two ways to look at PH: altruistic and pragmatic. From an altruistic perspective policies that promise to improve population health are most often framed in cost—benefit analyses: the benefits, if achievable, are easy to agree upon (who doesn’t want to be healthier?). The ROI is the challenge and most often the subject of political contention.

From a pragmatic perspective – particularly as PH has been manifested in the Affordable Care Act – what we are really talking about is cost control. Healthier people demand less healthcare services. Individuals with chronic conditions that more effectively manage those conditions need less healthcare. Economics 101: if we can reduce demand while maintaining or increasing supply, costs should decrease.

Parallel to this latter perspective is the growing base of knowledge that indicates improving the quality of care can achieve both lower costs AND better care. So if population health is a vehicle through which quality can be improved, it benefits from that additional policy advocacy.

Population Health Perceptions
Population Health means different things to different people. A good part of that difference can be explained in the inherent subjectivity of the concept of health outcomes. Some other portion can be explained by academic exercises seeking to cut the Gordian Knot. Still another by political extrapolations that seek to gain favor by equating improved population health with an appreciative electorate.

Whatever the feasible explanation(s) may be, Population Health suffers from an identity crisis. Beyond just a definitional problem, however, it fundamentally lacks in having been able to achieve a shared understanding of its meaning and purpose at a level that resonates with the very “population” whose health is of concern. In short, PH could use a brand positioning strategy.

Perceptual Positioning of Population Health
One of my favorite books on branding is Brand: It Ain’t the Logo: It’s what people think of  you™ by Ted Matthews. Matthews argues that,

“a brand is the sum total impression and memory of every remarkable, every so-so and every negative experience with any and all pieces of an organization. A brand is the personality of [that organization] . . . and is judged and assessed a value by everyone it touches, whether inside the [organization] or outside. These perceptions of value may, or may not, be what you want them to be. Which suggests a fact that may surprise you: your brand isn’t really yours (emphasis added). You don’t own it – all the people thinking about you do.”

It’s not a leap to borrow or migrate these concepts of perceptual brand positioning to PH. Many proponents of PH take an interventional approach as a means to advocacy. Their focus is on modifying individual behaviors, inducing health screening, creating artificial employment incentives and imposing restrictions and/or impositions on environmental elements. This is not a sustainable approach to PH brand positioning simply because it fails to recognize that the perception of PH is owned by the individual – and not the advocate.

What to do Differently
When I was giving presentations across the country a few years back on the newly passed Affordable Care Act, I made it a point to say that I believed if we were somehow successful in increasing access to healthcare services, in improving quality, in lowering costs, in enhancing efficiency and productivity – that none of that would matter long-term because the forecasted demand from an aging demographic would atomize those gains.  The only escape from a tragic gap between demand for quality healthcare and the ability to meet that demand will come from lowering innate demand.

Population health, however one wants to define it, is therefore a critical component of any strategy that seeks to address the looming care gap. But the underlying concepts of what make improving population health mutually beneficial cannot be thrust upon individuals for their own good. Nobody ever bought a Macintosh computer because Steve Jobs told them they should. If you are an advocate of PH, then it’s time to start looking at how to perceptually position its brand benefits differently.

Look at the most valuable brands in the world, and look at how they were built: such as Apple, Microsoft, Coca-Cola, IBM, Google, Disney. Marketing and advertising played important roles, but it has ultimately been each organization’s ability to offer something of value to individuals that drove sustainable perceptions. What can be learned from the branding strategies of organizations like these that can turn the perceptual positioning of Population Health on its head to achieve the long-term benefits that we believe can be achieved?


Policy Prescriptions ®

Advocates for Evidence-Based Health Policy™

Health Affairs BlogHealth Affairs Blog

mission: to inform & educate


with Dr. Bill Thomas