Population Health—Shibboleth or Mission Creep?
“Population health” is a buzz word meaning different things to different people, but seems predicated on the notion that it is possible to save money by preventing diseases. Recently, the NIH sponsored a conference to examine the state of the art in health promotion in the workplace. “Based on evidence review and workshop presentations, the panel could not determine the effectiveness of integrated interventions.” So, in the one area where considerable effort and money have been spent trying to improve worker health we have nothing to go on. The notion of improving worker health by workplace interventions is something sounds logical and “ought” to be true, but can’t be proven so.
Population health can also mean trying to get medical organizations to take a more global approach to improving health rather than focusing on one patient or one problem at a time. This is the basic notion examined by a detailed report from Intermountain Healthcare published this week in JAMA. The Intermountain Healthcare is on my short list of cutting edge systems. Unlike the Kaiser system, they are open-ended, and have attempted to create system changes in ways that attempt to preserve some aspects of local, traditional ways of providing care. This report looks at outcomes comparing a group of patients receiving traditional office-based care as compared to those receiving care from practices that had developed an integrated, team based care structure. Since they are not a closed system, they had to identify patients who seemed to be receiving their primary care within their system and who had stayed in the system for 10 years. Data were analyzed from the years 2010-2013.
During the study period, only 12 of their 113 primary care practices were providing team-based care for the entire four years and 20 were traditional practices for the entire four years. The others were in various stages of transition. However, the large number of patients in their data system allowed them to draw useful comparisons between the two styles of practice. The results were examined in terms of clinical quality measures, utilization of services, and financial impact.
In terms of clinical quality, those patients in team-based practices were more likely to have been screened for depression, have received all five parts of a diabetes bundle, (but only 24.6% versus 19.5%), and had documentation of self-care plans. Interestingly, blood pressure control, which was high in both groups, was better in the traditional practices, (97.7% versus 85.0%.)
Patients in team-based practices were somewhat more likely to have had an annual visit with a primary care physician, (84.2% v. 77.2%), and were less likely to have gone to the Emergency Room, (18.1 visits/100 person years v. 23.5 visits/100 person years). There was no difference in the number of visits to specialists between the two groups. They did not report total hospitalization data.
The system received less money for patients in team-based care, ($3400.62 v. $3515.71) a difference of $115.09 with a 95% confidence interval of $30.54 to $199.64 less. Detailed analysis suggested payment reductions were largest in those patients with at least one chronic condition. The analysis also suggested that for each of the targeted interventions in the team-based practices there was a reduction in income. For diabetic patients, for instance, the reduction was a mean of $337.89.
In their discussion, the authors note their experience highlights the challenge of transitioning physician practices. In this study, the team-based care patients were only 8% of the system’s total practice, and deploying team-based care increases costs substantially while reducing system revenues. “Although the investment costs of the program were lower than the reduction in payments received by the delivery system, the implementation of TBC practices was a resource-intensive health reform intitiative.”
My interpretation is less kind—the system lost money two ways. First, they had to spend a considerable amount of money to implement the system and the system generated less revenue than would otherwise have been expected. This seems to replicate the general experience of the early accountable care organization (ACO) data. Intermountain Healthcare has made the decision to pursue these kinds of changes because they think it is the right thing to do, and perhaps because they think it is the way of the future, but they are doing this in spite of the business results.
It requires no special insight to understand why payers are pushing for this kind of population health. After all, they saved an average of $115 for every patient in the new system. While this may not seem like a lot of money, multiply it by the number of Medicare beneficiaries and suddenly you are talking about enough money that even the Federal Government will notice.
In my view, population health is the new shibboleth, a code word designed to separate the “progressive” and the “reactionary” thinkers. It also cleverly disguises the fundamental tautology at work between making money and reducing expenditures. The marketplace, though, seems to be responding to this in fairly predictable ways. On the provider side the forward thinking are going for size—becoming too big to fail. This is being matched by insurance company mergers. Soon we will be down to three large private payers plus Medicare and Medicaid. To make matters more complicated, the insurance companies try to control expenditures by increasing the size of the deductibles, while the government tries to do it by increased regulation and covert payment reduction in the form of various “quality” penalties. All of these have the effect of reducing revenue for the providers, who respond by trying to increase volume. And so the cycle continues.
Where does it end? Your guess is as good as mine, but I predict it is the patient and the physician who will have to pick up the pieces. Maybe rather than using buzz-words like population health, we would be better served by thinking what interventions and changes make things better for our patients. I think most physicians know a lot of what they do is not helping, but they are afraid to stop. Changes in delivery system organization might make it easier to do so, but this remains to be proven. Intermountain Healthcare is doing what it can to achieve both—they are providing more services to meet patient needs and reducing unneeded services. As long as they don’t go bankrupt, patients win.
25 August 2016
 Bradley CJ, Grossman DC, Hubbard RA, Ortega AN, Curry SJ. Integrated Interventions for Improving Total Worker Health: A Panel Report From the National Institutes of Health Pathways to Prevention Workshop: Total Worker Health—What’s Work Got to Do With It. Ann Intern Med 2016;165(4):279-283. doi: 10.7326/M16-0740.
 Reiss-Brennan B, Brunisholz KD, Dredge C, Briot P, Grazier K, Wilcox A, Savitz L, James B. Association of Integrated Team-Based Care with Health Care Quality, Utilization, and Cost. JAMA 2016;316(8):826-834. doi: 10.1001/jama.2016.11232.
Three recent articles suggest the questions we should be asking about health care financing.
Measuring teamwork is difficult, but important if healthcare systems are to invest in their development. This article reviews the literature and provides suggestions for action now.
New Payment Methods
CMS is in the midst of major changes in the way it pays for health care, but thus far results are mixed.
Putting Patients At The Center Of Healthcare
Putting patients at the center is crucial for healthcare organizations, but how can it be done?
The Public Looks at Healthcare Reform