Population Health Management: Promise, Progress and Pitfalls Paula Lantz, PhD Associate Dean for Academic Affairs James B. Hudak Professor of Health Policy Ford School of Public Policy University of Michigan
Population Health: Policy is Key Patterns of health Health outcomes determinants over and their the life course distribution in a population Policies and interventions at individual, community and societal levels
Population Health has Long History Johan Peter Frank, (German Physician) The People’s Misery: Mother of Diseases, 1790 “...The e diseases es c caused ed b by the po poverty o of the pe people an and b by the lac lack o of all all goods of l f life fe a are exceedingly numerous.”
Epidemiological Transition
Infant Mortality Rates Vary by Place, Race and Ethnicity in US Non-Hispanic White Women Hispanic/Black Women
Average Life Expectancy is Decreasing in U.S. 6
Evaluating Policy Impact on Population Outcomes
U.S. is an Outlier in Health Care Spending
Tripl ple A Aim of f th the Inst nstitute f for or He Heal althca care Improvement ( t (2007)
Related yet different fields of inquiry and practice Popu pula lati tion n healt lth h (long ngstand nding ing) Public health Preventive medicine Population medicine Popu pulati tion n health m lth manageme ment nt: Aggreg egation an and use e of health ealth in informatio ion d data ata an and oth ther er ac acti tions t to im improve e clin linical an and f fin inancia ial outc tcomes es
Population Health Management
Population Health Management • 70+ universities in U.S. have colleges, departments, degree programs in population health, population medicine or population health management • Numerous health systems have PHM activities • New business products, data analytics, consulting, etc. • Them emes es: o Triple Aim - Emphasis on patient populations/outcomes o Recognition of social determinants of health o Partnerships with public health & community resources
Mostly Positive/ But….Three Caveats Medicalization and conflation Efforts are primarily downstream: o Referring patients with identified social needs to exhausted community partners and beleaguered safety net programs/agencies Unproven interventions/overpromise of results o Lack of evidence base for many interventions being used o False hope that addressing downstream patient social needs will somehow magically improve their health status in a short period of time 13
Medicalization of Population Health Process by which personal, behavioral and social issues are viewed through a biomedical lens, emphasizing individual-level pathology and authority/treatment through clinical care. (Conrad) CONCERNS: * Denominator s shrinkage : “Population” is those patients who temporarily share providers or insurance plan * Confla latio ion of SDOH with individual patient social needs 14
CONFLATION: Leads to fuzzy thinking/ medicalization/misguided efforts ≠ HEALTH CARE HEALTH ≠ HEALTH CARE DISPARITIES HEALTH DISPARITIES ≠ HEALTH CARE EQUITY HEALTH EQUITY ≠ HEALTH INSURANCE REFORM HEALTH REFORM ≠ POPULATION HEALTH MGMT POPULATION HEALTH ≠ PATIENT SOCIAL NEEDS SDOH/ SOCIAL DETERMINANTS OF HEALTH 15
More than Semantics Long history of public policy and community efforts attempting to address social, economic and political drivers of population health patterns (including disparities) with personal health services. When those efforts do not work, it reinforces notions that some subpopulations are too difficult, problems are intractable, and inequity is inevitable. 16
Three Caveats Medicalization and conflation Efforts are primarily downstream o Referring patients with identified social needs to exhausted community partners and beleaguered safety net programs/agencies Unproven interventions/overpromise of results o Lack of evidence base for many interventions being used o False hope that addressing downstream patient social needs will somehow magically improve their health status in a short period of time 17
WHO Conceptual Framework of Social Determinants of Health 18
SDOH Create Individual- Level Need and Advantage • Example: Housing is a social determinant of health • Addressing housing at level of individual need is necessary yet insufficient • To address housing as a social determinant , policy change and other action needs to happen at: Neighborhood level Mezzo-level Macro-level 19
Screening Patients for SDOH (actually social needs) 20
MD Tweet: “I screen because some of my patients have SDOH”
Screening Patients for Social Needs • Many “validated” measures – o Means screening tools do identify patient social and non- medical needs/concerns • Such information can provide more context for medical care • Primary questions: o What happens to the information collected? o What happens, if anything, for patients with serious social needs? o Screening 101: Never screen for something unless you can do something about it! • Lack of evaluation research 22
Screening in Clinical Settings Pros Cons Screening without the capacity to Clinicians need to understand social • • ensure linkage to appropriate situations/contexts of patients interventions/resources is in ineffective Important for predictive models/AI • and unethic ical Standard set of social and behavioral • Busy, untrained clinicians likely to • metrics ties into PCMH and Meaningful exacerbate patient concerns about Use social stigma Especially important for children and Can create unfulfilled expectations • • and further mistrust Medicaid population Medicalizes social factors; conflates • Accountable Health Communities : • SDOH with social needs CMS initiative to test novel models that Will likely divert resources away from • promote collaboration between health upstream interventions care and community AHC model will only work if • organizations/services community resources and capacity for addressing SDOH are there 23
Three Caveats Medicalization and conflation Efforts are primarily downstream: o Referring patients with identified social needs to exhausted community partners and beleaguered safety net programs/agencies Unproven interventions/overpromise of results o Lack of evidence base for many interventions being used o False hope that addressing downstream patient social needs will somehow magically improve their health status in a short period of time 24
Super-Utilizer Interventions: Most studies with control groups do not show impact
Progress and Promise • Medical-Legal Partnerships • Community Benefit • Housing Investments • System Design Change (AAMC projects)
Medical-Legal Partnership 27
Washington MLP Outcomes 28
Community Benefit Example: University of Michigan • Michigan Medicine made a commitment to target some of its community benefit dollars to upstream SDOH contributing to inequities in 3 priority areas identified by CHNA • U-M health system Department of Community Health Services: o Developed RFP process to solicit community-based proposals in 2018 o To date, $7.2 million awarded to 26 projects: Supportive housing initiatives School-based counseling for at-risk youth Mobile finance resource services Medical-Legal Partnership (child focus) 29
Health Care Systems & Insurers: Housing Funding Housing First and other supportive housing interventions for chronically homeless and other high-risk populations Working with developers and housing advocacy group to create affordable housing units: o Bon Secours Baltimore Health System (700 units) o UnitedHealthcare: Invested over $400 million in affordable housing in 80 housing communities (4,500 units) 30
Association of Academic Medical Colleges Funding from AHRQ and CDC 3-year projects focused on health equity 10 teams of 6, including Public Health and community partners Used CHNA as organizing principle
Leadership and Infrastructure Matter • Health care system efforts aimed at SDOH and health equity must be mission aligned, come from executive leadership, and be supported and coordinated throughout system • CHNA process should point to community priories • Efforts also need to be coordinated across entire system: o Research mission -- CTSA o Medical education – teaching mission o Outreach and communication o Development o Organizational learning / systems engineering o Training and workforce development
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Real Challenges for Health Care System to Go Upstream • Not primary mission or responsibility • Lack of expertise to engage in primary prevention through the upstream/macro-level social determinants of health • Involves partnerships with communities and sectors beyond health • Involves public policy analysis and design • Involves policy advocacy: o Politically and legally challenging
Financing Challenges: Who is going to pay? • Public Finance: Redirections and new investments • Public-Private partnerships; o Social impact bonds/Pay for Success projects • Medicaid policy changes, including incentives for MCOs • Bi-Partisan Social Determinants Accelerator Act (July, 2019; Bustos D-IL and Cole R-OK) 35
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