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From Individual to Community: The Mandate on Population Health

At a meeting of the American Board of Internal Medicine’s Foundation in August, David Nichols, MD, MBA, the president and chief executive officer of the American Board of Pediatrics and its foundation, told a story from his days in intensive care. A young patient had sustained burns to 90% of his body—an almost certain death sentence. Nichols had tended to 3 other children with similar fates in the weeks prior, all of them dying from fires started by open flames used for heat or light after the families had been unable to pay their utility bills.

Diana Mason, PhD, RN

Nichols was galvanized by these needless, tragic deaths. The parents’ loss was incalculable, and the costs to the health care system were much greater than the families’ utility bills. He appealed to the local utility company to change its policies but found a complex web of state and local agencies and interest groups that no one quite knew how to navigate. It took 2 years, public testimony by Nichols, and hard work by a team from the medical center, as well as volunteers, to get the public utility commission and the utility companies to change their policies to offer an extended grace period so that children from families who fell behind in their payments were not left with unsafe means to light their homes and keep warm.

I asked Nichols whether the experience had enabled him to put in place systems that would make it easier to address other community health problems more rapidly in the future. Sadly, he said, it had not. But that may be changing.

The Meaning of Population Health

The Institute for Healthcare Improvement’s Triple Aim of improving individual patient experiences with health care, promoting the health of populations, and reducing health care costs is designed to focus attention on some disturbing facts: we spend an estimated $2.7 trillionevery year on health care, yet we still rank poorly in leading national health indicators compared with other nations. It is no longer sufficient to think only about the patient in front of us. Rather, we must also keep our eyes on the health of the nation and the communities we serve.

“Population health” can refer to a specific group of patients, such as people with diabetes in a primary care practice. Or it can focus on a geographic area and take on a “community health” frame of reference. Regardless, the goal is discovering how to address the factors that can prevent further illness and death and even promote quality of life, well-being, and happiness. For David Nichols, this meant working with his hospital and the community to change utility companies’ policies. For others, it may mean promoting economic development and better jobs, adequate housing, or access to fresh fruits and vegetables and safe places to exercise. Such factors are referred to as social determinants of health, or “upstream” determinants, although a recent analysis of this language by the Robert Wood Johnson Foundation suggests that it may need to be reframed to resonate with all stakeholders, including policy makers.

Who Is Responsible?

But who is responsible for population health?

Some would argue that as underfunded as public health departments are, they’re responsible for ensuring that communities are healthy. But others have differentiated public health and population health, noting that governments have been responsible for traditional public health while population health is the responsibility of myriad public and private entities.  As researcher Michael A. Stoto, PhD, argues, “this shared responsibility makes it difficult for any one entity to be held accountable for specific health outcomes. However, entities can and should be held accountable for specific actions designed to improve these outcomes.”

What then is the responsibility of those who proclaim themselves to be health care experts? The Affordable Care Act (ACA) nudges health care professionals and organizations toward adopting a focus on population health in several ways.

  • Nonprofit hospitals already must show a “community benefit” to keep their tax-exempt status. The ACA raises the bar by requiring them to conduct a community health needs assessment every 3 years, prioritize these needs, and report yearly on how they are meeting these needs. And public health departments are required by the Public Health Accreditation Board to do community health assessments, providing opportunities for building a coalition of stakeholders who commit to improving a community’s health. But what about for-profit hospitals, other facilities, and primary care practices? Should long-term care facilities, for example, be responsible for contributing to the development of community support systems that help disabled people remain in their homes?

  • Accountable care organizations (ACOs) are expected to incentivize physicians, other health care professionals, and health care organizations to focus on improving the health of populations, although the law doesn’t specify whether the population of interest is geographic or disease-specific.

  • The Prevention and Public Health Fund authorized in the ACA supports a variety of strategies to promote the overall health of a community. For example, community transformation grants are designed to engage stakeholders in supporting community-level strategies that can prevent chronic illnesses. These might involve the development of employee wellness programs by small businesses or the creation of healthier school environments.

  • The law includes initiatives to promote individualized plans of disease prevention and health promotion. These include a Medicare Annual Wellness Visit that incorporates a health risk-assessment tool for designing individualized health promotion plans and the dissemination of evidence-based health promotion strategies that health professionals can use with patients. It also requires free access to common evidence-based preventive screenings and services, ensuring insurance coverage of these services and banning co-payments.

What It All Means

What does this mean for David Nichols and other health care professionals who see opportunities to prevent illness and death in the communities they serve?

First, if they are affiliated with a hospital, someone there should be responsible for community outreach or community affairs—someone who, for example, could help them work with utility companies to develop policies that don’t leave financially struggling families without heat or electricity.

Second, if they are participating in ACOs, they can find ways to build on the rewards for meaningful use of health information technology and use that technology to identify a population’s most pressing health problems, explore ways to reduce them, and evaluate the success of those approaches.

Third, when the most pressing health problems require community engagement, they might consider addressing community boards, school boards, or a town council to share their observations and recommendations for prevention.

Finally, we can all embrace the idea that we will not improve the health of individuals, families, and communities or reduce health care costs until we shift our attention to promoting healthful places for people to live, work, and go to school. It was clear to me that David Nichols was deeply moved by the preventable deaths of children. One of the strengths of the ACA that receives little attention is that it gives us a new focus: it moves our sights from the isolated deaths to the lives saved by policies that make for healthier communities.

About the author: Diana Mason, PhD, RN, is the Rudin Professor of Nursing and Co-Director of the Center for Health, Media, and Policy at the Hunter College, City University of New York, and President-elect of the American Academy of Nursing.
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