Population Health: Capital and Lower Case “P”

The term “population health” entered my vernacular in the late nineties when I was a new pediatric department chief and our hospital director of quality introduced me to the term. Like most clinicians I was a pretty good medical “tactician” in the ICU, the clinic, and on the hospital ward. But I didn’t consider the bigger “strategic” outcomes of groups of patients often enough. This changed.

The department and hospital took on pediatric asthma in our population and saw the hospitalization rate for our patients drop by two thirds. (In fairness, it was also the beginning of the era of “asthma control” so there were more tools available.) We championed telemedicine systems that provided pediatric subspecialty consultation for children six time zones and thousands of miles away and monitored children with asthma in their homes over the relatively new Internet. After helping to run health care facilities and systems for the Army and working in a few health care systems overseas, I was fortunate to begin work as a hospital executive focused on population health in an urban medical center.

These past two years I have been mentored by health care and community leaders regarding the impact of the social determinants of health (e.g. housing, education, food security, jobs, transportation) on the health and well-being of those living in the communities surrounding our hospital. These social determinants comprise up to 80% of the factors influencing health outcomes. In many cases the journey to ill-health in adulthood began for our adult patients in infancy or even earlier with insufficient or absent prenatal care.

Infant mortality for babies born in one neighborhood a half-mile from our hospital is ten times what it is five miles away in another part of town. Life expectancy is nearly twenty years shorter. Efforts to affect the long-term outcome of the two-dozen or so babies born in our city every day over the course of their lifetime include addressing their health care access and quality and the disparities that drive these outcomes. Even more importantly, efforts must address the social determinants that impact their health: Population Health with a capital “P.”

But in my new position I soon became aware of a tension in the understanding of population health. Early in my tenure someone referred to the patients frequenting the ER and hospital wards as “PAUers,” (“potentially avoidable utilization”). Other names that I continue to hear for these patients include “high-utilizers,” “frequent-flyers,” and even very recently “train-wrecks.” There is no question that health care facilities, payers and practices must address the high health care utilization of these patients who struggle with a tremendous burden of complex, chronic disease. By some estimates, 5% of our population consume 50% of health care resources.

What has become clear is that many discussions of population health in healthcare facilities center almost exclusively on the peak of the risk/care consumption pyramid: population health with a lower case “p.” While the health of these individuals is as important as that of anyone else on the pyramid, a focus on small “p” population health can sometimes become centered on how this population affects the healthcare institution. In this case solutions are driven by investments in the healthcare system and tend towards short-term goals and short-cycle return on investment. Small “p” population health is generally seen through the healthcare system lens and its effectiveness is measured using system-based interventions and metrics (e.g. readmission rates, ER utilization, etc.)

In contrast, Population Health with a capital “P” focuses on the base of the risk or utilization pyramid where people are not accessing health care but where they are making decisions that will ultimately impact their health. At the base of the pyramid the focus should be on how healthcare organizations – particularly those that serve as anchor institutions in urban or rural settings – can through intervention and influence positively affect the health & well-being of the population.

The expectation is a strategy that affects multiple generations over multiple generations; long-term goals and long-cycle return on investment that require community leadership and prioritization. With efforts seen through the lens of the health care recipient rather than the system, it is measured by the effectiveness of community-based interventions and metrics. And where small “p” population health tends toward blaming the patient and being pejorative, capital “P” Population Health with its focus and resources invested in the community has the potential to be restorative.

There is no doubt that American healthcare must address both small “p” and capital “P” population health. But we must be careful not to allow the economic urgency of the peak of the utilization pyramid to hijack our opportunity to invest in the health and well-being of those who are yet at the pyramid’s base.

They may not remain at the base of the pyramid.
But for their sake, for our communities and for our health care systems, we must do all we can to see that they do.

Chuck Callahan Henry V 4.3 – Lead from the Front      https://henryv43.wordpress.com/