Population Health: ACA and ACOs

Population health has become the lynchpin of healthcare delivery in the United States, especially since the passage of the Affordable Care Act (ACA) in March 2010. (This law was passed due to the unsustainable costs of US health care coupled with less than stellar population health outcomes in the US.) A key way the ACA proposes to reduce health care costs is through the formation of Accountable Care Organizations (ACO). These are networks of doctors, hospitals, and ancillary health care providers who form networks to coordinate patient care and share financial and medical responsibility for that care. Required by ACOs is coordination by primary care physician, care of Medicare patients, and answering to multiple measures of quality. Providers get paid more for keeping their patients (their local population) healthy and out of the hospital.

Communities and Health

A stark fact is that where one lives in the US (zip code) is predictive of health status and longevity. Poorer neighborhoods, with undue burden of negative social determinants of health (SDOH) have increased incidence of chronic disease and ongoing ill health.  To quote & paraphrase from Wikipedia:

The SDOH includes all the factors: social, environmental, cultural, and physical the different populations are born into, grow up and function with throughout their lifetimes which potentially have a measurable impact on health. The WHO commission on SDOH (2008) determined that worldwide the SDOH account for the major causes of health inequities and in the US, the SDOH account for 70% of avoidable mortality. In the US, 5% of the population costs 50% of health care expenditure. Thus the importance of Population Health and Population Health Management. Healthy People 2020 is US Government initiative to address 42 SDOH topics with 1200 specific goals.

Population Health Defined (From Wikipedia):

…the health outcomes of groups of individuals including distribution of such outcomes….aims to improve health of entire population. A priority considered important in achieving this aim is to reduce health inequities or disparities among different population groups due to, among other factors, the social determinants of health, SDOH.

Population Health Management Defined (From Wikipedia)

…the technical field of endeavor which utilizes variety of individual organizational and cultural interventions to help improve morbidity patterns (i.e. illness and injury burden) and the health care use behavior of defined populations…

The definitions emphasize:

1. Chronic conditions and diseases
2. Single point of contact and coordination
3. Predictive modeling across multiple clinical conditions with an operational strategy of
4. Intensive care management (by healthcare system) for individuals at highest level of risk
5. Personal health management for those at lower risk.

What It Means In General For All of Us

It is the operational strategy of personal responsibility for healthcare either by self-care or engaging in the health care system to receive needed care that is the crux of health care delivery in the US going forward. In order to succeed, those who have the most chronic disease burden, the most ill, will be intensively supported by the healthcare system (and healthcare dollars) while those most well will be educated to self-care. Both populations will need to receive more education about health and disease and the level of health literacy will need to rise. Both populations will benefit from and be required to use technology to care for themselves better and more fully interact with health care system. Patients will need to share data. Providers will need to communicate more fully with patients, and their offices provide ongoing communication to keep patients well. Technology will need to improve in order to allow free flow of patient data across health care delivery systems, interoperability, in order to insure better patient care, less waste, and more complete data. The government (specifically congress) must be enlightened and pass laws that improve population health such as Medicaid expansion, raising minimum wage, and improving the public school systems so that literacy and health literacy can be assumed. These are all population health issues.

What We Can Do Now

As we head home for the winter holidays, we have our marching orders. Population health begins in our homes, our families and friends and our communities. Population health considerations are global, national, community and within our own sphere of relationships. Can we make time to have a few heart to heart conversations with ourselves and others about our health, healthcare delivery and SDOH. Is our community doing enough to improve the health of those less fortunate. If we, ourselves are burdened by chronic diseases that are unaddressed, are there solutions in the community? What are we doing ourselves to take care of our own health, to put into practice all that we know about lifestyle changes and screening for disease. Are we putting in the needed effort to do our part for improved population health?

As we sit around holiday tables, at halftime during holiday football or gathered around the fireplace: Might we ask grandma how she is managing in her house with stairs? Maybe ask Bobby, age 8 who has put on too much weight what his favorite sport is and how his after school hours are spent? Perhaps ask Bob our 45 yr old buddy whether he has a primary care physician (he has gained weight, and Type A). Maybe have a conversation with him on the value of patient centered medical homes (PCMH) and tell him how much you appreciate your primary care physician. How about cousin Mary age 50? – a marathoner who never goes to the doctor or does screening but has family history of colon cancer? It is time for her to have a colonoscopy and her primary care doctor would speak with her about that. What about our incredibly independent 70 yo mom who put her car keys in the refrigerator this morning and thought it was funny…but actually? Can we bring up a memory issue and make sure her primary MD knows what happened? What about the 25 pound baby nephew guzzling sugary juice? Can you gently bring up childhood nutrition and print out some articles for her? How about our 80 yr parents, very independent, but we don’t know their advance directives or even if they have any. Forms can be downloaded and filled with their doctor’s office. How about the 90 yr grandmother with newly diagnosed cancer? Can we help her think about how to approach treatment, palliative therapy and eventually hospice? I know it is the holidays but how long will we wait to ask, to gently help? There is no time like the present.

Topics from our #hcldr tweetchat on Tuesday November 18th were:

• T1 How can we improve population health in our communities?
• T2 How can we improve the health of ourselves, our families and our friends?
• T3 How can government best insure improving population health?
• T4 Holidays: time with family and friends: Can we “Talk Turkey”?

References

The long reference list due to the subject matter and is just a tiny slice of the material available on Population Health. I recommend starting with the Wikipedia entry for an over view. (References 2-6 are sited in the wikipedia entry, should you wish more detail). The other references address population health initiatives, strategies and challenges.

”What is population health?” Kindig D and Stoddart G, American Journal of Public Health, March 2003, http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.93.3.380, accessed November 15 2014

“Social Determinants of Health”,  HealthyPeople.gov, http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health, accessed November 15 2014

Healthy People 2020, http://www.healthypeople.gov/2020/default.aspx, accessed November 15 2014

”Old age, new technology, and future innovations in disease management and home health care”, Coughlin, Pope and Leedle,  Home Health Care Management and Practice, April 2006,http://agelab.mit.edu/system/files/home.health.care_.pdf, accessed November 15 2014

International Population Health Management, Care Continuum Alliance,http://dmaa.pbworks.com/w/page/17960768/FrontPage, accessed November 15 2014

”Capturing Social & Behavioral Domains & Measures in Electronic Health Records: Phase 2”, Institute of Medicine, 2014, http://www.iom.edu/Reports/2014/~/media/Files/Report%20Files/2014/EHR-phase-2/EHRfindingsrecs.pdf, accessed November 15 2014

“Secrets of Population Health Management [Infographic]”, Abby Norman, HealthWorks Collective, November 7 2014, http://healthworkscollective.com/abby-norman/277021/secrets-population-health-management-infographic, accessed November 15 2014

“A Holistic Approach to Population Health”, Suzanne Cogan, HITech Answers, November 12 2014,http://www.hitechanswers.net/holistic-approach-population-health/, accessed November 15 2014

”Zip code better predictor of health than genetic code”, Amy Roeder, Harvard School of Public Health, August 4 2014, http://www.hsph.harvard.edu/news/features/zip-code-better-predictor-of-health-than-genetic-code-/, accessed November 15 2014

“Health by ZIP Code – Where You Live Determines Your Health – for Good or Ill”, Sandy Graham, The Colorado Health Foundation, http://www.coloradohealth.org/yellow.aspx?id=6187, accessed November 15 2014

“Commission to Build a Healthier America – City Maps”, Robert Wood Johnson Foundation,http://www.rwjf.org/en/about-rwjf/newsroom/features-and-articles/Commission/resources/city-maps.html, accessed November 15 2014

“Implementing the Tools to Support Accountable Care and Population Health at Bon Secours”, Mark Hagland, Healthcare Informatics, November 11 2014, http://www.healthcare-informatics.com/article/implementing-tools-support-accountable-care-and-population-health-bon-secours, accessed November 15 2014

“You Should Share Your Health Data: Its Value Outweighs the Privacy Risk”, Seidenberg Beth, Wired Magazine, November 6 2014, http://www.wired.com/2014/11/on-sharing-your-medical-info/, accessed November 15 2014

”The Evolution of population health: 10 statistics”, Ayla Ellison, Becker’s Hospital Review, October 20 2014, http://www.beckershospitalreview.com/accountable-care-organizations/the-evolution-of-population-health-10-statistics.html, accessed November 15 2014

”How to succeed at population health management in the shifting healthcare environment “, Ayla Ellison, Becker’s Hospital Review, October 8 2014, http://www.beckershospitalreview.com/hospital-management-administration/how-to-succeed-at-population-health-management-in-the-shifting-healthcare-environment.html, accessed November 15 2014

”Population health and analytics top new areas of investment for healthcare providers”, Shannon Barnet, Becker’s Hospital Review, October 7 2014, http://www.beckershospitalreview.com/news-analysis/population-health-and-analytics-top-new-areas-of-investment-for-healthcare-providers.html, accessed November 15 2014

“Population Health Challenges HIT, Quality Leaders”, Cheryl Clark, HealthLeaders Media, November 14 2014, http://www.healthleadersmedia.com/page-1/LED-310326/Population-Health-Challenges-HIT-Quality-Leaders, accessed November 15 2014

”4 big ACO trends & issues”, Carrie Pallardy, Becker’s Hospital Review, November 10 2014,http://www.beckershospitalreview.com/accountable-care-organizations/4-big-aco-trends-issues.html, accessed November 15 2014

”Differentials in the Concentration in the Level of Health Expenditures across Population Subgroups in the U.S., 2010”, Cohen and  Uberoi, Agency for Healthcare Research and Quality, August 2013,http://meps.ahrq.gov/data_files/publications/st421/stat421.shtml, accessed November 15 2014

“Digitizing Healthcare On The State Level”, Kaveh Safavi, InformationWeek Healthcare, November 7 2014, http://www.informationweek.com/healthcare/policy-and-regulation/digitizing-healthcare-on-the-state-level/a/d-id/1317299, accessed November 15 2014

”FAQ on ACOs: Accountable Care Organizations, Explained”, Jenny Gold, Kaiser Health News, April 16 2014, http://kaiserhealthnews.org/news/aco-accountable-care-organization-faq/, accessed November 15 2014

Image Credit

Crowd down Stockton street – Niall Kennedy

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