Improving Population Health

Did You Find Population Health in the State of the Union?

By David A. Kindig, MD, PhD

I listened carefully, but I don’t think I heard the words population health, public health, or prevention anywhere in the speech. But I think Obama is a closet population health advocate like Sam Brownback and Peter Orszag.

There was no mention of health outcomes, disparities, or even national health performance goals --  where we have much work to do, especially in relation to other countries. However, the domestic part of the speech dealt primarily with two major drivers of health -- education and jobs (fully 40% of the health factors score in our County Health Rankings is made up of social and economic indicators such as these).

Effective education policies have the dual benefit of improving both educational attainment and health status across the lifespan, from the earliest intrauterine life stages through formal schooling and beyond. And, in an evening when bipartisan dating was a major sub-theme, this should appeal to liberals and conservatives alike since it expands opportunity without the government directly reallocating resources.

In my experience, much of the population health research and advocacy in the areas of income and employment has focused on more liberal-leaning public governmental policies such as tax reform, income enhancement programs like earned income tax credits (EITC), and public job creation. These are important, but job creation is primarily in the private sector, and policies improving economic competitiveness need to be supported as well. I don’t know what the right balance between these is, but it should be made on evidence rather than ideology from either side of the dating game. The President also emphasized our expanding opportunities to create jobs in the clean energy sector; weaning off coal and oil has secondary unmentioned health benefits as well.

We did hear the word health, but of course only in the context of health insurance reform. Even though the County Health Rankings model only ascribes 20% of health outcomes to healthcare, it is critically important that all Americans have access to it. So I applaud the President for standing firm on this. Acknowledging that the Patient Protection Act is not perfect, he expressed hope for bipartisan enhancements. Though the President did not directly address the specifics of healthcare cost containment, it must remain a high, common ground priority on the health reform agenda. I believe we could and should eliminate or rationally ration high cost treatment options that offer little or no benefit, for both deficit reduction and redirecting savings towards prevention.

So population health improvement and disparity reduction did not rise to the level of an explicit State of the Union “Winning the Future” theme. But many of the featured components are so important in their own right that the combined secondary effect could represent a bipartisan stealth attack on this critical challenge.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Assessing Today's Health...and Tomorrow's

By David A. Kindig, MD, PhD

Today I’m starting a new series on population health measurement, motivated by the idea that “you can’t manage what you can’t measure.”  While there is no shortage of measures and rankings, there’s actually little consensus on what metrics are best suited to assess progress in population health improvement. Last week I urged Triple Aim architects to clarify how population health is defined in their model, but they’re not the only ones with definitional issues.

Metrics can assess a single item, such as infant mortality rates, or be bundled into groups to create summary measures. America’s Health Rankings (AHR) and the County Health Rankings (CHR) both use summary measures to annually rank, respectively, the health of states and counties within states. AHR has been ranking the health of states since 1990 and released its most recent rankings in December 2010. This important national resource informed work by the University of Wisconsin Population Health Institute to rank the health of Wisconsin counties beginning in 2003 and, for the first time in 2010, counties in every state. Dr. Pat Remington and I are proud to serve on AHR’s Scientific Advisory Committee.

The AHR and CHR share a common goal of population health improvement and both projects take pride in their deliberate, systematic, and transparent approaches. Both projects create summary measures for health outcomes (using metrics such as premature death, quality of life, and poor birth outcomes) and health factors or determinants (using metrics that capture health behaviors, clinical care, and social/economic/physical/policy environments). However, while CHR uses the health outcomes summary measure to identify the healthiest counties, AHR creates its overall rankings based on both outcomes and determinants.

So what does this look like in action? From 2009 to 2010, Wisconsin dropped from 11 to 18 in AHR overall rankings. But, a look at separate outcomes and determinants rankings over the same time period tells a slightly different story. Our determinants ranking is identical to the overall ranking (we dropped from 11 to 18). However, our health outcomes ranking improved slightly, from 16 to 15.

Why is this important? In general, we think of outcomes as a reflection of our current health and determinants as a predictor of our future health. The two summary measures often move in the same direction, but not always. When we launched the national CHR in 2010 with support from the Robert Wood Johnson Foundation, some wanted to know why our rankings didn’t have an overall score like AHR. The answer has to do with how the results are communicated and their implications for action. We felt strongly in the value of the two different measures to communicate different but equally important concepts about population health, particularly for policy makers.

Places with determinants better than outcomes are on the right track toward health improvement. But, for those such as Wisconsin with declining determinants, unless we act to reverse the trend, there is cause for concern about potential declines in health outcomes. It is the outcomes we are trying to improve, and the determinants that will get us there.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Unpacking the Triple Aim Model

By David A. Kindig, MD, PhD

Many thanks to those who offered some great blog ideas for 2011 – reader suggestions are always welcome. Jay Gold’s question about the Triple Aim caught my eye because it’s something I’ve been giving a lot of thought to recently: “How in your view does population health tie in with the other two elements (quality of care, cost-effectiveness) of Berwick's Triple Aim?”

This is a relevant and timely question, since the Triple Aim is getting much more attention since Don Berwick became the Administrator of the Center for Medicare and Medicaid Services. In a blog interview with John Whittington last fall, we explored the origins of Triple Aim within the Institute for Healthcare Improvement and their emerging regional strategy beyond individual health systems or plans.

I am a big fan of Triple Aim and have been privileged to present at several of their recent meetings. My appreciation for this work is based in the belief that IHI/Triple Aim is one of the leading forces in the U.S. to motivate healthcare systems to stretch beyond traditional clinical roles and work towards broad population health improvement. In fact, population health is prominently featured at the top of the Triple Aim triangle:

It’s great to see population health front and center in a model. But there’s a communication problem here that needs to be acknowledged: what does “population health” in the Triple Aim model actually represent?

My concern is that people looking at the Triple Aim model won’t necessarily know what to make of the “population health” leg of the triangle. As a result, they may focus on the other two more concrete goals of improving the experience of healthcare and reducing per capita costs of healthcare. In no way do I want to diminish the importance the model’s clinical goals, which may represent our best short-term strategy. However, the reality is that even major progress in these two areas over the next decade will not help us achieve our goals related to healthy life expectancy and disparity reduction.

To achieve our broad population health goals we need to understand and intervene across the whole spectrum of determinants, not just health care. Triple Aim leaders understand and appreciate this, but I’m not sure this is clearly communicated by the Triple Aim model so I’ve drafted an alternate view that combines the Triple Aim model with our model of population health.

As the figure shows, two of the legs of the Triple Aim stool relate only to a single determinant, healthcare. I’d like to see the population health part of the Triple Aim model more clearly defined to make it clear that population health outcomes (among populations or individuals) are influenced by multiple determinants, most of which are beyond health care (note the reddish boxes in the figure above).

I have discussed this constructive criticism openly with Triple Aim leaders and will continue to do so. They have a powerful brand which is serving us well in many regards. But when Berwick and others talk about “better health” as a shorthand for “population health” in the Triple Aim model, let’s be certain that everyone understands this means actions beyond just health care. Several Triple Aim sites have developed impressive population health agendas and are moving forward with broad and ambitious health goals. But I can’t help but wonder if a revamped model might enhance existing efforts and spur new dialogue and action in AND out of the health care system to improve health.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Improving Population Health...in 2011

By David A. Kindig, MD, PhD

I spent some time last week musing about potential blog topics for 2011, which brought me back to the population health model that underpins this blog.

 

Last year I touched on many parts of this model. I wrote about and offered opinions on the social determinants of health, how savings in healthcare could enhance the population health agenda, and the extent to which health-related behaviors are beyond individual control. I also addressed  policy-related topics such as the IRS consideration of Community Benefit policy and whether a cross-sectoral integrator is necessary or possible. I’ll revisit these topics in 2011 but will also cover other important population health issues, such as:

1. Which outcome measures are most useful in guiding population health policy?
2. How do improvement metrics differ from achievement metrics?
3. Will raising average health reduce disparities?
4. Are racial health disparities the most important ones?
5. Are genetics a modifiable determinant of population health?
6. Will climate change increase the importance of the physical determinants of health?
7. What is prevention?
8. Top down vs. bottom up approaches to population health policy
9. Why can’t historical patterns of investment in healthy and unhealthy communities show the optimal path for others?
10. What are population health incentives?
11. Is there a business model for population health improvement?
12. What is the health impact of non-healthcare programs and policies?

I’d love to know what you think of this list and I welcome suggestions for additional topics anytime. This week, I’m hoping for 10 new ideas from readers on questions or issues this blog should address as we head into 2011. Thanks in advance for your contributions!

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.