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David, your point is right on about the murkiness of the population health component of the TA model. It is good to see you attempting to address this with TA leaders, and indeed there is an opportunity, and even obligation, for other public health leaders to shed light on the population health component and what it really means. I often hear a very health care centric understanding of population health, that is along the lines of "the population of patients we care for". Your idea to breakout the components of population health is a very good one.

Hi David. I strongly agree with your point that population health requires actions well beyond healthcare. As Triple Aim measurement faculty along with Kevin Nolan, my principal focus is population health and this is a point central to all our work and presentations, and I use a driver diagram very similar to yours to illustrate that point. A prerequisite and difficult task for organizations new to the Triple Aim is to clearly define a population denominator, essential to both the population health and per capita cost aims. For many US healthcare systems, however, this is a new and challenging perspective, since many US healthcare systems take care of "patients", not populations. Defining a population, even if it starts with a small population, is the key first step toward the Triple Aim, as well as a broader conception of population health.

Great points, Greg and Matt. Thanks for joining the conversation.

I've actually been quite impressed with the description of "population health" in the Triple Aim material. The message has always seemed quite clear that an effective Triple Aim initiative must look (way) beyond the medical community. Do people out there really not understand Triple Aim's definition of "population health" ...or is it something else?

There are possible advantages to using geographic boundaries to define the target population in efforts that use Triple Aim principles - rather than plan-based or provider based definitions. These latter definitions necessarily exclude individuals who might otherwise benefit from being included in the target population. Furthermore, geographically defined target populations, as the denominators for per capita spending estimates, provide opportunities for resource reallocation considerations that do not arise when the "population" is plan- or provider-based. Because many of the same social determinants of health are shared among different plan and provider patient populations, sharing, ie not duplicating, interventions directed toward mitigation of negative social determinants of health may increase efficiency.

Presumably we benefit both as individuals and as populations when any of the modifiable determinants of health (MATCH model) are improved.

Thus, if the two bottom points of the Triple Aim model represent "interventions at the level of individual medical care" (improving the experience of medical care, and improving the per-capita cost of medical care), then perhaps the top point of the Triple Aim model should represent "interventions" at the population level rather than "outcomes" at the population level. Such population-level interventions would necessarily include improvements in physical environment, health behaviors, and socioeconomic determinants of health.

Alternatively, perhaps the Triple-Aim model could be replaced by a competing Quadruple-Aim Model - - something that would probably look suspiciously like the MATCH model of modifiable determinants of health [i.e.: a) physical environment, b) medical care; c) health behaviors, and d) socioeconomic factors]. If folks want to add "experience of care" and "per capita costs of care" as sub-points under the medical care portion of such a Quadruple-Aim model, I'm sure that would be fine.

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