By David A. Kindig, MD, PhD
We don’t usually repost the formal comments we get in response to a given blog, but we had several particularly thoughtful ones in response to the Nov 16 Triple Aim: Accelerating and Sustaining Collective Regional Action by John Whittington and I that I wanted to call attention to…as well as a provocative essay from Mt. Sinai Medical Center.
From Pamela Russo: Thank you for the brief history and evolution of the Triple Aim with regards to population health - clarifies and offers great promise. It offers a good model for broader and more collaborative interpretation of how hospital community benefits activities could evolve under the new regulations.
From Mary Lou Andersaen: At the end of the Clinton administration such a program was funded to provide $1M /year for 5 years to support the development of a small group of communities to develop such systems linking all important sectors. Lessons were learned and a continuing organization called Communities Joined in Action continue that mission struggling without the necessary support to achieve the spreading of the best results. That passion exists right now in this country. Tap into it!
From Robert Stone Newsom: Interesting approach and glad to see they have the critical element of “funders” in the list. The question as always remains: who are these funders? Whose pocketbook (profits, wages, income) must ultimately be reduced for such population health improvement to occur? All available evidence strongly supports the supposition that neither providers nor private sector insurers have any incentive to reducing their own income and profits for such ‘public good’ funding. Consequently increased taxation is likely the only sustainable approach. However, recent history has demonstrated both the 1% and 99%’s inability and / or unwillingness to meaningfully address the moral hazard inherent in our current healthcare ‘market’ models. In healthcare markets rational self-interest may guarantee that population health continues to be the victim of the tragedy of the commons.
I continue to remain bullish in thinking about Triple Aim regional projects as emerging beacons of where healthcare organizations are pushing the boundaries beyond traditional health care concerns, to fully embrace a population health view. But will the leadership, infrastructure, and funding challenges that John Whittington outlines evolve and grow, in the face of the Newsom comments above? I think it will only happen if Triple Aim leadership continues to embrace a robust definition of population health outcomes, including disparity reduction at the regional/community level.
It’s no wonder the November 22 Mt. Sinai Medical Center’s New York Times advertised commentary caught my eye. The piece, written by Kenneth Davis, is titled “Social Service Support: Better for Individuals and Health Care,” asserts that one reason for our lower health outcomes despite large health care expenditures is that "the US spends far less than other countries on critical services such as housing, employment training, improved education, and income supplements. Most OECD nations spend between 20 and 40 percent of their GDP on health care and social services combined.....the US spends about 15 percent on each, while other nations spend two or three times more on social services......Improving population health and reducing hospitalizations are everyone’s goals, but hospitals can only provide part of the solution. In order to lower costs, we need to invest in social support services outside of our health care institutions. By doing so we will improve the nation's health and meaningfully bend the health care cost curve".
Extremely well said, Dr. Davis. This is a perspective widely shared by those in the population and public health fields but is probably less familiar to those working in healthcare and academic health centers. Population health improvement very much needs such insight and support from leaders within the health care system. It is this perspective that needs to guide Triple Aim concepts and work on the ground to ensure development of three equally robust legs of the stool – population health, cost, and quality.
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. Follow him on twitter: @DAKindig.
Well, that's the problem, isn't it? Health care and public health were severed early in the 20th century, and we've been paying the price for that decision ever since. I had been a practicing critical care nurse for years when I began to wonder if preventing all the health disasters I was seeing might not be preferable to throwing technology at them. I found no support -- and I had never even heard of public health. It took me a while to find out how to proceed. When I entered my MPH program, I found that, as a clinician, I spoke a completely different language from those in public health. It was a complete re-socialization process.
I would submit that we re-think that initial disastrous decision. Training in population health should be integrated into the education of all health care professionals. As for non-clinical public health professionals -- a few clinical facts of life wouldn't hurt them either.
Posted by: Burden S Lundgren, MPH, PhD, RN | 12/15/2011 at 11:06 AM
As with provider-based improvement, population-based improvement is dependent on transparently shared, frequent observations of results. To paraphrase Lord Kelvin, as many others have, one can not improve unless one measures. Applying triple aim principles to population health requires a geographically defined population and simultaneous, frequent, transparent, interpretable measurement of population health, experience of care and cost per capita. Adherence to these principles prevents viewing only the silver lining without the cloud.
Posted by: Ed Donovan | 12/15/2011 at 01:18 PM