I just became aware of an interesting program that works to repair homes in Southeast Washington, DC and Maryland. The initiative, called the Healthy Housing Virtual Home Visiting (VHV) Program, seeks to improve the living conditions of residents in some of the lowest income parts of the District and surrounding areas. Since this program is happening in my city, and because it aims to improve health outcomes for children in particular, I thought it was worthy of note.

The backstory is this: Children’s National Hospital (CNHS) in Washington, DC won an Innovation Challenge contract award through Fannie Mae to help improve the health of children with asthma in low socioeconomic areas by cutting down on the level of allergens in their homes. The award helped the project team accomplish the following:

• Hire a project coordinator, a program lead, and a physician to lead all virtual health visits.
• Pay for remediation equipment and work, including HVAC filters and vacuums, mattress bedding, and roofing and plumbing repairs.
• Evaluate outcomes of the virtual visit program.
• Write a paper evaluating the program using key performance indicators.

According to the American Lung Association, “Asthma is the most common chronic condition among children, currently affecting an estimated 6.1 million children under 18 years.” Further, according to the Fannie Mae website, “In Washington, D.C., pediatric asthma rates are highest in Wards 7 and 8, an area southeast of the Anacostia River where the District’s greatest share of older, poorly maintained housing is also concentrated.”

This is no coincidence, says the website, since, “according to doctors at Children’s National Hospital…substandard housing conditions can act as environmental triggers for asthma.” That’s a serious problem that might prompt someone to ask, “So why don’t folks just move out of these old, run-down buildings?” Aside from the fact that members of lower socioeconomic groups often don’t possess the capital to simply pick up and move, there is also a deep sense of dislocation that comes with leaving a home where, in some cases, the same family has lived for generations.

And if that’s not enough reason, on the political front, these DC wards are undergoing redistricting. That means that shifting political boundaries will likely be accompanied by vibrant economic expansion. So while these changes may usher in challenging times, they may also herald opportunities. For example, as the article notes:

“When advisory neighborhood commissions negotiate community benefit agreements with developers constructing new buildings in the District, they sometimes include clauses requiring the developer to preferentially hire residents of the ward where the building will be built. If developers on the Wharf or in Navy Yard have to hire residents of Ward 8, lower-income communities could benefit.”

For the uninitiated, the Wharf is a “mile-long stretch along the Potomac River…with restaurants, retailers, residences, and businesses,” and the Navy Yard is “an area that has been reborn as a haven for sports fans, nature lovers and foodies.” The bottom line is this: by staying put, residents might be able to land a good job, becoming upwardly mobile without having to uproot their family.

All this talk of politics and economics is taking us a little afield from the scope of this blog, so let’s regain focus on what’s most important from a population health standpoint: this program seeks to improve the health of a specific patient population ‐‐ children dealing with asthma ‐‐ so that they can live happier, more productive lives.

But how to ensure this group is equipped to change with the shifting landscape, and stay healthy while doing it? That’s where the VHV project comes in. Program stakeholders represent a wide gamut of specialties both within and outside of medicine, and to me illustrate how coordinated care can overcome social determinants of health and improve the wellbeing of specific populations: in short, they agreed on a goal, worked in close collaboration to achieve it, and then assessed population-level outcomes at the conclusion of a set time period (comparing numbers of sick patients six months before and six months after the intervention) to ensure that they were on track with their objectives.

How It Works

The project team consists of both medical and housing experts who understand the unique needs of populations throughout the Washington, DC area: IMPACT D.C. Asthma Clinic and Child Health Advocacy Institute, an award-winning pediatric asthma program run through Children’s National Hospital; a nonprofit housing remediation organization called Yachad; Local Initiatives Support Corporation (LISC) DC; and the Institute for Public Health Innovation (IPHI).

To start the program rolling, stakeholders agreed on a working hypothesis: can asthma-related illnesses in children be improved by identifying possible triggers inside the home and connecting families to remediation resources? The project’s initial objective was to reduce the number of asthma-related hospital visits by identifying indoor asthma triggers and establishing remediation plans, though it’s not clear to me if at the outset they had any firm numbers in mind for target goals.

That said, one thing I really like about this program, and a prime reason why I think it could scale to other settings, is that it leverages a telehealth approach in assessing the overall state of a given home. Each Virtual Home Visit includes a visit from a medical provider, a VHV coordinator, and two housing specialists from Yachad, with each VHV lasting about 30 minutes. According to the Fannie Mae website:

“Using a telehealth platform on their smartphones, families connect with providers who conduct virtual medical and home assessments. Once housing conditions that trigger asthma, such as mold or pest infestations, are identified, families receive education and a remediation plan.”

Once a remediation plan is agreed upon by residents and the project team, that’s when the Yachad organization seems to get more involved:

“Yachad provides remediations ranging from new furnace filters and dehumidifiers to extensive roof repairs. The remediations improve the quality of housing and reduce the risk of future displacement of long‐term residents.”

Program Success

During its first year in existence, the VHV program seems to have been a success. A number of children in affected homes have seen their health improve. According to an overview of the program, “The frequency of emergency visits, hospitalizations, and oral steroid courses dramatically decreased in the six months following the VHV, compared to the six months prior.”

As the resulting paper chronicled, the team provided remediation support to 46 homes, with most participants receiving two or more remediations. Further, “The most commonly provided home remediation services were dust mite covers (100%), pest control (52.1%), and HEPA vacuums (52.1%)…In total, the pilot program completed over 112 home remediation services.”

In one example of program success, Yachad was able to provide a family with “two treatments for roaches and mice, advised them to remove all the carpeting in the house, and repaired the roof and a leaking sky light.” On the medical front, children in the household “are being treated with daily doses of prescribed asthma medication.”

Progress made in improving children’s health was reflected in satisfaction surveys administered 72 hours, one month, and six months following the VHV. According to the paper, these results “clearly highlight the acceptability of this format by patients and their families. Nearly all families would recommend the VHV to another person (98%) and expressed overall satisfaction (100%). Most families felt the VHV had a positive impact on their child’s health (76%).”

Future Plans

Although Fannie Mae has agreed to extend the award contract by a year, it sounds like CNHS is already exploring ways to finance home remediations beyond the length of the contract via reimbursement models through Managed Care Organizations. In the meantime, here are their short term goals for the next year:

• Sustain the Virtual Home Visit (VHV) model by completing 75 virtual home visits and 100 home remediation measures
• Develop an interactive property-level map for Washington, DC that identifies high morbidity properties and their remediation needs
• Estimate the projected healthcare savings that could result from remediation at problematic properties
• Collaborate with Fannie Mae’s Multifamily Asset Management to review property inspection guidelines and identify opportunities to enhance them using findings from the mapping project

This is encouraging news, and I’ll be sure to keep checking in to see how it goes. If they can build on what they’ve accomplished here and make this a sustainable program over the long haul, I don’t see any reason why it can’t scale to other cities.

In a recent Harvard Business Review article titled “Enlist Medical Specialists in the Drive to Improve Population Health,”  authors Ryan Howard and Michael Englesbe make a compelling argument with respect to population health management: recruit specialties to become entry points into the population health management ecosystem.

The issue they highlight is straightforward, if not challenging to surmount: “Today,” the authors write, “a patient in the United States and other developed countries may see an array of specialists, undergo a variety of procedures, but never speak to a doctor about fundamental health behaviors such as smoking, diet, or exercise or chronic conditions such as diabetes, obesity, and stress.”

In other words, a treating physician will zero in on the narrow health issue with which the patient presents, ignoring the possibility of screening for potential comorbidities or unhealthy lifestyle choices and, in so doing, squander a chance to enroll that patient into an early disease management program. Howard and Englesbe, who are both physicians at the University of Michigan, characterize this as a missed opportunity. And I have to agree.

This focus on the here-and-now, as opposed to providing longitudinal, coordinated care that heeds warning signs about future health complications to course correct, does us all a disservice. For those of us in the U.S., there are many reasons we’ve ended up here, not the least of which being a reimbursement system where providers are paid separately for each individual service they perform, which is known as fee-for-service (FFS).

As a side note, there’s currently a push within CMS and among many private insurance carriers to get beyond FFS by incentivizing health systems and healthcare groups to enter into accountable care organizations (ACOs) and alternative payment models (APMs). These payment models spread risk between payers and healthcare providers, providing incentives for providers to provide top-quality care at affordable costs (I’ve written about APMs before). Although there’s room for optimism that risk sharing is the wave of the future, so far uptake of APMs has remained relatively low.

But don’t despair! The authors propose a solution that could work within today’s care delivery infrastructure: “integrate existing resources that address foundational health issues like health behaviors and chronic conditions — which account for the majority of premature deaths — into specialty care pathways.” Although it would represent a big shift in how medicine is currently practiced in countries like the U.S., if the capacity could be built into every specialist/patient encounter to screen for potential health issues, more people could get the care they need, and in the long run our healthcare system would become more economically sustainable.

This isn’t just speculation; a few sites of care are already engaged in this kind of work both in the U.S. and abroad. The two domestic programs spotlighted in the article are the Michigan Surgical Home and Optimization Program (MSHOP) at Michigan Medicine and the Preoperative Anesthesia and Surgical Screening (PASS) program at Duke Health. The authors call them “interdisciplinary programs that address longitudinal health around the time of surgery” and in each, whenever a patient comes in for surgery, they’re screened for a range of chronic conditions including “diabetes, obesity, smoking, malnutrition, physical inactivity, frailty, and stress.” Anyone found to be struggling with these indications are then referred to providers who can establish appropriate longitudinal care pathways for them.

As an illustration of how this works in action, a 2020 article on the website for the University of Michigan’s Institute for Healthcare Policy & Innovation details how MSHOP guided high-risk surgical patients to live healthier lifestyles ahead of their surgeries. This so-called “prehabilitation” program is unique in that it “uses the weeks before surgery to encourage patients to move more, eat healthier, cut back on tobacco, breathe deeper, reduce their stress and focus on their goals for after their operation.”

The parameters of the program are well-defined:

“Once enrolled, (patients) received a call or electronic message from a member of the MSHOP team, and materials about the importance of better nutrition, tobacco cessation, engaging in positive thinking and goal-setting, and reducing stress to their pre-surgery preparation. They also received a pedometer to track their steps, and an incentive spirometer to encourage them to practice taking deep breaths, to improve their lung function before and after surgery.”

Although the compliance rate seems reasonable, with 62% of participants tracking their walking “three or more times a week, entering them into their medical record or calling them in to a secure voicemail box,” what I find even more impressive is that the program staff followed up to encourage reluctant participants to complete their prehab regimen. 

Not surprisingly, the results have been promising. According to the article, the program had the effect of reducing medical costs for patients, along with their length of stay in the hospital. A recent study found that “prehab patients across the state left the hospital one day earlier, and were more likely to go straight home rather than to a skilled nursing facility, compared with similar patients treated at the same hospital. Total costs for all care up to three months after surgery were nearly $3,200 less on average for those who went through prehab.”

What I like most about the MSHOP approach, aside from the fact that it’s clearly helping people live healthier lives, is the fact that its advocates frame the program in business-style language that members of the C-suite can clearly understand. Witness the following quote from Michael Englesbe, MD, co-author of the HBR article and leader of the U-M Department of Surgery team that has published multiple studies related to the prehab approach: “Every time the prehab study has been studied, it’s found to increase the value of surgical care by improving care while reducing cost. This study cements the business case for hospitals to support it.”

It’s an approach I’ve long supported: while making the case for PHM, it’s as important to emphasize the bottom-line, downstream revenue features of preventative care as it is to highlight how it betters people’s lives.

Similarly, the PASS program at Duke Health seeks to position surgery patients for success. According the the program’s website, prior to undergoing anesthesia, PASS program workers ask participants to complete a preoperative assessment. This assessment “includes a physical exam that helps identify and evaluate medical conditions — such as anemia, diabetes, nutritional deficiencies, or other conditions — that could affect how you do during surgery.”

In an article on the website for the American Society of Anasthesiologists, Jeanna Blitz, MD, FASA, director of the PASS Clinic at Duke, makes a key connection between preparation and good patient outcomes: thinking of preoperative medicine as proactive medicine.

“We must expand our involvement in our patient’s preoperative care,” notes Blitz, “and challenge ourselves to consider the impact of health behaviors (smoking, dietary choices) and socioeconomic factors such as living environment, social support, education, and employment status.”

Many of these factors fit in the category of social determinants of health, and it’s great to see that the PASS Clinic is taking a targeted approach to improving health outcomes like this.

Like the MSHOP program, the Duke PASS Clinic offers a specific intervention to make each patient’s surgery and recovery a success. In Duke’s case, this comes in the form of providing access to tobacco cessation and nutrition specialists. As the clinic’s website states, “A licensed social worker can provide cognitive behavioral therapy for people who want to quit smoking and/or who want to improve stress management before surgery. Our registered dietitian can provide nutritional counseling.”

Both programs also consider the patient a true partner in ensuring optimal health outcomes. Getting patients invested in their own care seems to me a crucial element if proactive health interventions are to work. One advantage to an approach like this, state Howard and Englesbe, is that it’s a way to “improve population health within current care-delivery pathways” as opposed to having to create a whole new care delivery infrastructure. To prove their point, in the article they refer to a substantial body of evidence supporting these kinds of practical interventions.

Of course, this new solution will necessitate a shift in mindset; after all, if people are focused on the ailment that brought them to specialty care to the exclusion of their overall health, being met with screening questions at a “one-off” health encounter may seem strange. And unless quality measures that reward this kind of proactive course are adopted, there will be real challenges in convincing the medical establishment to take this path.

Indeed, as Howard and Englesbe state, “Expanding measures of quality to include things like referral for longitudinal health management at the time of surgery — an equally important component of high-quality care — is an essential step in changing clinical practice.” Some insurance carriers, like Blue Cross Blue Shield of Michigan, have begun incentivizing physicians to report screenings and referrals for certain conditions, along with bonuses for referrals to smoking cessation counseling. But there is still a long way to go.

I wholeheartedly agree with Howard and Englesbe’s conclusion that specialists are currently an undervalued piece of the PHM puzzle. Specialists should begin to view themselves as entry points to improving patient health in a more holistic way, and there’s a business case to be made for doing it.

There are also international efforts underway to bring specialties more into the PHM fold. For example, as the HBR authors point out, a UK National Health Service program called Making Every Contact Count, or MECC, has made real inroads to improving population health. In this program, “(p)atients undergoing anything from a routine eye examination to a minor operation are screened for chronic health conditions and offered brief interventions and referral to treatment.”

Even though we have a long road ahead of us in the U.S. before longitudinal care becomes the norm, I’m encouraged that surveillance for comorbidities is starting to spread out beyond primary care. And I hope this trend continues to take root in specialties across the medical industry.           

Something I’ve often wondered while reading up on population health and PHM is if they’re really new concepts, or if they’re just different names for older ideas. Updated branding, if you will. After all, the concept of patient-centered care has been around since at least the 1980s, if not since the dawn of medicine. So too have related concepts such as improving access to care and affordable healthcare.

So, I find myself wondering, is PHM just an old idea wrapped in shiny new paper?

One comparison often made by skeptics is to health maintenance organizations (HMOs). Although HMOs may be making a bit of a comeback in the COVID era, their promise of fixing counterproductive incentives in the U.S. healthcare system back in the 70s and 80s has never fully panned out. Instead, as one writer notes, “HMOs solved a problem of counterproductive incentives but then this led to a new problem of counterproductive incentives.”

So I come back to my question: is PHM just HMOs by a different name?

In her article titled “Population Health Management is So in Vogue,” author Dr. Helen Davies attempts to answer this question. Davies, a general practitioner (GP) and PHM clinical lead in the UK’s National Health Service (NHS), argues that, despite her article’s cheeky title, PHM isn’t just a fad; quite to the contrary, says Davies, PHM is here for the long haul, and we’d all better get used to it.

Although the NHS is different in many ways from the U.S. healthcare system, it shares some common features and many of the same challenges. Primary among these challenges is how to provide top-quality care to a large aging population. As an outsider looking in, it seems to me that the NHS has been on a decades-long march toward decentralization, so there may be even fewer differences between the fundamentals of our two systems than I’m aware of. Because of this, it’s no surprise that looking forward, their care delivery models give every evidence of stressing the importance of localized care.

In the spirit of this more focused, targeted care, Davies favors a definition of PHM that I would endorse: “Service redesign for the whole population by targeting groups with similar needs.”

She builds her article around three pitfalls to avoid as we continue into a new era of accountable, patient-centered care. These landmines include re-labeling activity, entrenching the public health gap, and conflating enablers with the endgame for what PHM is trying to achieve.

Avoid Re-Labeling

Although I really like that Davies believes deeply in PHM, I’m of two minds about her first point. On the one hand, I keep telling people that if everything is PHM, nothing is PHM. We cannot simply lump every patient-centered activity or process improvement initiative into the PHM bucket or else, as Davies accurately says, we will risk reinforcing the status quo.

On the other hand, ensuring adoption of this new, complex ecosystem of care will require a fine balance of system overhaul with not asking all physicians to completely change their workflow. As a case in point, witness the U.S. government’s attempt at modernizing healthcare by passing the 2009 HITECH Act and attendant Meaningful Use Rules. These innovations functioned brilliantly to get a huge number of physicians hooked up to electronic health record (EHR) systems in a relatively short period of time; however, in the end, they never fulfilled their promise of ushering in appreciably higher quality care.

Although Meaningful Use has morphed and still exists in some form, many physicians initially balked at the burden of extra work the legislation entailed. My worry is that if healthcare practitioners perceive PHM as just another government mandate grafted on top of their already challenging profession, uptake will lag. Another quote by Davies captures this idea perfectly: “It is only when we use the best available insights to understand groups with common needs and design services around them that we are doing PHM.”

In this spirit, if we can demonstrate to physicians and other caregivers that PHM, while indeed a new way to conceptualize medical care delivery, may also build on some activities they already do regularly (such as cancer screening or coordinating care in rural settings to streamline care visits for patients who must travel great distances), then maybe PHM will make real inroads.

Entrenching the public health gap

Losing the forest for the trees is one thing, but it’s also possible to lose sight of individual trees when gazing at a timberline. For this reason, Davies urges advocates for PHM chart a middle course (to mix my metaphors) and not get so close to the fringes that we lose perspective. Speaking from experience, she puts it like this:

“Many of us will recognise the position of frontline pragmatists, who tend to describe PHM as being all about individual care and view the big picture with its trappings of analytics and incentive alignment, as remote and out of touch with the harsh realities of delivery. Meanwhile at the other end of the spectrum are those focused on whole-system strategy who risk becoming distracted by the act of planning and perhaps removed from ‘true’ care delivery.”

While systems-level thinking is important in this discussion, PHM won’t be adopted successfully unless it’s perceived as being adaptable to different circumstances. To my mind, this kind of allowance is even more important in decentralized settings like the U.S. healthcare system. Sure, one in three Americans are covered by Medicare and Medicaid, and those agencies will exercise significant influence over how PHM plays out in this country. But there is no central agency that can guide implementation a unified program of proactive interventions; for this reason, PHM must be conceptualized with maximum flexibility built into it, and the rewards infrastructure must be similarly adaptable.

Conflating enablers with the endgame

“Just as a car cannot be summed up by just the engine, the wheels or the chassis,” says Davies, “critical though all these things are, they are not the car!” I couldn’t agree more. Sometimes it seems like instead of jumping in and changing how things are done, the medical industry likes to plan every detail ahead of time, assigning roles and maximizing accountability. While there’s something to be said for planning ahead, Davies’ point is that this over-planning can be, and often is, taken too far.

Her “just get on with it school of PHM” is an idea that should be emulated within reason here in the U.S. Here is how she defines it:

“As my colleague Dr. Steve Laitner puts it – focus, function, finance, then form – in that order. Identify the group you are going to focus on, use the best available insights, codesign with users the best care function or delivery model then establish what contractual model will drive the behaviours needed for success, then and only then formalise the governance structures needed for accountability and monitoring.”

At the end of the day, she says, it’s all about inspiring and engaging the workforce tasked with delivering care. If PHM frameworks can deliver demonstrably better care, momentum will build and healthcare will be transformed for the better.

I’m finishing up an online course on PHM, so I figured I’d publish my final paper here. It’s called “Addressing Healthcare Disparities in Tuscrawas County, Ohio” and the idea was to propose an intervention targeting a real population health indicator/social determinant of health that, if improved, would bring about an attendant improvement in a related population health outcome. Although I don’t have a track record of creating interventions like this, I hope it provides insight into how targeted, population-level interventions can work in the real world.

Introduction

In this assessment and improvement activity, I will be focusing on outcomes and indicators of social determinants of health (SDOH) for residents of Tuscarawas County, Ohio. Members of my extended family live in the area, so I have a keen interest in how the county stacks up against national and state health benchmarks, along with strategies the population can employ to improve their collective health.

According to the website County Health Rankings & Roadmaps put together by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation — the high-quality data resource I chose to use for this project — Tuscarawas County ranks in the higher middle range in terms of “health outcomes” (higher 50%-75%) and in the lower middle range for “health factors” (lower 25%-50%) among counties in Ohio.¹

Assessment

For the assessment portion of this project, under the category of “population health outcomes” I chose to focus on the areas of adult obesity, teen births, and mammography screening. As far as “health indicators of social determinants of health” are concerned, I will zero in on the low scores earned by the county on the following measures: access to exercise opportunities, those residents who have attended some college, and those who are uninsured.

The outcomes in my list correspond to the SDOH that I chose such that, if each of the latter were improved, that action should bring about a corresponding improvement in each item’s related health outcome. To illustrate what I mean, take the outcome “adult obesity,” which I will further elaborate on later in this paper, for example: improving “access to exercise opportunities” to all adults in Tuscarawas County should in theory lead to a lower overall adult obesity rate. Adult obesity is an appropriate focal point for this discussion, since Tuscarawas’ percentage of obese adults ranks a bit higher than the state average (35% versus 34%, respectively), and well above the “Top U.S. Performers” (35% versus 26%, respectively).¹

To provide context to the problem of adult obesity, in the article “A review of evidence-based strategies to treat obesity in adults” which appears in the journal Nutrition in Clinical Practice,the authors state the following: “In simplest terms, weight loss and maintenance depend on energy balance, and a combination of increased energy expenditure by exercise and decreased energy intake through caloric restriction is the mainstay of behavioral interventions.”² The authors focus on lifestyle changes as the key ingredient to lowering adult obesity rates, which include “regular physical activity, healthy food choices, and portion control,” all of which require “ongoing support.”

When it comes to exercise, the authors of a separate literature review say that although all types of physical activity (PA) are associated with better health outcomes, “moderate to vigorous PA (MVPA) is considered especially crucial to the prevention of chronic disease and premature mortality.”³ But when one examines the level of participation in MVPA, one sees there is a disparity between those living in underserved communities versus residents of more privileged areas. One important reason for this difference is a lack of access to, and a perceived lack of safety in being able to use, exercise facilities in underserved areas.³ Since Tuscarawas County, Ohio underperforms both nationally and within the state on certain key SDOH measures like “access to exercise opportunities,” it is an appropriate setting for deployment of MVPA interventions.

For the racial and ethnic minority residents of Tuscarawas County, which make up less than 4% of the population, culturally-appropriate MVPA interventions should be tailored to different groups. As a case in point, the authors of the above-mentioned literature review cited The Body and Soul Health Initiative, a “24-week PA and dietary intervention targeting members of predominantly black churches.”³ Aimed primarily at African-American women, this program employed meetings to educate participants about diet and exercise, and were led by African-American staff members. The initiative resulted in a substantial improvement in participants’ minutes exercised over the course of 24 weeks.

When predicated on socioeconomic status (SES), the design of intervention strategies might look somewhat different. SES can be defined as “a combined measure of an individual’s income, education level and occupation.”⁴ The SES measure is most often inclusive of all members of a society, regardless of background. When looking at the health of low-SES communities, it is important to remember that although the terms “overweight” and “obese” are not interchangeable, they are not as divergent as one might think. Indeed, the WHO defines adults who are overweight as having a body mass index (BMI) greater than or equal to 25, and those who are obese have a BMI greater than or equal to 30.⁵

When evaluating ways to lower the adult obesity rate in low-SES communities, highly-structured programs involving goal-setting and accountability are likely essential. One study identified “goal setting, self-monitoring and goal review” as key ingredients of any community-based weight-loss program.⁴ In addition, in an article titled “Exploring Community-Based Weight Loss Initiatives, Retention, and Motivation,” the author notes that “due to the complex interplay of factors contributing to obesity, the International Obesity Task Force and the World Health Organization (WHO) recommend population-based community approaches that connect people, families, schools, and municipalities.”⁶

While some interventions target adults who are already obese, an alternate approach could involve focusing on adults who are at risk for becoming obese. According to the Mayo Clinic website, “Being overweight is a primary risk factor for prediabetes.”⁷ Since many overweight people are pre-diabetic, one qualifying factor for such a program could be community members who are prediabetic. 

Proposed Solution

To ameliorate the effects of adult obesity in Tuscarawas County, Ohio, I would propose addressing the SDOH of limited access to exercise by establishing a cost-effective weight-loss program that targets overweight, pre-diabetic community members at risk for becoming obese through a combined exercise and healthy eating regimen. This program would incorporate goal-setting, self-monitoring, and accountability as crucial features. In addition, the initiative would have to be aligned with a local organization to facilitate buy-in by the maximum number of participants.

Such a program might look similar to the YMCA’s Diabetes Prevention Program (DPP). This national program promotes modest weight loss through healthy eating and regular physical activity.⁸ The program found that an intensive lifestyle intervention in line with its approach can reduce the development of diabetes by more than half in adults with prediabetes.⁹

The DPP is a one-year program consisting of weekly and monthly sessions in a group setting.¹⁰ These sessions are facilitated by coaches who lead small groups of adults. The overall goal of the program is that each participant sets out to lose 7% of their body weight while increasing physical activity each week. The program has achieved real-world success: nearly 30,000 people have attended at least one session, an average of 5.6% of participant’s body weight has been lost over the course of one year, and more than 2,775 lifestyle coaches have been trained to run the program.¹⁰

Eligibility requirements for my proposed intervention would track closely with those of the DPP. In line with WHO standards, DPP participants must have a BMI of greater than 25, with fasting plasma glucose levels between 100-125 mg/dL, 2-hour plasma glucose between 140-99 mg/dL, and a 1c between 5.7% and 6.4%. A previous diagnosis of gestational diabetes will suffice, but if no blood test is available, “a qualifying risk score based on a combination of risk factors” including family history and age can count toward eligibility.¹⁰ It is important to note that anyone already diagnosed with either type 1 or type 2 diabetes is unable to participate in the DPP, and people in those groups would be similarly ineligible to participate in my proposed intervention.

Goal

The goal of this intervention, much like the DPP, would be for each participant to lose at least 7% of their body weight. Participants would also be required to aim to increase their overall physical activity by 10 minutes each week.

The Intervention

Similar to some versions of the DPP, the program would be free contingent upon a physician referral.¹¹ Participants in this intervention would meet in a mixture of group and one-on-one sessions with trained lifestyle coaches for 16 weekly core sessions.¹² Coaches would instruct participants on how to make healthy food choices. In addition, the curriculum would cover effective exercise regimens, how to make more time for physical activities, and also how to manage their weight more effectively.

Program participants would be tasked with tracking their eating and exercise habits during this time, setting modest, attainable goals for each week. At the conclusion of the 16 weeks, as in the DPP, participants would be expected meet each month thereafter in a series of support sessions to ensure their continued progress. Participants and coaches would make a joint decision as to when the program would end for each individual, with the understanding that each participant would continue to be accountable to themselves for maintaining a healthy balance of good nutrition and exercise.

Organizations/Agencies/Systems/People Required to Perform the Intervention

Since no YMCAs in Tuscarawas County, Ohio currently offer the Diabetes Prevention Program, this intervention could be sponsored by the local government in a central location. The city of New Philadelphia, Ohio is the county seat, so I would propose setting up the counseling location there since it is geographically central to the area.

Due to COVID-19, at least for the time being, I would set up large-group counseling sessions over zoom but allow in-person, one-on-one meetings with lifestyle coaches — done in a safe manner in line with CDC guidelines — in a meeting room at the main branch library in New Philadelphia, Ohio. Participants would be given the option to go fully remote even for one-on-one meetings to bolster participation. Similarly, after the 16-week program concluded, I would ask lifestyle coaches to honor participants’ wishes to either do hybrid or fully remote one-on-one sessions in a way that conforms to CDC guidance.

Challenges

The main challenge to uptake of this program, apart from inherent motivation issues with individual participants, would likely stem from the ongoing pandemic. There is no substitute for in-person counseling when it comes to overcoming deeply entrenched habits, so the physical distance imposed by remote coaching sessions may be insurmountable for some people. Consequently, placing extra emphasis on the value of personal accountability may be warranted.

To foster this accountability, it may be necessary to involve friends and family members when personal accountability becomes tenuous. Engendering the value of self-improvement is of paramount importance, and tactics to bring that about may vary from person to person, necessitating a tailored approach.

Other challenges may include wifi and internet connectivity issues in lower-SES communities that would make involvement in the remote aspect of this initiative challenging. Also, even though the USDA has found that by almost every metric it is more affordable to eat healthy foods versus unhealthy foods, it may be difficult to overcome the perception that eating healthy foods is more expensive.¹³ Relatedly, it may prove challenging to overcome preconceived notions about the time commitment involved with preparing one’s own meal as opposed to eating prepackaged or fast food. Finally, for any in-person components, it may be challenging for lower-SES participants to show up if public transportation is an issue in their local community.

Why the Intervention Should Work

This intervention should work in Tuscarawas County, Ohio because one of the prime social determinants of health at work there, namely a paucity of exercise opportunities and its attendant high adult obesity rate, can be mitigated by a program of guided exercise and healthy eating interventions. As long as thought is given to facilitating a hybrid (or fully remote) course of coaching sessions, and also a targeted approach to attaining buy-in from both attendees and their support networks, this plan should yield positive results.

One way to overcome the bandwidth issue might entail subsidizing wifi in participants’ residences for the duration of the pandemic. Additionally, ensuring transportation to and from one-on-one meetings (if a given participant opts for the hybrid option) would also bolster participation. This might involve distributing vouchers for Uber or arranging carpools for those participants who do not have reliable transportation. 

Endnotes

• County Health Rankings & Roadmaps. Retrieved 1/26/22 from https://www.countyhealthrankings.org/app/ohio/2021/rankings/tuscarawas/county/outcomes/overall/snapshot

• Laddu D, Dow C, Hingle M, Thomson C, Going S. A review of evidence-based strategies to treat obesity in adults. Nutr Clin Pract. 2011 Oct;26(5):512-25. doi: 10.1177/0884533611418335. PMID: 21947634. [Link]

• Curr Sports Med Rep. 2016 Jul-Aug; 15(4): 290–297. doi: 10.1249/JSR.0000000000000276 [Link]

• BMC Public Health. 2018; 18: 967. Published online 2018 Aug 3. doi: 10.1186/s12889-018-5877-8 [Link]

• World Health Organization. Obesity and Overweight. Retrieved 1/26/22 from https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight#:~:text=For%20adults%2C%20WHO%20defines%20overweight,than%20or%20equal%20to%2030.

• Martinez, M. (2020). Exploring Community-Based Weight Loss Initiatives, Retention, and Motivation. UTHealth School of Public Health. [Link]

• Mayo Clinic. Prediabetes. Retrieved 1/26/22 from https://www.mayoclinic.org/diseases-conditions/prediabetes/symptoms-causes/syc-20355278#:~:text=Being%20overweight%20is%20a%20primary,your%20cells%20become%20to%20insulin

• YMCA. YMCA’s Diabetes Prevention Program. Retrieved 1/26/22 from https://www.ymca.org/what-we-do/healthy-living/fitness/diabetes-prevention

• Am J Prev Med. 2008 Oct;35(4):357-63. doi: 10.1016/j.amepre.2008.06.035. [Link]

• YMCA. YMCA’s Diabetes Prevention Program. Program Overview: How It Works. Retrieved 1/26/22 from http://divvy.cantaloupe.tv/storybooks/dd97cff8-5e7d-4968-9c71-d6e02b854a7c/embed/episode/7

• https://ssymca.org/program/health/diabetes-management-prevention/#:~:text=YMCA’s%20Diabetes%20Prevention%20Program&text=hour%20in%20length.-,Ages%2018%2B.,physician%20referral%20(%24429.00%20value).

• South Shore YMCA. Diabetes Management & Prevention. Retrieved 1/26/22 from https://www.ymcadc.org/programs/health-fitness/ymcas-diabetes-prevention-program/

• USDA. Carlson A, Frazao, E. “Are Healthy Foods Really More Expensive? It Depends on How You Measure the Price.” 2012. [Link]

Those of you who have worked in the public health field for a while are probably already familiar with the County Health Rankings & Roadmaps (CHR&R) program. A joint effort of the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation, the CHR&R program “works to improve health outcomes for all and to close the health disparities between those with the most and least opportunities for good health.” I found out about this awesome resource via an online course I’m currently taking called “Assessing and Improving Community Health” through the University of Michigan.

The big idea behind the CHR&R program is that health equity is of paramount importance, and the project’s stated goals are as follows:

• Build awareness of the multiple factors that influence health.  
• Provide a reliable, sustainable source of local data and evidence to communities to help them identify opportunities to improve their health.
• Engage and activate local leaders from many sectors in creating sustainable community change.
• Connect & empower community leaders working to improve health.

Further, The CHR&R program focuses on people’s health in nearly every U.S. county by providing “data, evidence, guidance, and examples to build awareness of the multiple factors that influence health and support community leaders working to improve health and increase health equity.” 

I’m working on the final project for my course now, and the CHR&R has proven to be an invaluable resource. My plan is to create three interventions for health disparities in a U.S. county that will remain nameless, where much of the population falls into the category of “lower socioeconomic status” or lower SES. The project asks that we identify three suboptimal population health outcomes that have beset the population I’ve chosen to focus on, and to correlate these outcomes with social determinants of health (SDOH) that, if improved, would result in a corresponding improvement in the population health outcomes.

As I said above, I’ve chosen to focus on a specific U.S. county, and three population health outcomes that score low on the CHR&R for this county are adult obesity, teen births, and mammography screening. SDOH that the county scores low on include access to exercise opportunities, percentage of residents who have attended some college, and the percentage of those residents who are uninsured. In my essay I will attempt, for example, to make an argument that, by designing exercise programs, building walking trails, etc. for adults, this will open up exercising opportunities and thus lead to a corresponding decline in adult obesity.

That’s the theory, anyway.

I’m currently in the research stage of this project and have only sketched out a few ideas. But I thought it might be helpful to share the CHR&R resource with you all in case it would come in handy in your work. I’ll follow up once I get further into my research and share any interesting facts that I come across along the way.       

I’d like to start doing an intermittent series of posts about how PHM is being implemented around the world. I think one can get tunnel vision focusing too much on how things work in their own backyard, so I figured it might be productive to zoom out a bit. PHM has so many moving parts that it’s unlikely that any one country or even region has thought of every possible angle.

Well then, what better way to begin this little odyssey than by looking at how the World Health Organization views PHM? Great idea, I thought. But, oddly enough, when you type “population health management” into the search engine on the WHO website, you get nothing.

One might think that this comes down to semantics. Maybe, one might say, PHM is an American term. But no, that’s not the case as I’ll detail below. The term “population health,” a closely related but distinct term, does return quite a few hits on the WHO site. But again, even though there is some overlap between PHM and population health, there does seem to be a consensus that they’re two distinct concepts.

Anyway, we have to delve a little deeper to find where the WHO comes down on PHM. After doing some legwork, I discovered that the organization has segmented its literature on different PHM frameworks into discreet sectors.

The sector I’ll focus on in this post is Europe. I’m sure there are plenty of good examples that demonstrate how the WHO envisions PHM rolling out across Europe, but the best breakdown I could find was in the form of a document called “The European Framework for Action on Integrated Health Services Delivery: an overview.”

The strategy outlined in this document shares many similarities with ones laid out by U.S. organizations such as the Institute for Healthcare Improvement (and their influential “Triple Aim”), the AHA, and others. Interestingly but perhaps unsurprisingly, elements such as “Stratifying health needs and risks,” “Identifying the determinants of health,” and “Linking provider payment mechanisms to performance” feature prominently in both the European and American approaches to PHM.

What seems a bit different on the surface, however, is the emphasis that European countries, along with the WHO, place on the concept of “co-locating” services. A good definition of “co-location” can be found on the website for the Rural Health Information Hub, a group supported by the Health Resources and Services Administration of the U.S. Department of Health and Human Services (HHS). They define the term like this:

Co-location refers to services that are located in the same physical space (e.g. office, building, campus), though not necessarily fully integrated with one another. Co-location can involve shared space, equipment, and staff for health and human services; coordinated care between services; or a partnership between health providers and human services providers. Co-location can streamline referrals, increase access to care, and increase communication between different providers.

Source: https://www.ruralhealthinfo.org/toolkits/services-integration/2/co-location 

This idea of co-locating services can be found in the subtext of most materials on PHM implementation in the U.S. But I’ve noticed that it seems to take on more paramount importance, and is more explicitly mentioned, in literature about the European approach to PHM. For example, the King’s Fund in the UK did a great video about the country’s vision for rolling out PHM over the next few years. At about the 29:30 mark of the video you’ll find one of the panelists discussing the key nature of co-location to the overall vision.

Another terrific example of the concept of co-location and PHM pops up in a case study, endorsed by the WHO, where PHM strategies were deployed in an Austrian municipality called Schwaz in 2016. The introduction to the case study notes the crucial importance of building community to optimize people’s health:

…co-location of services increased coordination and improved access for vulnerable groups; shared living spaces, group activities and cooperative initiatives within the House of Generations generated a sense of community, fostering a supportive and inclusive environment for vulnerable groups…

Source: https://www.integratedcare4people.org/practices/319/house-of-generations-schwaz-a-one-stop-shop-for-providing-health-and-social-services-in-austria/ 

As the case study describes, in the early 2000s “the Municipality of Schwaz observed a narrowing of family structures within its ageing population.” I take this to mean that a breakdown of the family unit was becoming worryingly obvious, especially among vulnerable groups. Adding to this already concerning situation, a “fragmented organization of local health and social services, coupled with a lack of coordination between the various actors involved, hindered the system’s ability to respond to increasing demands.”

So the city took action. 

To ensure better coordinated service delivery, by 2007 they’d built a “’one-stop shop’ for health and social services.” I won’t go into the details, but building up an infrastructure where people’s health needs can be met all in one place, and where their care is consequently more tightly coordinated, has fostered a strong sense of community spirit that has led to an overall improved quality of life for residents.

In all the talk of coordinating care in the U.S., there seems to be less of an emphasis on the proximity of that care. Part of this is no doubt due to the vastly geographically larger nature of the U.S.; indeed, it’s not unheard of for people to travel from one state to another, driving hours each way, in search of quality care. Because their populations are smaller in European countries, and because (in my estimation) mobility from one city to another isn’t as integral to the culture as it is in the U.S., organizing coordinated care around local communities to cultivate healthier lifestyles is more of a natural fit in Europe. Still, there’s something to be said for incentivizing people to forge stronger bonds in their local community, and this seems to be the guiding principal for much of the work in this space across Europe.

Stay tuned for more installments in this series. I’m excited to learn more about how other regions are handling this shift to more targeted, coordinated care, a trend which seems to be taking root across the world. 

This week I attended the virtual Health Care Payment Learning & Action Network (HCP-LAN) Summit. For those who don’t know, the HCP-LAN, or “LAN” for short, is, in their own words, “an active group of public and private health care leaders dedicated to providing thought leadership, strategic direction, and ongoing support to accelerate our care system’s adoption of alternative payment models (APMs).” 

CMS, along with a host of private payers, is interested in motivating health care entities to share in risk alongside insurers to lower healthcare costs and slow down out-of-control healthcare spending. The LAN works to make this transition to risk-sharing between insurers and providers happen.

So how does this fit into population health management?

Before going on, it might help to understand what risk-sharing means exactly, and the reasoning behind this paradigm shift. I found a good, straightforward formulation of this on a blog for a health insurance company I’ve never heard of called “Oscar.” I’m not endorsing this company, but I like their wording:

By sharing the risk, you (i.e. the patient), your insurance company, and doctors/hospitals are protected from individually bearing the costs for those who need a lot of health care or have medical emergencies during the year…From a statistical perspective, risk sharing works best when there are more people in a group – and this is especially true for health insurance.

Source: https://www.hioscar.com/blog/how-health-insurance-works-risk-sharing

For the sake of clarity, I added the “(i.e. the patient)” to the quote. And there’s more nuance to this, such as the fact that this kind of pool is optimized when not only older and less healthy people, but also younger, healthier people are included. But for our purposes, the above quote serves as a good starting place.

Suffice it to say that there is a big transition going on right now in the way medical providers are reimbursed, and the LAN is working to build a smooth glide path for that change. In the past, insurance companies (whether public or private) have paid doctors based on individual services rendered to patients under a pay structure called “fee-for-service” (FFS). But this approach led to a wasteful, inefficient system where care hasn’t been tightly integrated, costs have spiraled out of control, and quality outcomes haven’t kept pace with our peer nations. This result is down to care delivery not being viewed holistically, but rather as one-off events that don’t take the full scope of each individual patient into account.

To remedy this, CMS and a growing number of private insurance companies are transitioning to a value-based, coordinated care environment where the reimbursement structures (or payment models) are based on shared risk. In other words, providers who hit certain pre-determined cost and quality targets and who consequently save the health system money can share in these cost savings by receiving payment bonuses. This is what’s called an “upward payment adjustment.” In some payment models in this space, there are only “upside-only” or “one-sided” risk-sharing arrangements in which doctors are only rewarded if they beat expectations, but don’t get dinged financially if they don’t.

But in the future, if CMS has their way, it appears that all doctors and healthcare entities will move into two-sided risk models. The idea behind this flavor of payment model is that costs are held down and quality patient care is enhanced when providers are held accountable for patient outcomes. The most prominent kind of two-sided payment model is the accountable care organization, or ACO. “Health Affairs” has a handy definition of the two-sided risk payment model:

In two-sided risk models, providers still share in the savings but are also responsible for some of the loss if spending is above the benchmark.

Source: https://www.healthaffairs.org/do/10.1377/hblog20181011.442864/full/

That’s where the LAN comes in. They act as a bridge between the current, mostly FFS landscape and a future where healthcare providers are held accountable for cost and quality care. This group brings together payers, providers, manufacturers, policymakers, patients, and others to figure out new ways to, as they say, “lower care costs, improve patient experiences and outcomes, reduce the barriers to APM participation, and promote shared accountability.”

So this past week I attended a few LAN Summit sessions, and I noticed something that only earned a passing mention during one of the presentations: population-based payment (PBP) models. Although one of the less utilized alternative payment models, it seems to have made steady progress in the past couple of years toward adoption by a growing number of healthcare practitioners.

So what are population-based payment models? I actually didn’t know anything about them until this meeting, so I decided to look into them. Here is a helpful definition by the LAN:

The core premise of a PBP model is that providers are accountable for patient-centric care for a specific population over a fixed timeframe and across the full continuum of care.

Source: https://hcp-lan.org/2016/05/pbp-models-overcoming-barriers-accelerating-adoption/

The LAN has convened a PBP Work Group, which has identified four priority areas essential to adoption of these models:  patient attribution, financial benchmarking, data sharing, and performance measurement. One reason these models have lagged in their uptake among healthcare providers seems to be because, unlike other, more popular models, the PBP model is completely uncoupled from FFS. As the site Health Payer Intelligence notes:

Population-based payment models are models that are detached from fee-for-service reimbursement altogether, as opposed to other alternative payment models that continue to build off of fee-for-service structures…

Source: https://healthpayerintelligence.com/news/how-payers-can-support-population-based-payment-model-uptake 

Evidently the LAN has identified three types of PBP models, which are as follows: condition-specific population-based payment model, comprehensive population-based payment model, and integrated finance and delivery systems model. I won’t go into the finer points of these, which can be found in a 2017 white paper published by the LAN, but overall, as they say, “…(PBP models) represent the furthest departure from traditional FFS payments, while they simultaneously ensure that providers possess the strongest possible incentives to deliver high-quality and efficient care.”

I could easily see writing a future blog post that breaks down the details of each type of PBP model. I have a feeling that motivating providers to enter into this kind of forward-thinking model will involve developing new quality metrics that incentivize them to do so. I will keep track of this and update the blog with any new developments I come across. 

Over the past two years or so, the Centers for Medicare and Medicaid Services (CMS) has placed increasing importance on a program they’re in the process of developing which is collectively called MIPS Value Pathways, or MVPs. MVPs are seen by some as the next step in the process of incentivizing physicians and everyone else in medicine to move away from the Merit-based Incentive Payment System (MIPS) as their value-based payment model of choice, and instead begin taking on risk as part of any one of a number of advanced alternative payment models.

So what is MIPS, what are value pathways, and what the heck does any of this have to do with population health?

Let me explain it as I see it.

What is MIPS?

There have been a couple of iterations of MIPS so far, but the most concise definition I’ve seen was put forward by the American Academy of Physical Medicine and Rehabilitation:

The Merit-Based Incentive Payment System (MIPS) is the program that will determine Medicare payment adjustments. Using a composite performance score, eligible clinicians (ECs) may receive a payment bonus, a payment penalty or no payment adjustment.

Source: https://www.aapmr.org/quality-practice/quality-reporting/merit-incentive-payment-system 

MIPS is one of two tracks set up under something called the Quality Payment Program (QPP) by CMS, the other track being something called Advanced Alternative Payment Models (APMs). I won’t spend much time on APMs in this post, but they’re basically the future of physician reimbursement and probably deserve a post of their own.

Anyway, under MIPS, participating physicians, groups, or health systems report the measures and activities they collect during a performance period within four different performance categories: Quality, Improvement Activities, Promoting Interoperability, and Cost.

I won’t go into the myriad activities that count toward attesting to these requirements, but suffice it to say that participants earn a composite score in these four domains and, as the AAPM&R website says, “Your final score determines the payment adjustment applied to your Medicare Part B claims.”

Put simply: if you outperform the overall measurement expectation, you’ll earn a positive pay adjustment and receive a bonus. If, on the other hand, you underperform on the metrics, you’ll get a negative payment adjustment. On the bright side, CMS collects and calculates all cost measures, so at least that burden doesn’t fall on the physician. 

This formulation is at the heart of risk-sharing as conceived by CMS. The point of all this is to rein in out-of-control medical spending while improving the patient experience. I’ve left out plenty of other details about MIPS, such as the fact that not every physician fits into the MIPS framework and are thus exempt from participating, but you get the general idea.

What are MVPs?

I’m glad you asked, because I’m still trying to figure this one out myself. For the most part, MVPs seem like an attempt by CMS to overhaul the MIPS process because they got a lot of negative feedback from the medical establishment that participation was too challenging.

So through MVPs, CMS is attempting to streamline the reporting process while at the same time empowering patients to take on more of an active role in their care. And in another encouraging sign, CMS is actively soliciting ideas for MVPs from the field.

According to a 2019 article in Health Affairs, CMS has put forward several guiding principles which it hopes will resonate with the house of medicine. According to the article:

…value pathway design should reduce barriers to provider participation in alternative payment models (APMs) by prioritizing quality measures that align with improvement activities and cost measures. CMS proposes holding clinicians from all specialties accountable for a foundational set of health information technology and population health measures, while allowing quality, improvement activity, and cost measures to vary by clinical specialty. Creating common measures to assess performance in fee-for-service (via MIPS) and APMs may facilitate the transition to APMs.

Source: https://www.healthaffairs.org/do/10.1377/hblog20191107.686469/full/ 

To put a finer point on it, here is how CMS explains this new approach:

The MVPs framework aims to align and connect measures and activities across the quality, cost, and improvement activities performance categories of MIPS for different specialties or conditions. In addition, the MVPs framework incorporates a foundation that leverages Promoting Interoperability measures and a set of administrative claims-based quality measures that focus on population health/public health priorities and reduce reporting. 

Implementing the MVP framework honors our commitment to keeping the patient at the center of our work. In addition to achieving better health outcomes and lowering costs for patients, we anticipate that these MVPs will result in comparable performance data that helps patients make more informed healthcare decisions.

Source: https://qpp.cms.gov/mips/mips-value-pathways

So not only is patient empowerment at the heart of this program, but these measures will “focus on population health/public health priorities.”

What Role Does Population Health Play in MVPs?

This is the part I’m foggiest about. Part of the reason for my confusion is that CMS is still developing this concept, so it’s only natural that there would be gaps in the public’s understanding of it. Speaking of gaps, in 2020 CMS commissioned something called an “MDP Population Health Environmental Scan and Gap Analysis Report.” As stated above, one major goal of this report — and of MVPs in general — was to bring about “a future state of MIPS that CMS envisions to include a foundation of measures focused on population health.”¹

But when CMS highlights “population health” as important to their program, it’s not entirely clear to me what they mean by “population.”  I previously covered the flexibility of this term, so for more on that, check out this blog post.

In other words, are they taking an inclusive perspective, where “population” can mean everything from designing metrics around patient populations in clinical settings to those predicated on geographic pools of potential patients, such as a county with higher-than-average smoking rates? Or do they have a narrower definition in mind?

According to the report, “The scan was organized by six topics of population health: access, clinical outcomes, coordination of care and community services, health behaviors, preventive care and screening, and utilization of health services.” To me, this signals that CMS is applying a more inclusive definition of “population” beyond just the clinical setting. And they seem to be really keying in on underserved populations in both urban and rural settings. Much remains to be seen, though, so stay tuned.

Endnote

1. CMS Quality Measure Development Plan. “2020 Population Health Environmental Scan and Gap Analysis Report For the Quality Payment Program.” Page 1. Accessed on 12/1/21

I’ve been reading quite a bit about population health management (PHM) lately since the concept seems to be taking on increasing importance in medicine. PHM has been around for decades, but only now is it catching everyone’s attention, particularly in light of COVID which has laid bare the serious flaws with the U.S. medical system.

Bottom line: the medical system likely can’t continue in its present form without delivering worsening levels of care to large swaths of the American public. So it’s of paramount importance for people to be incentivized to live healthier lifestyles to avoid them ending up in the hospital system for as long as possible.

For me, when trying to get my mind around an enormous topic like PHM, it helps to start with first principles. In the case of PHM, in my opinion, that takes the form of asking who is the “population” in “population health management”?

Well, the answer to that question depends on who you ask. As part of their Medicaid and Public Health Partnership Learning Series, the Association of State and Territorial Health Officials (ASTHO) released a document titled “Public Health and Population Health 101” which I find helpful.

As their website states, ASTHO is the “national nonprofit organization representing public health agencies in the United States, the U.S. Territories, and the District of Columbia.” Because of the constituency they represent, their view is pretty comprehensive. To me, this document provides the best breakdown of the differences between public health and PHM — and the best parsing of the word “population” within that definition — that I’ve come across yet.

Here is what ASTHO says about what the word “population” means to different groups, and why, because of this range of views, it’s so challenging at this point to nail down a definition of PHM:

For example, public health officials, community organizations, and business leaders often use the word “population” in the geographic sense, because they work in terms of geographic units (e.g., federal, state, or county.) This usage differs from how “population” is used in the clinical healthcare system, which often more narrowly refers to patients using a facility within a specific time period, members of an insurance plan, or patients being treated for a specific diagnosis.

And then there are insurers, particularly Medicare and Medicaid, who have their own definition:

Medicaid typically uses the term “population” to refer to the total population of Medicaid beneficiaries (a subgroup of the total United States population) or a specific subgroup of beneficiaries, like pregnant women, children, seniors, individuals with disabilities, or dual eligible individuals. Medicaid serves its part of the population by constructing health plans and reimbursing providers.

So, as you can see, it may be a while before everyone has a clear picture of what the terms “population health” and “population health management” mean. At the end of the day, I suspect that the terms will go away at some point, replaced by more precise terms that better align with the various stakeholders involved.

I’ve been reading about a concept that’s been around for a while but I’m only now becoming aware of: narrative medicine. It has interesting connections to population health management, and places a premium on building empathy between physicians and patients in this era of hyper-short interactions.

According to an article on the Association of American Medical Colleges’ website, narrative medicine is a discipline taught in a handful of medical schools that helps future doctors better understand how to interact with patients on a human level.

The article connects this approach to population health management in the sense that understanding each patient’s specific life circumstances (i.e. social determinants of health) is at the heart of narrative medicine.

Those stories can illuminate how a person became ill, the tipping point that compelled them to seek help, and, perhaps most importantly, the social challenges they face in getting better. 

AAMC website

Fans of prose fiction and poetry — and creative non-fiction, for that matter — will be aware of narrative’s power to transport readers into the consciousness of characters that may, by outward appearances or circumstances, seem much different than themselves. In this way, the reader comes to strongly identify with someone to whom they might otherwise not have given the time of day. Practitioners of narrative medicine assert that by teaching future doctors to develop this same kind of empathy for their patients, overall patient health can improve.

Interest in learning the craft of writing has taken hold in medical programs like the Columbia University College of Physicians and Surgeons, Brown University’s medical school, and the University of Nevada, Reno School of Medicine. Rita Charon, MD, PhD, executive director of Columbia’s Program in Narrative Medicine and founder of the field, says, “It’s not a stretch to say we need help to look at our own processes or to see and appreciate what patients are telling us. For me, it became a way for patients to feel heard and noticed.”

That last part really gets me: “A way for patients to feel heard and noticed.” Traditionally, doctors were often considered diagnosticians, and still are to some extent. But it feels like things are changing: now, although time is still at a premium and interactions between healthcare providers and patients is too short, there seems to be a growing acknowledgement that the patient should be allowed to exercise some amount of agency over their own course of care.

Interestingly, baked into the concept of narrative medicine is “close reading,” another approach borrowed directly from literary studies. As defined by the writing center at the University of Wisconsin-Madison, close reading is a “deep analysis of how a literary text works; it is both a reading process and something you include in a literary analysis paper, though in a refined form.”

Fiction writers and poets build texts out of many central components, including subject, form, and specific word choices. Literary analysis involves examining these components, which allows us to find in small parts of the text clues to help us understand the whole.

The Writing Center at the University of Wisconsin-Madison

Understanding the constituent parts of a patient’s life can begin to help their care team to hone a care pathway that conforms to their actual life circumstances. Such an outlook goes beyond aspects that can be entered into an electronic health record, such as which zip code they live in, whether or not they have reliable transportation, and how likely they are to adhere to different care regimens. And treating the whole patient in this way can be an antidote to physician burnout as well, giving doctors permission to construct rich stories around those in their care as opposed to seeing them as a collection of data points.

Because of the opportunities it affords physicians to gain a deeper appreciation for those they treat, the discipline of narrative medicine has spread beyond the U.S. Several medical schools in Taiwan, for instance, have incorporated this new mode of understanding into their curricula. In one study of 15 participants engaged in narrative medicine or medical humanity education at various medical schools and hospitals across Taiwan, the authors “performed manual thematic analysis to identify the themes and concepts of narrative competence through a six-step theme generation process” with an eye to “exploring the dimensions and connotations of the clinical narrative competence of medical personnel.”

Unsurprisingly, the study found that “Cultivating narrative competence in medical education can complement traditional biomedical orientation” and that “(p)atients often use metaphors or symbols to explain their conditions.” In other words, treating patients as one-dimensional figures ignores a rich source of information that could help physicians deliver higher quality care and improve the health of entire populations.