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.
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.