Population Health- If Not Now, When?
Gordon Hawthorne, JD
A fatigued US healthcare system and workforce tetter on the brink as they heroically care for citizens infected by this pandemic. The NYT reports “a nation numbed by misery and loss” as we surpass the half-million mark of US deaths from COVID 19. “Black, Hispanic, and Native American COVID-19 cases and deaths exceed their share of our population.” Hospitals continue to be pushed to their limits. Average life expectancy in the US drops again in 2020. “Gone are the days we applauded healthcare workers outside hospitals and on city streets.” Research predicts the pandemic’s toll on our nation’s healthcare workforce will remain long after we receive our vaccines, and herd immunity slows the spread. A “mass PTSD on a scale not felt since World War II. This burden should not be ignored.”
Some view the pandemic as a once-in-a-lifetime black swan event. Might it have been less catastrophic if population health had taken deeper root in healthcare systems and the populations they serve? More focus on health outcomes and determinants and implementing policies and interventions that link them may have reduced pre-existing conditions and strengthened our collective resilience.
An American Dies from a Death by Despair Every Two and a Half Minutes
Lost in the 2019 Democratic Primary, this sound bite from Marianne Williamson, considered by many a fringe candidate.
“The biggest problem with America’s health care system is that it is not a health care system so much as a sickness care system. It reflects an outdated perspective on health and healing, in which far too little attention is given to the actual cultivation of health and prevention of disease.”
Maybe more of a premonition when considering the pre-pandemic health status of the backbone and the front-line of America- its working-class and working-poor population of 25 to 64-year-olds.
- Many remain unemployed or underemployed and often underinsured.
- An increasing number suffer from some form of food insecurity. It is estimated that 17M children are going hungry today.
- The cheap, convenient, and engineered-to-taste good ultra-processed foods that dominate America’s diet are linked to obesity, heart disease, and Type 2 Diabetes.
- Nearly half have some form of cardiovascular disease.
- Close to half of the US population is projected to have obesity by 2030; a quarter will be severe.
- One-third are estimated to have Metabolic Syndrome or Pre-Metabolic Syndrome.
- Stress, anxiety disorders, and despair-related illness have risen to an invisible $1 trillion primary care health epidemic impacting over 40 million adults annually.
- One in seven faces substance abuse disorders, while only 10 percent of those addicted receive treatment.
A Generational Opportunity
I have read many inspirational population health vision statements and goals. Yet, I continue to observe the infrastructure, accountabilities, and funding for actualizing population health often remain siloed at the organization’s edges. Strikingly, only 20% of our health and wellbeing is related to access to traditional healthcare systems offerings. The remaining 80% is influenced by a social structure that includes physical environment 10%, socioeconomic factors 40%, and life/behavior choices 30%. All dimensions are relevant to an integrated population health value chain and ecosystem.
Healthcare consumes over 17% of our economy. Our current model relies heavily upon increasing volume and access to advanced medical interventions, polypharmacy, and super specialists. At the same time, our system fails to move us toward enhanced health and greater resilience. Imagine a right to equitable health and wellbeing instead of our current debate on cost and the right to healthcare.
In 2020 the McKinsey Global Institute made a case for improved “health capital” as a post-pandemic growth and economic recovery strategy. It notes that COVID 19 provides a “once-in-a-generation opportunity” to advance broad-based health and prosperity. That said, it outlines that 70 % of this estimated health capital improvement potential requires a broader focus by healthcare providers on environmental, social, behavioral, and preventive interventions. Again, all dimensions of a more intentional population health value chain and ecosystem.
The “Big Blanket”-A Stubborn “Set Point.”
In the late 80′ and early 90’s I served as SVP of Corporate Development for Baptist Medical System, now Baptist Health, a statewide healthcare system in Arkansas. My title’s irony is not lost on me today, given my advocacy for healthcare as a human endeavor, not a corporate one. That said, in 1991, as part of a comprehensive statewide repositioning strategy, we published an illustrated children’s book called “The Big Blanket.” Today I find its sentiment eerily significant.
“This little book began with a dream, the dream of total, life-long health for every man, woman, and child in Arkansas… we believe that like a quilt, healthcare should wrap around all of us at birth, keep us healthy, happy, safe, and secure for an entire lifetime, and enable each of us to live life to its fullest.”
I wish that “total health” vision had become more of a reality. I keep the book visible in my studio as I continue to carry that dream still thirty years later.
Apart from more visible providers like Kaiser Permanente, health systems and payors are often stuck at cross purposes. We covet our traditional incentives to generate sickness-related revenue while endorsing, albeit slowly, a movement to value and consumer-centric population health. I liken this tension to one’s weight loss program. You hit that stubborn physiological/psychological set point. Even with your extra effort, the body quickly returns to former homeostasis, where it feels most comfortable but maybe not most healthy. Consider where we find ourselves today:
- A significant proportion of value-based payment alternatives to physicians and hospitals still rely on some form of fee-for-service chassis.
- Healthcare leaders, clinicians, boards, and consultants relish adding new programs yet struggle with fundamentally disrupting an industry in which they have invested their careers and community efforts.
- Since the70s, we have strategically layered “health” related initiatives considered precursors to a population health value chain. Specifically: preventative health/wellness; integrated medicine; community health/outcomes; early managed care (PPO’s, MSO’s and IPA’s, medical homes, care coordination, and navigation; home health, occupational health, behavioral health, school-based clinics, retail health; concierge practices; personalized medicine, high-reliability healthcare, combined with today’s ACO’s, CIN’s, value-based care, bundled payments, shared savings, digital health, telehealth, whole person care and narrative medicine.
- Significant investments continue to be made in system consolidation, increasing scale, high-end technologies, designer medications, and new bricks and mortar calculated to consolidate and sustain an inherent competitive dimension of today’s healthcare delivery.
- Innovative value-based, lower cost, consumer-centric health solutions emerge more from outside disruptors or at the edges of our legacy healthcare providers.
- Traditional hierarchal and centralized operating and compensation models provide line-of-sight P&L management and control of resource allocation while encouraging further disintegration of the patient experience and are counter-intuitive to the localized nature of population health.
Strategic Decluttering, Realigning and Redeploying
Consumers often confront an episode of injury or disease by piecing together and navigating a set of complex provider/payor relationships and imposed options. Such navigation is generally absent of actual health data and devoid of the impact of knowledge of one’s past and current health and life trajectory. Under a Population Health scenario, this same consumer will have an increased awareness of their health trajectory and be guided by a personalized health pathway. A generative algorithm and value chain would integrate lower-cost, high-impact services, diagnostics, technologies, and evidenced-based interventions appropriate to restoring one’s achievable levels of health. Services would be delivered through an intelligent consumer platform and ecosystem of providers and payors dedicated to restoring equitable health and mitigating further decline.
Nothing Changes Until Something Changes
Today’s leaders, clinicians, board members, and changemakers hold the tension of current disruption and despair along with its emerging possibility. On a recent webinar, Peter Senge noted, “we all have been thrown in the river, and now we have to swim.” I suspect we may all need to become health service researchers, designers, and actuaries or recruit some good ones. Learning to balance this tension between a sickness-based system and a restorative health-based one may take years. Yet, by sifting through the strategic layers of past “health” related efforts, I believe we may find the emerging possibility of improved “health capital.”
Given our $3 trillion annual expenditure, resources do not appear to be the issue. I sense it may be what Otto Scharmer, Senior Lecturer in the MIT Management Sloan School and co-founder of the Presencing Institute, describes as action confidence-“the necessary courage and capacity to step into something new and bring it into being.” For starters:
- Decluttering, dusting off, and sensemaking of our past and current population health strategies and initiatives.
- Welcoming and partnering with the more disruptive forces at the edges and our traditional healthcare systems’ white spaces.
- Moving out to our organizations’ edges to re-form, realign and redeploy these resources in an integrated consumer-centric value chain with an end game of restoring health.
- Accelerating the implementation of a “value-based” financing and compensation model designed to incent economic recovery and growth whether treating our sickness or restoring our health.
Structural changes alone are insufficient. This effort requires the connection between individual and collective inner wellbeing and the desired system change. Thus, the need for a shift in perspective, inner intent, and courageous action by a community of consumers, providers, payors, social entrepreneurs, regulators, and legislatures.
At times, this shift may begin with our sense of discontent, powerlessness, and burnout. One that requires a painful self-examination of our internal landscape and external habitat and taking greater accountability for restoring its health. This experience liberates within a deeper awareness and motivation to influence health restoration within one’s family, organization, and the broader ecosystem. As stewards of this $3T annual spend, I believe we owe this to our first responders, front-line workers, and most vulnerable populations. It seems better than thank you posters, applause, and bellringing. Now is the time for Population Health in America-if, not now, when?
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