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January 28, 2015
View from Here
Christopher F. Koller
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“Don’t try to teach a pig to sing, Chris,” a colleague once advised me, quoting the well-known saying. “You won’t succeed and you will only tick off the pig.”
The image of singing swine seems particularly apt right now as we look at the question of whether medical providers can practice “population health.” A recent op-ed in The Milbank Quarterly and presentations about community health and paramedicine workers have led me to think more carefully about the music and the singers involved in the effort.
“Population health” is a new catchphrase in health policy. Policymakers say they want to pay for it. Plenty of providers say they do it. Consultants can help everybody get it. With the well-documented problems of fee-for-service medicine, payers find the possibility of holding some entity accountable for the cost and clinical outcomes of a group of people very appealing. With such an effort, proponents of habitually underfunded public health efforts see a chance to redirect savings from care coordination directly to prevention, perhaps within the same organization. “Practicing population health” also offers thoughtful medical workers in those organizations a chance to venture upstream—possibly preventing the suffering they treat every day. With such potential benefits, it is no wonder the phrase is appealing to many constituencies.
But a more precise use of the term is needed. In a recent op-ed in The Milbank Quarterly, Joshua Sharfstein, Associate Dean for Public Health Practice and Training at the Johns Hopkins Bloomberg School of Public Health, lamented the vagueness with which “population health” is currently used. He notes that “as originally conceived, the term encompassed the impact of income inequality, educational differences, and unjust disparities.” He proposes that insurers and clinicians “can continue using the term ‘population health,’ but with a few conditions.” These include:
Population Health–More than Care Coordination
Sharfstein is right to link the practice of population health to geographic communities–this connection to place is also a connection to the social factors that determine health. While the term “population health” engages the actions of providers and payers more directly than the broader phrase “public health,” his is a high standard. As such, it consists of more than coordinating care for the highest cost patients and identifying those who soon will become “super utilizers”—sufficiently large challenges for newly forming accountable care organizations.
What kind of workforce does it take to “do” population health? At a recent meeting of the Fund’s Reforming States Group, members examined the emerging roles of community health workers (CHWs) and community paramedicine workers (PMWs). There are clear differences in the work that they do, which speak to the differences between care coordination and population health.
In presentations from community paramedicine directors in Fort Worth, Texas, and Brooklyn Center, Minnesota, we encountered the jarring notion of hospitals actually hiring paramedicine professionals to visit people in their homes to monitor them and teach self-monitoring skills in order to reduce unnecessary ER visits and inpatient admissions. What makes this possible? It all comes down to a revised payment model that emphasizes shared returns on reductions in total cost. Impressive, yes. Needed, yes. But not population health.
Community health workers, by contrast, do not provide medical services or procedures nor do they coordinate care to reduce unnecessary utilization. They do offer broad education programs to disenfranchised members of their own geographic or cultural communities. We learned about programs in South Carolina and New Mexico where CHWs identify needs and work to help people in those communities become healthier through lifestyle changes that address those needs, such as diet and nutrition, exercise or tobacco cessation. The evidence indicates that the payoffs for CHW services are long-term and result in improved health for these groups.
Who is singing with whom?
In a blog post accompanying an issue of Health Affairs devoted to community health, Alan Weil, Editor- in-Chief, wrote about two possible directions for CHWs, one in which they become part of the health system and the other in which they remain part of their communities. He worried about the future of community health workers in the large delivery systems. “We should honor the wisdom and experience of CHWs as they define their future rather than assuming that they will be absorbed into a health care system that is only beginning to learn how to support people in their communities,” he wrote.
He is right to be cautious. Transactions that deliver clear and immediate benefits lend themselves well to private providers and financing, if the motivations of payment and benefit design are the same for patients and providers. That is the focus of efforts like PMWs to improve care coordination and reduce unnecessary utilization. But it is not the practice of population health.
Using Sharfstein’s standards, no one organization alone can say it “does” population health. The work of making geographic communities healthier, or preventing disease among specific populations in the community, is inherently collaborative. It requires coordinating efforts to educate and employ, and to help people eat well, exercise regularly, and avoid unhealthy behaviors. The entirety of this work cannot be assigned or contracted out to any one organization—accountable, coordinating, or managed. Rather, we do this work together and learn new tools and techniques—payment reform, staffing models, analytics—t o help us do it.
So I was wrong. The work of population health is not about getting pigs to sing. Population health is not really a tune—it’s more like a concert. And there are no solo acts. I am not even sure there is an audience for this performance—we are all on stage, with different parts for different musicians.
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