Population health is on fire and, importantly, makes sense. And though the term is somewhat new (popularized by the Triple Aim), attempts to improve the health of populations are old. Hospitals and larger health systems have appropriated the term, but they do not corner the market on population health initiatives. Other stakeholders, too, have rich histories of improving the health of populations, but those efforts can fall short when they are siloed.
Government
In a famous early example of a government-led public health intervention, John Snow traced an 1854 cholera outbreak in London to a water pump. His groundbreaking epidemiologic study led the local government to remove the pump’s handle. Since then, disease-prevention and health-promotion efforts have expanded at the global, federal, state and local levels.
Governmental investments in population health can be quite rational. Childhood vaccination is one of the best examples of a smart government intervention that is cost-effective and yields attractive cost-benefit ratios. Childhood vaccination creates herd immunity, benefitting the vaccinated child as well as the people that come into contact with the child — a secondary benefit that economists call a positive externality. In this example, government responds to a clear market failure in which the allocation of resources (i.e., vaccines) would otherwise likely be inefficient.
Employers
Paul Starr, author of The Social Transformation of American Medicine, noted that railroad, lumber, and mining companies of the late 1880s voluntarily developed employee medical programs because they were geographically isolated and workers experienced high injury rates. Back then, corporate physicians largely treated and recorded workplace injuries, but Starr observed an expansion to the prevention of workplace injuries in response to the adoption of worker’s compensations laws around 1910. Today, many employers provide comprehensive health benefits that includes preventive care services. Some of the richest benefits are provided to employees in competitive labor markets (e.g., coders) to attract and retain talent, and in sectors with lower turnover (e.g., teachers) where long-term investments in health are more likely to be realized.
Payers
Kaiser Permanente is one of the oldest payers in the U.S. and has been providing prepaid, comprehensive health services since World War II. By definition, payers are responsible for managing the care of a defined population. Because of high turnover rates in their memberships, payers typically are not financially incented to make long-term investments in population health. That said, all payers are financially motivated to provide healthcare services that are likely to offset other medical costs in the short term.
Hospitals
Hospitals have a long tradition of providing care to people residing in their local service areas. Whatever the organization’s mission may be, the provision of care in a way that lowers its costs makes sense. For example, providing primary care to local uninsured patients in a community-based health center may be more cost-effective than providing uncompensated care to the same patients in an emergency department. And partnering with community-based organizations can more effectively and efficiently tackle the social, behavioral and environmental determinants of population health.
Population health makes less sense when a significant portion of the hospital’s revenue is derived from patients far and wide. For example, leading cancer centers may attract patients from other regions and even other nations. In these cases, any fit with population health is pretty weak. The same is true with competing nearby institutions in large urban centers with overlapping service areas. These hospitals are less likely to see a return on their investments in population health.
In the 1960s, Mount Sinai School of Medicine in New York City was a pioneer in what was then called “community medicine.” For decades, its department of community medicine worked with neighborhood groups to improve the health status of people living in East Harlem, its local community. Just a few years ago, Mount Sinai Medical Center, the hospital affiliated with the medical school, ran a centerfold ad in the New York Times Magazine that trumpeted, “If our beds are filled, it means we’ve failed.” Guess what? When this ad ran, their beds were filled! Hmm. Hospitals that both serve a local service area and are global magnets for specialty care have competing interests that are not easily reconciled. And let’s not forget how population health can help hospitals maintain positive community relations.
Diffusion of responsibility
When witnessing a person in need of assistance, social psychologists observe that one is less likely to intervene when others are present, and feelings of responsibility tend to decrease as the number of potential helpers increases. It is quite possible that similar dynamics plague population health efforts. Multiple stakeholders engage in population health efforts, yet this fragmented approach may erode efforts by each.
Government does not need to address all market failures, because employers, payers, and hospitals each have a role in doing the same. And each other stakeholder considers its own role and comes to the same conclusion: that others are responsible for the solution. Meanwhile, the efforts of each go uncoordinated and an optimal allocation of resources is not achieved. Instead, each stakeholder makes a level of investment that is commensurate with the perceived return.
Who owns population health? Milton Friedman said, “When everybody owns something, nobody owns it, and nobody has a direct interest in maintaining or improving its condition.” Therein lies the problem.
Call it public health, or health benefits, or managed care, or community medicine — or be cool and call it population health… whatever. Nike’s ad campaign says: “Just Do It.” But when the diverse stakeholders just do only whatever they perceive to be in their self-interest (e.g., reduce or avoid costs, avoid lawsuits, attract and retain talent, boost productivity), the population’s health is not optimally served. Hopefully, we’ll find ways to better coordinate efforts and minimize, if not eliminate, gaps in the provision of population health. And if we do, then we’ll all benefit.
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