With the implementation of the Affordable Care Act and the push toward the Triple Aim of patient-focused care, lower costs, and improved health of populations — “population health” has become a buzzword, often coming to mean improving medical care or simply delivering healthcare to larger groups of people. While providing high-quality healthcare is critical, improving the health of a population is a much bigger endeavor.
Improving population health ultimately means creating healthy communities. It involves a myriad of interrelated factors that contribute to an individual’s health – such as safety in the home, appropriate housing, education, access to healthy food, clean air, time and space for recreation, social connections, and mental health services.
In a large, diverse, and inclusive state willing to invest in its people—with many funders pledging support for new approaches, California has become a proving ground for innovative programs to improve population health and serve as models that can be replicated elsewhere. Successful models have some things in common: They use data to precisely identify which factors are impacting health: establish shared goals and benchmarks; and track progress over time.
Programs that are scalable and effectively improve community health encourage cross-sector collaboration—so that it’s not just hospitals, physicians, or community health centers working to keep people healthy. Schools, social organizations, housing agencies, and other government departments are all striving to move the needle.
Sonoma County, Stockton, and Ventura County are among many bright spots in California, providing examples of successful efforts to create healthier communities using data and cross-sector collaboration to target specific needs — bringing schools, governments, non-profits, and health centers together to address them.
Picturing Health in Sonoma County
Sonoma County commissioned a study that gathered and analyzed information from an array of publicly available data sources to create A Portrait of Sonoma County, a snapshot of factors that affect the health of residents, with many measures focused down to a granular neighborhood level. More than 75 organizations and individuals pledged to use the report to improve factors that are impacting the health of Sonoma County communities. Since the report was broken down by issues affected health, education, and income at a neighborhood level, it led to specific, targeted actions.
Among those actions, a community health collective identified specific neighborhoods to receive additional health screenings and attract healthy food markets. The county supervisors, noting the major impact smoking had on health countywide, expanded policies providing secondhand smoke protections to include e-cigarettes. A community health program created resource guides in Spanish and English to address this gap in the safety net.
Identifying Trauma Victims Earlier
In Stockton, data from a community needs assessment showed trauma was significantly impacting health in South Stockton. The California Accountable Communities for Health Initiative, established by a group of health funders including Blue Shield of California Foundation, funded their efforts to develop and expand trauma prevention recovery programs in the South Stockton Promise Zone. Young people exposed to abuse or violence in the home and the community are at risk for poor mental health and even for heart disease, depression, and alcoholism as adults. The grant creates a system of care providers, mentors, and school personnel trained to identify victims of trauma as early as possible and match them with social support and recovery services.
Customizing support for probation
Ventura County is testing a program to reduce recidivism by providing evidence-based services to men and women on probation. The goal is to help each client get access to the services they need most to help them lead healthy and productive lives when returning to their families and communities. Success will be measured by an independent evaluator, using administrative data in a randomized controlled trial conducted by the University of California, Los Angeles. The project uses a “Pay for Success” funding model where investors will recoup their investments if the rate at which participants commit new crimes is at least 5 percent lower than similar people who are not getting the customized services.
These examples of healthier communities are made possible when data infrastructure and support for cross-sector collaboration are in place. Improvements in community health will become visible when we bring models like these to a national scale — where communities, including the healthcare system, are focused first on creating environments that keep people healthy and, when necessary, providing services in a way that supports healthy populations.
The Biggest Barrier to Improving Population Health
While cross-sector models demonstrate that it is possible to make communities healthier, we can’t ignore one of the biggest barriers — our fee-for-service system for paying for healthcare — which encourages us to treat many health and social issues like medical problems, or to wait until they become medical problems, rather than identifying and systematically addressing the root causes.
A payment system that provides incentives and rewards for keeping people healthy is critical to an infrastructure that supports healthy communities.
When Blue Shield of California Foundation brought together 25 leaders from all corners of healthcare to talk about healthcare innovation, they all agreed that ending the fee-for-service payment system would be a cornerstone for encouraging innovation, reducing the volume of healthcare consumed, and lowering costs for everyone. The fee-for-service payment system creates a strong business case for creating, promoting and selling new products, which has led to great innovation in drugs and services. It also creates a systemic disincentive for creating healthy communities, preventing violence, preventing illness, and avoiding unnecessary hospitalizations and procedures.
As a testing ground for innovation, California has shown that when we provide the infrastructure of data to get a better picture of the factors that impact health, and when we invest the seed money that supports and encourages cross-sector collaboration, it is possible to foster the creation of healthier communities.
About Peter Long, PhD
Peter Long, PhD, is the president and CEO of Blue Shield of California Foundation. He leads the Foundation in its mission to improve the lives of all Californians, particularly the underserved, by making health care accessible, effective, and affordable, and by ending domestic violence. Prior to joining Blue Shield of California Foundation, Dr. Long served in leadership roles at the Henry J. Kaiser Family Foundation and The California Endowment. He has extensive experience working on health policy issues at the state, national, and global levels, and has written numerous papers on the topic. Dr. Long also served as the director of development and programs for the Indian Health Center of Santa Clara Valley in San Jose, before assuming his position there as executive director.
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Thank you all for the strong, and smart, reactions to this article. I shared initial thoughts and examples because we don’t yet have all the answers to create the perfect healthcare system. What we do know is that the current U.S. healthcare system isn’t producing good or even decent results for the number of dollars invested. For example, as Americans, our life expectancy has declined over the past two years while the rest of the world continues to make progress. The Foundation has developed a broad vision for where we want to go and what we can achieve. How the healthcare system ultimately improves will depend upon learning, partnership, and conversations just like this one.
The problem is that if we take a definitions-first approach too strictly, we never stop arguing about definitions. You’re not going to get a universal consensus on a definition of health, or common good, or social capital. That’s why committees are set up to find a local and practical consensus for defining scope, and given the authority to move ahead setting policy based on that consensus.
To your point, I disagree that this has to be either/or. The ability to achieve greater health in a society could depend both on things like caring relationships and information processing.
Also, as an aside, what’s up with ALL CAPS?
Let’s say capitation and salary are equally good alternatives to FFS (each has minor advantages and disadvantages). You can get around the anti-competitive restrictions by forming an IPA, and then discuss with payers collective reimbursement mechanisms, and aligning payment with outcomes rather than just the volume of services delivered. Or you could join a larger medical group. It doesn’t have to be solo private practice vs giant hospital-led health system.
It is true that as an individual private practice doc you are in a bad position to take on medical risk for patient outcomes (when both cost and quality are considered). There is so much variation around an individual physician’s patients, and a couple of “unlucky” patients could throw off your numbers so much, that FFS is indeed the best payment method. So there is a real tension here, and unless we go to a global budget system in which increased volume triggers decreasing reimbursement per service, and a greater share of the total dollars is earmarked for prevention and taken out of the clinical care ecosystem, I don’t see how FFS survives.
Leo, since others have not replied to your rhetorical questions, I will offer a few comments. The mechanism by which FFS payment fails to encourage prevention is well-understood: no volume, no revenue. It’s not that a doctor being paid FFS causes the patient to be sicker on an individual basis. That would be absurd. It’s about where the focus of the system lies. If you pay a fireman for each fire he fights, he’s not going to have a reason to focus on prevention of fires, which is where the greater value lies. When I go to a doctor (almost always paid FFS here on the east coast), prevention and wellness are clearly afterthoughts. I have high cholesterol and another chronic condition that has environmental and stress triggers. I’ve moved around a fair amount so have experienced at least a half dozen new primary care doctors over the last 15 years. They typically do not even bother to have a conversation about diet and exercise, or have a highly perfunctory one. No attempt to provide motivation or discuss social interventions, what has worked for others, etc. Why would they? they don’t get paid for it. Of course we want highly trained firefighters, but our real goal should be to see them as little as possible. While our bodies cannot be brought up to code as easily as a building, there is a tremendous amount that could be done but isn’t. This isn’t just the responsibility of doctors, but public health officials and others.
There is also a darker side to this, which is the pursuit of higher intensity, higher cost treatments than is warranted. Japan also uses FFS and has a healthy population and much lower costs per treatment/visit/admit than we do. Japan, however, has a system in which fees are loosely tied to a national budget for health care expenditures and so increasing the volume of services delivered gets cancelled out because the national fees for these services get lowered. It’s a zero-sum game from the provider point of view, which doesn’t stop an explosion in the use of some services, like medical imaging, but the increased volume results in super low costs compared to the US. it’s not a market mechanism, but a top down government mechanism. The United States has no such mechanism (we tried with the sustainable growth rate formula, but provider lobbies fought it successfully until finally the “doc fix” became permanent). So, I would offer that if you want to keep FFS, the only way it could work is with some kind of global budget or global cap or per capita cap (variations on the same theme). This would allow the system to re-orient itself towards whatever best works to keep people healthy, out of the hospitals, and away from the MRIs, transfusions, biologics, etc. The need to find out what best works was the point of the original post you responded to. How you could object to that is still not clear to me.
Perry, the author explicitly states that population health has become a buzzword and then makes a distinction between a less radical/helpful interpretation of the word and a more helpful one, which he then proceeds to give examples of. Where exactly could you see this was going?
When I started reading this and saw all the “buzzwords” in the first paragraph, I could see where this was going….
You forgot to link FFS to global warming and nuclear proliferation.
Do you really think that FFS is what is holding up the grand vision you have for population health? You are not going to encourage innovation, reduce healthcare consumption or lower costs by coming up with one intervention over another to try to reduce healthcare costs. Are you not creating, promoting and selling new products in this very post? How else would you be funded? Do you really think a payment system is creating a systemic disincentive for creating healthy communities, preventing violence, preventing illness, and avoiding unnecessary hospitalizations and procedures? By what mechanism do I show up to work each day and create illness and encourage violence? What 25 leaders did you get together with? The same ones who got our healthcare system exactly where it is today?
Thanks for the cloud talk. Let us know when you come up with some tangible solutions and how you are going to fund them. I am sure you will come back around to FFS when it comes to supporting your agenda.
Tell us what you want. Do you want everyone on capitation? Do you want us on salaries? Do you want every good/service to be bundled in prices? Can docs legally work with hospitals to offer bids for large bundled services?
Tell us what you plan for pharmacy. Does Pharma get included? Are you going to negotiate with PBMs to provide all the drugs needed for a certain population for a certain price per year?
Executives? Hospital supplies? Labor? All input factors of production? Tell us how to remove FFS from them.
“Population health” sounds as if others–outside the health care sector–should often be responsible: social services; education; criminal justice; agriculture and food specialists; housing resources…How about their FFS styles of compensation…are you proposing to change those?
Say that you would like docs to be on salary. Anti-trust forbids us from even getting together to negotiate this with employers. Are you going to change the law to allow this? What is your strategy here?
Pretty vague stuff….help us out with specifics.
Any discussion of Population HEALTH should begin with a uniformly understood definition of HEALTH. From a population stand point, the HEALTH of any community is directly associated with its COMMON GOOD and the Social capital that maintains it. I offer the following definition of Social Capital.
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….the spontaneously communicated attributes of TRUST, COOPERATION and RECIPROCITY
….that occur more frequently for resolving the SOCIAL DILEMMAS occurring
….during each citizen’s participation in the civil life of their community
….when CARING RELATIONSHIPS increasingly characterize
….the enduring networks of the community’s citizens,
….especially within the FAMILY NEIGHBORHOOD NETWORK of each citizen.
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I propose that the connection between a community’s COMMON GOOD with its capability to achieve the attributes as a Blue Zone is mostly determined by its level of SOCIAL CAPITAL and not by the level of information processing by its healthcare industry.