With support from the Robert Wood Johnson Foundation, AcademyHealth is working to identify the challenges and barriers in linking the health care payment system to community-wide population health. This four-part blog series features diverse perspectives from members of the Payment Reform for Population Health initiative’s Guiding Committee on the critical need for collaboration across sectors. The first three posts highlight promising approaches to collaboration with a focus on health care system and public health systems, using data sharing to bring collaborators together, and setting the right incentives to spur population health investments. The four-week series will wrap up with a post by AcademyHealth staff:

  1. The Sweet Spot in Health Care and Public Health
  2. Using Data Sharing to Bring Collaborators Together
  3. Supplementing Payment Reform to Promote Needed Investments in Population Health
  4. Addressing the Elements in the Room

A variety of forces are pushing health care delivery systems to define and address “population health.” These forces include: 1) the relationship between life expectancy and the geographic location of residency; 2) the role of social determinants in health outcomes; and 3) the expanding access to “big data;” 4) and payment reform. As systems move from volume to value—from fee-for-service to global payment and risk sharing arrangements, the role of community context in determining individual health outcomes has become more apparent and more critical.

But the definition of “population health” can shift depending on the perspective. While public health institutions generally consider populations defined by geopolitical boundaries (cities, counties, states, nations), the health care delivery system has focused on populations of patients, for example insured members, or those with specific characteristics, such as chronic diseases (diabetes, heart disease, COPD) minorities, those with co-morbidities, and those who are big drivers of health care costs. The health care concept of “population health” rests somewhere between medicine’s historical individual approach and public health’s jurisdictional approach. The overlap between these perspectives represents an important “sweet spot” which holds enormous potential for multi-sector collaboration.

The health delivery system is most equipped to take care of patients, particularly those with complex diseases, but less capable of extending its reach to interventions aimed at improving community health. Even with payment reform, most health care delivery systems will likely choose strategies that involve heavily managing high-cost patients rather than strategies that involve broad-based public and community health interventions or those that target the social determinants of health. This does not mean that they do not value these interventions. Healthy food access, academic enrichment, lead abatement, and smoking policies, for example, are all critical to supporting population health. However, health care systems lack the expertise and/or staff to take on these public/community health interventions independently. Thus a collaboration with multiple sectors such as public health, human services, education, civic planning, and local government will be necessary to address these issues.

The health care delivery system has a variety of choices for bridging the divide between health care and public health. In some cases, the health system may choose through its community benefits or other financial avenues to develop programs independently. However, it is unlikely that this approach will be either sustainable or comprehensive. Instead, the health delivery system can be a participant in ongoing work led by other actors. This can take the form of actual financial contributions or in-kind contributions. It places the health care delivery system within a network of existing collaborators who are actively involved in addressing the social determinants of health.

The health delivery system can also drive and support policy that addresses the social determinants by working with entities that have regulatory authority for health as well as built environment, food access and housing. For example, the health system could play an important role in advocating for a wide range of policies including sin taxes, non-smoking policies, vaccination mandates, lead screening, affordable housing, universal kindergarten, and transportation improvements. Health care providers are large employers with political capital in their local jurisdictions and their voice matters.

Lastly, the health care delivery system has now become an unprecedented source of data that could be used to monitor health and understand “hot spots” where health disparities exist. Yet this data exists in a fragmented manner given the volume of insurers, hospitals and doctors and the format of the data itself. In addition, the obstacles to systematic data sharing are many including HIPAA, competitive markets, inadequate information technology infrastructure and financial resources. To date, a few places including Denver and the state of Massachusetts have achieved examples of integrated data but sustainable nationwide solutions remain elusive.  Today, community and public health as well as health care delivery systems need to understand where the problems are greatest, target them with evidence-based solutions, and monitor the results. And they need to do this together. Only when a comprehensive “data” view of a jurisdiction’s population is available will public health and health care be able to truly understand the scope of the issues and the impact of interventions. This collaboration will allow all partners to jointly decide the best strategies to effectively address population health.

Stay tuned here, at the AcademyHealth blog, for updates on our initiative’s progress and emerging findings. If you are doing related work, please contact Enrique Martinez-Vidal; we’d like to include you in our efforts!

Karen Hacker
Committee Member

Karen Hacker, M.D., M.P.H.

Director - Allegheny County Health Department

Karen Hacker, M.D., M.P.H., is the Director of the Allegheny County Health Department. She is an Adjunct Profe... Read Bio

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