Essentially, the health of a population is largely determined by what we have come to call the social determinants of health—that is, socioeconomic status, the environment, individual behavior, rather than the actual delivery of healthcare services. The unequal distribution of morbidity, mortality and quality of life also determine population health. And then there are the laws of the society that help define and sculpt the population's health, such as Social Security, Medicare and Medicaid, and the new kid on the block, the Affordable Care Act, in the U.S. So population health is not really a new concept, but it is back in play as an important topic because of the ACA (aka "Obamacare"), which encourages the healthcare community to pay attention to these factors.(1)

Population health is dedicated to creating a fundamentally different healthcare culture and perspective. Its primary attribute is its focus on wellness, as opposed to disease. This changed perspective has major implications for everyone — providers, payers and consumers — and seeks to align healthcare with the society's overall transformation to a technology-driven, information-based focus, where options, management, choices, costs and outcomes are based on actionable data not anecdotes.(2)

How Did We Get Here

We all know that healthcare costs have surged over the past decades. Inexorably. We also know that the increased costs have not necessarily produced improved quality. The current U.S. life expectancy for newborn Americans, for example, is 78.8 years,(3) which, according to the World Health Organization, puts the U.S. in 39th place behind Greece, Canada, Lebanon, Chile, Taiwan, Italy, France and 30 other countries.(4) With the expansion of a graying population as the Baby Boomer generation retires, our healthcare system faces increased pressures to insure that the social safety network of Medicare, Medicaid and now Obamacare are sufficiently endowed to meet the healthcare needs of our 21^st Century society.

The urgent questions are: Will we have enough resources, economic and organizational, to respond to these demographic shifts? Will we have the expertise to manage continuing and emerging, sometimes unexpected, socio-medical challenges that impact everyone's health? To name a few current concerns: the morbidity and mortality from gun violence, the obesity epidemic, drug resistance, anti-vaccination movements, health consequences of global warming (e.g., effects on food production and nutrition), Ebola and other internationalized infectious threats. Will our traditional, patient-by-patient care strategy be able, in short, to respond to a very full plate of interconnected issues that impact the individual patient above and beyond their particular medical history and physical examination?

The Past Morphs Into The Present and Future

Until recently, for most Americans, healthcare was primarily delivered by the individual physician or small group practice on a fee-for-service basis. The model was volume-based reimbursement — the more providers did, the more they were paid. The economics of this approach were not sustainable in the face of the demographics. As a result of these larger societal pressures, the healthcare systems has gradually been moving to other practice combinations and payment arrangements.

Beginning with the Nixon Administration's introduction of HMOs (health maintenance organizations) in the 1970s, which encouraged patients to receive medical care from a group of physicians, together with the rising costs of diagnostic technologies, liability insurance, start-up costs for a new physician practice, as well as the debt load a physician carried from the lengthy medical educational process, physicians found it difficult to justify, especially in competitive urban areas, launching an individual or small practice. As members of a larger practitioner group, they were more likely to gain the economic security they needed faster, albeit with new types of costs. (5) And as a member of these groups, physicians also quickly realized that like any business they needed to include non-medical managers and analytical personnel whose mission was to monitor costs, improve practice development (i.e., marketing and advertising), increase quality and profit. This was also true for the payers and public health officials whose mandate has always been to help foster a better healthcare system.

Good-bye to Parking Meters...

I like to use the parking meter analogy to represent the new reality: formerly, each motorist "rented" a single parking space by feeding the meter with coins, which required an army of revenue maids to collect the monies and maintain the meters; today, one machine, which accepts various methods of payment, issues a printed parking receipt for a much larger number of parking spaces, thus fewer coin collectors and parking meter maintenance personnel are needed, and the parking authority can now hire a professional to analyze parking utilization by various factors, all with an eye to doing a better job planning parking and making more money.

Similarly, in the healthcare sector, payers (government and private), many of whom had pushed for provider consolidation, sought to change how they reimbursed services: with the number of providers effectively reduced, payment could now be made to fewer but larger "providers," according to standardized criteria, which, in effect, gave the payers much more "influence" over the providers such that reimbursement could be continually analyzed, revisited and revised, all in the name of cost-containment and improved quality.

As a result of provider consolidation and the impending rise in healthcare expenditures for a graying population, we are now moving away from fee-for-service to so-called bundled payments and to an evolving system of pay-for-performance(6) that I think can best be characterized as "no outcome, no income." This mantra would have been unworkable when physicians were all single practitioners, solitary parking meters, managing their own practice and patients, with a patient sample size too small to provide usable data about their patients and their health, and thus unable to influence the society's larger need for healthcare strategic planning.

...And Hello to Big Data

But this is no longer the case today because now analysts can collect and analyze outcome data from a provider group that services a larger, statistically significant set of patients/providers. Thus we are now able to make comparative assessments that hopefully will push all providers to improved service, rewarded by incentives including higher reimbursement. The legislated mandate for electronic medical records will, of course, only strengthen and expand the "no outcome, no income" mantra. So, to sum up, the unmistakable trend is that, eventually, we are likely to have a healthcare world defined by the value of the services rendered and how those services contribute to improving the health of the population.

All the information generated from electronic medical records, from the many diagnostic machines that produce digitized data, from other technologies including telehealth and from burgeoning interest by both providers and consumers in individual human genomic portraits (59% of consumers in one recent survey)(7) has produced another new reality, the so-called Big Data, that is totally consistent with the trend towards emphasizing quality over volume.(8) The essential feature of Big Data is that it offers healthcare analysts, as well as providers, through deep data mining, unparalleled opportunities to find linkages, relationships and epidemiologic patterns, some previously unnoticed. (9)(10)

Many years of research have shown that the providers, the physicians, are very positive about Big Data. Give the providers the comparative data, then teach them how to do a better job, and they will enthusiastically support these efforts,(11) so long as the whole approach is not punitive, that is, not an effort to embarrass them or lower their income.

With respect to the payers, they too want to do a better job and find where they can get the biggest bang for their investment. Should they invest, for example, in inner city pediatric asthma therapy or would it be better to put more resources behind influenza vaccinations? This is a typical community health question that could not really be answered previously until we had, as we now do, the possibility of collecting and then analyzing comprehensive community-centric health data.

So, we believe and the research supports this belief that this new awareness of connections — from all the data sources including eventually also from genome wide analysis — will guide not only personalized therapeutic options but will likely help refashion the design and delivery of healthcare at the community and national levels. We may, one day, have as many administrative trials as clinical trials.

For more information about Big Data click here.

How Might Population Health Help With A Chronic Health Issue

The creation of electronic medical record-based registry function is critical to delivering population-based services. A registry enables practitioners to quickly assess their own practice with regard to improving the health of a defined group of persons. For example, registry tools available from companies such as Epic, Cerner, Phytel and others, help physicians, nurses and pharmacists to see how their practice compares to best performers on a regional and even national basis.

By focusing on the health of a population, physicians, nurses and pharmacists are definitely able to improve outcomes. Our ability to track, for example, outcomes of patients with diabetes, patients with congestive heart failure, and patients with chronic lung disease, for example, enables us to get a broader view of how we are doing. It enables us to identify gaps in care and then to close those gaps using care coordination techniques.

Can Population Health Address More Challenging Health and Social Issues?

Population health perspectives are clearly useful for chronic medical diseases and conditions, where the search for multiple strategies and personalized therapies is likely to be increasingly based on mining large datasets and genome-wide profiles. But are population health perspectives useful for the issues that population health claims it is uniquely qualified to address, the "socio-economic-demographic" conditions that affect individual and societal health and are much more than simply medical? Let's look at one intractable "health" problem.

The Limited Epidemiology of Gun Violence

Gun violence in America claims the lives of an estimated 30,000 annually,(12) and injuries many more citizens, significantly burdening the healthcare system(13) and costing, by one recent estimate, $88 billion dollars between 2006-2010.(14) In 2008, according to one study, twenty American children and teenagers were hospitalized each day as a result of gun-related violence. (15) Among U.S. 15-34-year-olds, suicide and homicide are the second and third leading causes of death;(16) presumably many of these are the result of guns.

Political and Legislative Impediments

In the face of and despite these alarming statistics, Congress, under political pressure from the National Rifle Association (NRA), passed in 1996 an amendment to a necessary budget resolution specifically preventing the Centers for Disease Control and Prevention (CDC) from spending any monies to do anything with respect to gun control.(17) The CDC was forbidden, in essence, to perform its core, mandated epidemiological task — it was not allowed to collect, track, analyze or report data about gun-related violence. Over time, with the continued political lobbying by the NRA and favorable judicial Second Amendment decisions, this prohibition has essentially expanded, including all the health assets of the federal government, so that no researcher from the NIH or the NSF or anyone receiving federal grant support would ever risk researching gun-related issues.

And in 2011, Florida legislators enacted the Firearm Owner's Privacy Act,(18) which declared, as summarized by the U.S. District Court, that:

… "practitioners" may not (i) intentionally record any disclosed information concerning firearm ownership in a patient's medical record if the practitioner knows the information is not relevant to the patient's medical care or safety, or the safety of others (the "record-keeping provision"); (ii) ask a patient whether she owns a firearm unless the practitioner in good faith believes the information is relevant to the patient's medical care or safety, or the safety of others (the "inquiry restriction provision"); (iii) discriminate against a patient based solely on firearm ownership (the "anti-discrimination provision"); or (iv) unnecessarily harass a patient about firearm ownership (the "anti-harassment provision"). Violation of any provision of the law constitutes grounds for disciplinary action under Fla. Stats. §§ 456.072, 395.1055.(19)

Physician plaintiffs appealed the Florida law on the basis that the State of Florida in seeking to protect the Second Amendment rights of gun owners by unfairly and unconstitutionally infringing their First Amendment free speech rights. The U.S. District Court found in favor of the plaintiffs. The State of Florida has appealed to the 11th U.S. Circuit Court, and that decision is still pending.

How Can We Collect Any Data?

In the face of this restrictive environment, how might population health strategies, with its emphasis on social determinants, demographics and data, still be applied to getting at the epidemiology of gun violence and improving outcomes?

Once providers become economically responsible for the care of specific populations, gun violence will rise to the top of some of the key issues we must consider. For example, if a hospital is at economic risk for every trauma patient admitted with a gunshot, they will begin to take a broader view of what stimulates gun violence. Despite legislative obstacles to collecting data on and discussing gun safety with an individual patient, there is nothing to prevent health care providers, hospitals and health insurers from working directly with school systems and other organizations such as churches and synagogues to educate their members about the danger of even having a gun in the home. At some point, digitized patient history and physical software will be configured to insist that primary care doctors and others specifically ask patients about the presence of a gun in the home. In other words, when we realign economic incentives, we can then confront the epidemiology of gun violence.

There are also indirect ways to collect relevant data. We could review and analyze data on domestic violence that doesn't involve a firearm. Or study data on hours spent watching violent media, playing violent videogames, and relating this data to school performance, truancy, arrests, family demographics (income, education, occupation, composition) and then to various measures of health and disease.

Future Creative Initiatives Offer Hope

In an ideal population health research world, it would be critically important that every persons' electronic medical record have a notation as to whether they own a gun or if there is a gun in the family, and it would be also important to know whether children are in the home where a gun is present. This would enable us to create a map of gun-related incidents in a way not yet possible in most communities. And we can insure that the electronic record ask about alcohol, drugs, etc., and any other indicators of personal or familial stress. Once we have identified all these areas of risk, we can intervene appropriately.

Other institutions such as the criminal justice system, which has a vested stake in reducing gun violence morbidity and mortality, might be able, with a little creativity, to collect "epidemiological" data as part of the legal disposition or payment for services, data which could then be linked back to health and medical data, and studied in de-identified, aggregated blocks.

Health insurers may also play a greater role in helping populations reduce gun violence. As part of paying a claim, for example, a health insurer might one day ask either the claimant or the provider, perhaps both, to provide more information on the injury or incident: specifically where it occurred (at work, in the home, in public); time of day; did it involve other people (e.g., family, co-workers, friends, strangers); what actually caused the bodily injury (a man-made object or vehicle); were alcohol or drugs involved (if so, detailed alcohol/drug history); did the individuals involved have on-going mental health or social service counseling; were there any law enforcement issues or consequences; has the individual been involved in any other prior similar incidents or injuries; are they receiving or have they received any care from mental health care professionals, counselors or therapists? The latter is important because a claimant might only ask to be reimbursed for the medical component, while the unmentioned and unreimbursed involvement (or non-involvement) of other medical/social service professionals might suggest the severity and risk of the incident.

Additionally, health care providers could eventually provide customized patient education, disseminate important research findings, public service announcements and related educational activities, each tailored to the specific socio-medico demographics and issues confronting the patient and their family, and in so doing improve the health of the patient and the larger population.(20)

Summary

The emergence of new technologies catalyzed the development of so-called Big Data which promises to help healthcare planners identify significant epidemiological links and administrative insights. Combined with legislative and economic pressures to both improve quality and more prudently allocate scarce resources, we announce the era of population health.