Insights from the 11 th Population Health and Care Coordination Colloquium

1) We all appear to be on the same page.

The consensus of the participants was that the attendees and presenters were all are saying the same thing: we need to keep healthy people healthy, reduce health risk, and assure appropriate care for people who are already sick. With that level of agreement, there is an opportunity to make real progress.

Along the same lines, there was a common understanding of the term “population health” and the concept of “population segments” –those who are well/healthy, at-risk, acutely ill, chronically ill, and those with catastrophic illnesses. It was generally understood that, in order to deliver an effective population health effort, every segment must be addressed while keeping in mind that well people acquire risks over time, which have the potential to turn into chronic diseases.

The long-term goal is to try to keep people well for as long as possible so that they have a relatively short period of chronic illness and an even shorter period of catastrophic illness before the end of life - a basic understanding that appeared to be shared by the presenters and the audience.

There was a remarkable convergence of conceptual thinking despite the heterogeneous nature of the group (diverse professional backgrounds and areas of expertise representing different types of organizations with, in some cases, different objectives and goals). It was reassuring to hear certain common themes: better use and integration of data, recognition of the limits of the old medical model, and the need for technology to be a part of the solution. One participant observed that finally, in 2011, (largely economic) circumstances are converging to support the conceptual framework of the biopsychosocial model of health that was first proposed in 1977 by George Engel.

2) The time is now

It's an exciting time to be in health care. Moments when all the right factors come into play to support meaningful change are rare, but we appear to be at one of those transformational tipping points. It will be critical to take advantage of that opportunity. The current “petri dish” of experimentation will enable us to learn and to translate that knowledge into accountable care organizations (ACOs) or whatever the delivery system evolves into.

Current models exist in an environment that is increasingly dependent on technology and data sharing. There is also a push to promote consumerism, a theory in which patients assume responsibility for their own health (and health care) to a much greater degree. Concurrently, all stakeholders have come to realize that the status quo is unacceptable and unsustainable. These combined factors increase the likelihood of real change. The opportunity for success is much greater than it was 25 years ago.

Today virtually everyone agrees that, in many respects, the United States has reached its limits. Our businesses are losing their competitive advantage in the global marketplace; families are under economic pressure; state coffers are strained by their growing Medicaid responsibilities; and the federal government is struggling to find common ground over health reform. We cannot afford to train doctors in the traditional model of care - doing nothing to keep people well in favor of waiting until they need to “fix” them or for someone to invent the next miracle drug. We have had to acknowledge that we have limits and that the old model will no longer suffice.

3) Working together

There is a fledgling transition from a paternalistic care model to a more consumer-focused one wherein patients and their families are actively involved in shared decision making - but different organizations are at various points in the transition process. The fear is that we will not learn from past mistakes—everyone will talk about doing the same thing at 5 different locations, or in 5 different organizations. A primary goal should be to have discussions about how we work together as a group to actually deliver a service directed at population behavior change.

To a certain degree, the industry still seems to work in silos. More collaboration is needed. The issue will be to find ways for competing vendors and organizations to work together on a unified solution. The goals are best achieved by working as true partners.

4) Technology

The existing delivery system is excellent at the level of individual episodes of acute care, but we're at the point where the principles of population health can be applied in the delivery system through information exchange, health coaching, and new technologies. Experts are looking to ACOs to be the vehicle to accomplish that comprehensive vision.

The alignment of new capabilities (eg, data, technology, different ways to engage the consumer) afford us the opportunity to be even more successful than we have been in the past. The question is how to build that alignment into a systemic model to allow advancement to the next level. How do we put all the pieces together holistically to create meaningful change at an employer, community, or consumer level?

5) Concerns

One concern is that we do not know what form change will take. There are plans for widespread use of ACOs and medical homes, but the economic consequences of those models are unclear at this point. If the pie is getting smaller, then some entity may be economically damaged in that process. If the nation becomes healthier, we may reach the point where there are too many acute care resources. As we experience the various manifestations of a restructured system, it will be interesting to see if we can maintain our unanimity of purpose.

In response to this concern it was pointed out that a Congressional Budget Office analysis demonstrated that, if both capacity and per capita spending were frozen, the total spending on health care would still grow at about 4% to 5% a year due to the increase in population numbers. Therefore, it isn't necessarily a zero-sum game for doctors and hospitals, because redistribution of resources and population growth may serve to pick up the excess capacity. There is a way out of this conundrum without having to close hospitals.

Another concern is that a good deal of innovation is occurring without much evidence regarding proof of concept. Perhaps a thrust of future conferences can be to ask presenters to share their data along with their innovative ideas.

A final concern was that we need to do a better job reaching out to providers (particularly physician groups in hospitals) and employers. These groups still do not fully understand what is meant by population health management. We who work in our industry—and the attendees and presenters at the Colloquium—know what we mean, and we believe we've proved the concept and the strategies. But many providers, particularly those seeking to develop ACOs, may not understand or appreciate the role of population health management strategies to support ACOs or medical homes.

In the early days, doctors didn't understand what HMOs were either. They felt that managed care was forced down their throats, and they were part of the backlash that repositioned HMOs as a much smaller player in the delivery space. This scenario may recur if we don't reach out much more aggressively to at least explain what an ACO entails and can do.

6) Additional thoughts

There was recognition of the important role that behavior plays in the solution and that, regardless of what form the new health care system will take, a key will be for us to help people adopt healthier behaviors. In order to do that, we have to understand them—what motivates them and what moves them.

Engagement rather than goal orientation is the right focus. Numerous techniques, strategies, and approaches are in development, being brought to market, and proven to be sustainable models.

Well structured ACOs will be key to this process. It will be highly problematic if there is any hegemony on the provider side and the payer side. ACOs must exist in the middle. If they do, it will be “back to the future” in terms of managed care in many ways, but it will be a more empowered type of structure.

It was heartening to hear a smattering of thinking regarding the overarching cultural issues that interfere with our ability to do a good job medically.