Aiming for Quality Improvement: Aligning Population Health and Higher Education

Value Proposition of Health Care

Value in health care often is defined as health outcomes achieved per dollars spent. Health care costs currently account for 17% of the US gross domestic product, with an estimated growth to 20% by 2020. Despite having the most expensive health care system in the world, the United States has the lowest health outcomes among wealthy nations. ¹ The implementation of incremental solutions (eg, electronic medical records, practice-based guidelines, reducing medical errors) to improve patient outcomes has resulted in minimal improvements. It is increasingly accepted that systematic changes are needed in order to bend the cost curve and achieve population-level improvements.

In 2008, the Institute for Healthcare Improvement created the Triple Aim, a framework for optimizing health system performance by simultaneously: (1) improving patient outcomes (improving the health of populations), (2) improving patient experience (satisfaction and quality), and (3) reducing health care costs. ² Implementation of the Triple Aim requires a radical transformation of health care from a fragmented, volume-driven system to a more coordinated, accessible, high-quality, patient-centered system. Interoperable electronic medical record systems, provider alerts for preventive and chronic diseases, team-based approaches for the continuum of care, clinical information at the point of care, patient decision aids, interactive patient portals, and a highly engaged workforce are among the many changes that are needed to effectively manage the health of populations in the current era.

Existing approaches to bring these strategies to scale have created a stressful work environment, including numerous bureaucratic tasks, excessive hours at work, depersonalization, and increased computerization of practice that have resulted in a high prevalence of burnout among health care providers. In recognition of the growing prevalence of burnout among health care providers, the original Triple Aim was expanded to include a focus on improving the provider experience. ^3,4

Value Proposition of Higher Education

Decades of evidence show a positive correlation between attainment of higher education and better employment prospects, higher earning potential, higher levels of political efficacy, and better health status – factors that have been linked to happiness and well-being. Despite demonstrated benefits from attainment of higher education, there is increasing pressure on colleges, universities, and professional schools to improve the quality of student outcomes and experiences while reducing costs; expectations that parallel the mandates to health care systems.

Quadruple Aim of Higher Education

Health care and higher education have been described as “America's two most troubled sectors.” ⁷ These large sectors of society represent 25% of the economy and have many parallels, face similar challenges, and are both in need of transformation. According to Isabel Sawhill of the Brookings Institute, ⁷ 4 similarities between health care and education account for the poor performance in these sectors, including: (1) fee for service instead of pay for performance, (2) low productivity, (3) third-party payment, and (4) entrenched institutional and professional interests that mitigate against change. Since 2003, the insurance industry nudged the health care industry to begin a process of significant transformation moving from a volume- to value-based system – a move further catalyzed by the Patient Protection and Affordable Care Act (PPACA). Mandates to increase the value proposition in higher education have been delivered by state and federal governments in an effort to improve student outcomes and provide a quality product for a lower cost. Changes to the health care and higher education industries have resulted in significant stress placed on both sectors and their respective professional stakeholders: health care providers and faculty members. Unlike the health care industry, however, higher education has not yet proposed a system-wide framework to address and improve their plight. We contend that the Quadruple Aim can be applied to higher education as a framework and road map for system change.

Lastly, the effects of demographic population shifts in the United States will continue to tether these 2 sectors. For health care, this will mean more baby boomers entering retirement, likely encountering additional stresses and increasingly complex health care needs. As it relates to education, this population will retire from academia, leaving a dearth of experienced educators; this is particularly concerning given the reduced numbers of younger doctoral graduates entering higher education. Further, other population trends will result in a higher number of students from lower income backgrounds who will enter college with additional academic, social, and environmental challenges that will need to be addressed by colleges and universities. Without a clearly articulated, system-wide strategy to proactively address these challenges, higher education may succumb to shrinkages from consolidation and campus-specific specialization. Early indications of these changes are evident by a multitude of recent college/university mergers such as the College of Charleston and the Medical College of South Carolina, Rutgers University and the University of Medicine and Dentistry of New Jersey, and others. Reductions in the number of colleges and universities have been predicted for years; however, the shrinking financial landscape, coupled with changing expectations from numerous stakeholder groups, has never been more intense.

The fates of the health care and higher education sectors are intertwined. Colleges and universities are both customers of, and suppliers for health care, as they educate the future health care workforce and serve as major providers of health care delivery. As major employers, they clearly have a vested interest in supporting a more efficient and cost-effective health care system. Conversely, as value-based payment arrangements become normative, health care systems have a vested interest in maintaining a healthy workforce that can improve productivity, lower costs over time, and improve family and community well-being.

Conclusion

Questioning the value of higher education is not new. The cover story of a 1976 issue of Newsweek entitled, “Who Needs College?” ⁸ photographically illustrated recent college graduates in hard hats performing construction work. Despite the assaults on higher education, however, the value proposition for higher education is still exceptionally strong. College graduates have more job opportunities, enjoy higher salaries, and have a better health status compared with their peers with a high school education. However, even with the unemployment rate among American college graduates down to 2.8%, the United States remains at risk of not having enough graduates to meet our country's workforce demands in the next decade, raising the stakes for both higher education and health care. Policies that decrease economic barriers and increase access for more promising students to attend college are critically needed to overcome this anticipated deficit in college graduates.

Public debate about the rising cost of tuition and student debt dominated the topics of the recent presidential election cycle, and resulted in renewed calls for free tuition. Tennessee (Tennessee Promise), Minnesota (MnSCU Two-year Occupational Grant Pilot Program), and Oregon (Oregon Promise) have enacted tuition-free community college programs for their residents and the University of Michigan has introduced a tuition-free program for low-income Michiganders. The State of New York broke new ground in the push for tuition-free college as it became the first state in the nation to make tuition free for middle-class students attending 2- and 4-year public colleges. Although some have praised this accomplishment, critics and skeptics of the policy have voiced concerns ranging from the postgraduation residency requirement, to concerns over replicating the current situation in California, where tens of thousands of students were denied college admission because of a lack of state funding. ⁹ Similarly, in health we have seen expanded health care in selected states such as Massachusetts to provide coverage for more than 98% of its residents. But for our nation to achieve its full potential, we must embrace and enact universal, quality, affordable education and health care for all citizens. In the words of Mahatma Gandhi, “The true measure of any society can be found in how it treats its most vulnerable members.”