Abstract
Schools of medicine are increasingly focusing on efforts beyond the immediate needs of individual patients and addressing the needs of whole populations. This study examined the characteristics of population health departments and related programs within, and affiliated with, schools of medicine and how these programs address the schools' educational, clinical care, research, and service missions. Structured reviews of school of medicine websites were used to identify population health departments and related programs. An on-line survey was distributed to a subset of these programs to capture details on their activities and organizational characteristics. The authors convened leaders of population health programs to elaborate on core themes. Of 154 school of medicine websites reviewed, 37 (24%) had affiliated population health programs, including 28 (18%) with distinct departments of population health. Departments reported a variety of teaching activities related to undergraduate medical education, graduate degree programs, and certificate programs addressing a variety of population health domains including public health, health administration, epidemiology, biostatistics, informatics, and research methods. Research was a core activity for most departments with significant support coming from federal funding, with many playing major roles in clinical and translational research institutes and cancer centers. Most departments had research, data sharing, and other collaborations with affiliated health systems. All departments engaged in community service activities, including activities supporting the response to the COVID-19 pandemic. Population health programs are playing an increasingly important role in the teaching, clinical care, research, and community service missions in schools of medicine and academic medical centers.
Background
Berwick et al introduced the Triple Aim strategy in 2008 to advance health care in the United States. 1 The Triple Aim, which seeks to improve the experience of care, improve the health of populations, and reduce per capita costs, has elevated population health improvement as an important goal for schools of medicine and academic medical centers. The term population health precedes Berwick et al and has been defined by Kindig and Stoddard as the “health of outcomes of a group of individuals, including distribution of such outcomes within a group.” 2
Although population health is often viewed as a clinical and financial blueprint to describe health care delivery to patients served by particular health care institutions, the more comprehensive field has also been referred to as total population health 3 brings greater focus to public health and the social and structural determinants of health. 4 This has been accompanied by a growing interest of health care systems in public health 5 and has led to substantial efforts by health systems to identify social determinants of health and help patients meet social needs.
This movement to integrate medicine and public health continues to gain momentum, accelerated even further by the challenges and opportunities brought forward by the COVID-19 pandemic and the social justice movement. 6 Health care delivery systems, practitioners, payers, and government are essential stakeholders in population health improvement. Academic medicine, with its growing quadripartite mission of education, research, clinical care, and service to the community, 7 has the opportunity to lead in advancing the health of populations, but the emergence of population health as a discipline in academic medicine is still a relatively new idea.
In 2019, Gourevitch et al highlighted the emergence and development of population health-focused, department-level initiatives in medical schools and described a variety of organizational structures, missions, and focus areas for these departments with varied goals in research, education, clinical care, and service to the community. 8 Interest emerged in creating an organizing forum to share approaches to developing and supporting such departments, which coalesced as a group called Population Health Leaders in Academic Medicine (PHLAM). 9
Since the initial Gourevitch et al article and the launch of PHLAM, the discipline of population health in academic medicine has continued to evolve with other medical schools and universities creating new academic departments and schools focused on integrating medicine and public health. Although these departments and schools continue to vary in structure, their evolution and growth demonstrate an expanded sense of responsibility in academic medicine to prioritize population health-focused education, research, clinical care, and service to the community. This study was designed to describe the evolution and current state of this growing field in academic medicine.
Methods
Setting
This study was conducted on behalf of the membership of PHLAM. PHLAM's mission is to bring together leaders of academic population health departments within schools of medicine and similar entities to provide a platform for strengthening and sustaining the growing field of population health science. 9 PHLAM members meet quarterly to discuss matters of organizational structure, intradepartmental relationships, health system involvement, research, education, and community engagement.
Identification of population health programs in schools of medicine
In August 2021, the authors identified 154 Schools of Medicine from the Association of Medical Colleges (AAMC) membership directory, 10 and then conducted a structured review of the webpage for each school of medicine to identify departments of population health or similar programs with “population” in the title. For each unit identified, the name and type of unit (ie, department, program, center, or institute) were captured.
Survey of population health programs
In the fall of 2020, PHLAM created a workgroup to specifically look at the makeup and financing of medical school-sponsored population health programs. The workgroup developed a survey of PHLAM members in May 2021 that was designed to capture 6 major domains related to the operation of a department: administrative structure and characteristics; education and training programs; clinical and health system related activities; research funding; community services, including activities conducted in response to COVID-19; and departmental financial support.
An initial draft of the survey was pilot tested by 2 programs and then reviewed by the full PHLAM membership before being finalized. The survey and study plan were submitted to the institutional review board of the Southern Illinois University School of Medicine where it was deemed as exempt from human subjects review.
The survey was coded into REDCap (Research Electronic Data Capture, Vanderbilt University, Nashville, TN) and distributed to the PHLAM membership in June 2021. Preliminary results were presented to the PHLAM membership in September 2021. After this review and clarification of several questions, the survey was redistributed to several previous respondents who indicated an interest in modifying their responses and also administered to several new members who had not previously participated.
Qualitative review of findings at annual meeting.
Supplementary questions were asked during the national PHLAM meeting in October 2021 and recorded in a live-forum session (Google Jamboard). These questions allowed the collection of qualitative data from each institution that were not easily asked in the initial REDCap survey. The questions that were asked on the live-forum session included: what is the role of your department in the university or college's clinical and translational science institute and/or cancer center, what specific information unique to your organization was not reflected in the data presented on service to the community, what opportunities exist for population health organizations in academic medicine in a post-COVID-19 health care service delivery and medical education environment, how long has your department been in existence, what specific information unique to your organization is not reflected in this description of relationships with health systems, and what characteristics of your educational programming are we missing?
Data analysis
Univariate analyses of all quantitative survey responses were conducted. To account for the large variation exhibited across departments, the range of responses is presented along with means and standard deviations. Two authors (M.A.W., S.S.V.) independently coded all open-ended responses from both the survey and the annual meeting and then came together to address any disparities in coding.
Ethical approval
This study received a “Non-Human Subjects Determination” from the Springfield Committee for Research Involving Human Subjects (SCRIHS) at Southern Illinois University School of Medicine on May 24, 2021 (IRB No. 21-825).
Results
Population health units within schools of medicine
From the 154 school of medicine websites reviewed, 37 (24%) had affiliated population health programs. These programs included 28 departments of population health, 4 affiliated schools, and 5 centers, programs, or population health initiatives located within a department, institute, or health center.
Survey of population health units
Figure 1 shows the geographical distribution of PHLAM members in the United States. Of the 35 population health departments, colleges, and schools in PHLAM invited to participate, 26 (74.3%) completed the survey. Respondents included 21 departments within allopathic schools of medicine, 2 colleges, 1 school, 1 department in an osteopathic school of medicine, and 1 department within a school of community and rural health that also served as a community site for third year medical students. In the next sections, the survey responses from the 21 departments within allopathic schools of medicine are delineated.
Location of population health leaders in academic medicine members.
Department composition
As described in Table 1, departments ranged in size from 6 to 110 primary faculty members (mean 38.0; SD 27.5), from 0 to 98 secondary faculty members (mean 23.0; SD 25.3), and from 0 to 159 adjunct or volunteer faculty (mean 31.9; SD 41.2). Total annual departmental budgets varied in size from less than $2 million to more than $80 million (mean $23.7 million; SD 26.4).
Characteristics of 21 Departments of Population Health
Educational programming
The departments reported a variety of teaching activities related to undergraduate medical education, graduate programs, and certificate programs (Table 1). Biostatistics, epidemiology, population health, public health, and health systems/health policy were commonly offered as formal graduate courses or included in the undergraduate medical school curriculum. Many programs also taught informatics, data science, and translational research for both medical students and graduate students. Seventeen departments reporting identified an average of 9.3 faculty full time equivalents devoted to education (SD: 11.6; range: 0.1–50).
Undergraduate medical education was identified as a major activity in 18 (85.7%) of the departments, addressing a number of core population health disciplines (Table 2). Graduate degree and certificate programs also addressed a wide variety of population health domains including public health, health administration, epidemiology, biostatistics, informatics/data sciences, and research methods. Of the 18 departments with graduate degree programs, 2 had only masters degree programs, 2 had only PhD programs, and 9 had both masters and PhD programs. These 18 departments reported an average of 138.8 graduate students (SD: 166.7; range 22–652). Six departments supported residency programs in preventive medicine (3), family medicine (2), primary care and population medicine (1), and aerospace medicine (1).
Population Health-Related Educational Offerings Within 26 Departments, Colleges, and Schools of Population Health
Of the 21 departments surveyed, 6 (28.6%) reported close affiliations with an existing or emerging school of public health. Of these 6 departments, none had masters degree programs; 1 has a PhD program. In contrast, of the 15 departments not affiliated with a school of public health, 12 had graduate degree programs (11 with masters degree programs and 10 with PhD programs).
Research support
Nineteen departments provided details on research support, reporting an average of 59.9% (SD: 25.1; range 5%–94%) of their total department budget derived from research, with 68.7% of that funding coming from the NIH or other federal sources.
Health system relationships
Eighteen (85.7%) of the departments had research, data sharing, or other collaborations with 1 or more affiliated health systems. Although collaboration on research grants was the most commonly cited activity, departments also provided their health systems with statistics, epidemiology, informatics, predictive analytics, and modeling support. They also collaborated on smoking cessation programs, quality improvement activities, program evaluation, bioethics, and community assessment activities.
These services were supported both by contracts with the health system and by direct salary support to faculty. For 3 departments, health system support accounted for more than 30% of their overall revenue, whereas the remainder reported less than 6% of their revenue coming from health system activities.
Few departments, 6 (28.6%), provided direct clinical services. Nevertheless, all but 1 department had clinicians on their faculty. Faculty with secondary appointments were more likely to be clinicians (29.1%) than those with primary appointments (8.8%).
State and community services
All departments reported participating in a variety of community-related activities (Table 3), though only 4 reported generating 10% or more of their overall revenue from this type of work. Departments reported collaborating with a variety of state and local programs, including state health departments (13), local health departments (10), state Medicaid (4), other insurers (4), and local nonprofit organizations (6). Departments also reported on a variety of activities in response to COVID-19.
Examples of Community Service
Qualitative responses at annual meeting
From the live-forum session, several themes emerged showcasing the wide-reaching impact of these population health departments and schools, both within and outside their respective institutions. Of the 19 PHLAM members present, 13 reported relationships with their university's clinical and translational science award programs and 14 reported affiliations with academic cancer centers. Twelve of these departments reported holding leadership positions within 1 or both of these entities.
Members highlighted their departments' responses to the COVID-19 pandemic and their parent institutions' appreciation of this preparedness. Participants also highlighted the important role of population health in advancing social justice and health equity policies in response to longstanding health inequities that have been exacerbated by the COVID-19 pandemic.
Although some departments report being relatively young, others have been around for longer under various titles. The most commonly reported age was 4 years with the average department age at 7 years. Many population health entities play vital roles within their institutions, setting up practice guidelines for health systems, supporting research missions of clinical departments, as well as educating future clinical providers.
PHLAM members described the multiple, complex relationships established by their departments and suggested that future research should seek insight into the relationships between the population health departments and outside entities, such as community, private and semiprivate organizations, and federally qualified health centers as well as city, county, and state leaders. They also advocated for further research into how their departments can better support educational programming.
Discussion
These findings demonstrate a rapid increase in population health programs in schools of medicine and academic medical centers. Multiple organizational units in the forms of departments, schools, or colleges of population health, centers, and other initiatives have emerged. This reflects a growing recognition of the importance of addressing population health and the need for medical school-affiliated programs to advance education and research to promote the discipline.
In 2019, Gourevitch et al identified 15 departments of population health within 149 accredited US Medical Schools; the 28 departments identified within 154 accredited school in this study represent an increase in departments of population health from 10% of schools to 18% in less than 4 years. 8 The survey described in this article highlights an organic evolution of academic population health with substantial variability across multiple characteristics. However, it also identifies some commonalities that address key institutional priorities.
Academic population health programs find themselves at the intersection of public health and health care delivery—applying the principles of population health to address the health of clinical and nonclinical populations. These programs take on research, service, and teaching activities that often overlap with activities attributed to schools of public health. However, they are distinct in the fact that they align their work with undergraduate medical education, research, and service activities done in collaboration with affiliated academic medical centers. The majority of programs that are not affiliated with schools of public health offer a variety of population health-related graduate training programs.
Academic population health programs are also aligning with health systems. Many health systems encompass Accountable Care Organizations 11 or are engaging in new alternative payment models that focus on the quality and costs of care for defined populations. 12 Although only a minority of departments are providing direct clinical services, population health departments have the potential to provide critical data analytics and technology to support health care delivery and foster the development of true learning health systems. 13
Population health departments provide opportunities for academic medical centers and health systems to align research and development with value-based care. As Jacko et al propose, academic medical centers will need to transition from their traditional focus on biomedical and clinical research to more partnerships with the private sector, service grants at the county and state level, and population health contracts. 14
Department-level collaborations with health systems engaged in value-based contracts could provide critical opportunities for population health departments' sustainability and growth. Operational collaborations between health systems and population health programs could also be strengthened by better integrating population health expertise in implementation science with ongoing needs for quality improvement. 15
Funding and sustainability are critical considerations in the evolution of academic population health. Although only a minority of departments reported that greater than 30% of their budget came from health systems, 85% of respondents reported at least some collaborative relationships with health systems. Effective relationships with providers of medical care may be a source of funding to enhance some programs' success and sustainability.
There was substantial variability across departments in terms of research activities, but most departments had major research efforts with more than half of departmental budgets devoted to research and with the majority of that funding coming from the NIH and other federal sources. At the live forum session, three fourths of the participants reported strong relationships with clinical and translational science awards programs and/or with their cancer centers. Population health departments are uniquely positioned to support such collaborative efforts as many employ educators and researchers with a range of useful expertise in epidemiology, biostatistics, data science, public health, and clinical care.
Although all respondents reported involvement in community activities, departmental revenues from this study were modest. The integration of the social determinants of health into medical care is a new challenge being undertaken by many health care systems, propelled by health inequities made more apparent through the COVID-19 pandemic. Academic medical centers are bridging the gap between community health and medical care to promote socially accountable academic medical centers. 7 These strive to advance education, research, clinical care, and social accountability.
Health systems along with academic population health programs are being challenged to integrate and fund these collaborations with community and public health programs. As academic departments of population health rise to meet this challenge, they will need to identify the resources required to sustain this mission.
This study shows how academic population health can start to address critical needs in under-represented areas. The COVID-19 pandemic has brought to light the need for unified efforts around preventive measures including vaccination as well as further chronic disease management, especially in underserved areas and populations. Successful collaborative efforts among population health departments could provide network to pursue common goals aligned to care for the health of the US population.
As more population health departments are emerging and growing, partnerships with professional societies and national organizations that promote population health could serve to bring member institutions together to collaboratively advance the quadripartite mission. Reducing geographic voids of population health departments and increasing collaborative efforts could significantly impact the reduction of chronic disease and increase coordinated efforts in the management of disease outbreaks as identified with the COVID-19 pandemic.
Limitations
This report has several limitations. The initial search for the departments included in this study focused on allopathic medical schools looking for the word “population” in the title of the department and population health departments with alternative titles may have been missed in this search. Population health departments outside of schools of medicine are emerging and growing; although these programs were largely excluded from this report, they too deserve further study. With new population health-oriented departments emerging at a rapid rate, those departments in the planning stages or recently launched and not mentioned on the school of medicine websites were not included in the results.
In addition, the significant variability among population health departments in schools of medicine and its impact on the quadripartite mission are still evolving. As this mission evolves, future studies will need to examine the impact that academic population health programs can have on their affiliated health systems and the communities that they serve. The categorization of educational activities, particularly in undergraduate education, is still evolving and may not fully capture the breadth and depth of population health educational efforts.
Conclusion
Population health within schools of medicine and academic medical centers is evolving quickly and reflects the growing appreciation of the discipline's importance. Although there is wide variability between programs, common themes help provide a roadmap for successful evolution. Funding and sustainability are critical considerations for the future. Academic population health programs can align with health care systems and communities, and contribute their unique capabilities in education, research, clinical care, and social accountability.
Footnotes
Acknowledgments
The authors thank the following individuals for their contributions to the collection of data and thorough and valuable feedback on the evolution of the article: Dr. Adam Berman (Medical College of Georgia), Dr. Amelie Ramirez (University of Texas Health Science Center at San Antonio), Dr. Andrew Pumerantz (Western University of Health Sciences), Dr. Brad Pollock (University of California, Davis), Dr. Emily Oken (Harvard University), Dr. Eric Schrimshaw (University of Central Florida), Dr. Howard Hu (University of Southern California), Dr. Jonathan Haines (Case Western Reserve University), Dr. Julie Jacko (Nova Southeastern University), Dr. Kirsten Bibbins-Domingo (University of California, San Francisco), Dr. Kristen M. Peek (University of Texas Medical Branch, School of Medicine), Dr. Lesley Curtis (Duke University), Dr. Marc Adams (Arizona State University), Dr. Marc Gourevitch (New York University Grossman School of Medicine), Dr. Mark Wolfson (University of California, Riverside), Dr. Maureen Durkin (University of Wisconsin-Madison School of Medicine and Public Health), Dr. Melissa Bondy (Stanford University), Dr. Navkiran Shokar (The University of Texas at Austin), Dr. Paul McGaha (University of Texas at Tyler), Dr. Thomas Rohan (Albert Einstein College of Medicine), Dr. Tracie Collins (University of New Mexico Health Sciences Center), Dr. Varghese George (Medical College of Georgia at Augusta University), Dr. Winston Liaw (University of Houston), Dr. Celette Sugg Skinner (University of Texas Southwestern Medical Center), Dr. Jeroan Allison (University of Massachusetts Medical School), and Dr. Rainu Kaushal (Cornell University).
Authors' Contributions
Vohra: Conceptualization (lead), Methodology, Data analysis; Rajupet: Writing—original draft (equal); Kaminski: Writing—original draft (equal); White: Data curation (lead); Fagerlin: Conceptualization, Writing—review and editing; Ellerbeck: Conceptualization; Data analysis (lead); Writing—review and editing.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.