Population Health What it is and its Potential for Fixing what Ails America
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- Myra Carson
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1 Population Health What it is and its Potential for Fixing what Ails America Health Expenditure Per Capita $10,000 $9,000 $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $ United States Canada Sweden Japan Germany United Kingdom Brazil Argentina Panama Mexico The World Bank Data for
2 US Health Care Unit Pricing Is Much Higher Non clinical Sources of Waste Exceed Clinical Sources US National Health Care Expenditures, By Year as % of GDP Source: Berwick, D. M. et al. JAMA April 11,
3 Supply Side Issues Cost System Inefficiency Pricing Fraud/Abuse Cost of Chronic Disease/Health Risks Many Preventable 84% of health care spending for 50% of the population with 1 or more conditions Heart disease/stroke 2010 $315B, $193B direct 2012 estimated cost for diabetes $245B ($175 direct/$69 indirect) Obesity costs 2008 $147B Cost of smoking $289B annually Cost of too much alcohol $223.5B or $1.90 a drink Source Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Aged 18 Years or older Obesity (BMI 30 kg/m 2 ) No Data <14.0% % % % >26.0% Diabetes No Data <4.5% % % % >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at 3
4 LifeStyle and its Impact The United States Centers for Disease Control and Prevention has found that: 80% of Heart Disease and Type II Diabetes as well as 40% of Cancer are Preventable if people just:» stopped smoking,» ate healthy and» exercised The Triple AIM Improving the US health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an integrator ) that accepts responsibility for all three aims for the population. The integrator s role includes at least five components: partnership with individuals and families, redesign of primary care, population health management, financial management and macro system integration. Source Donald Berwick, Thomas W. Nolan, John Whittington, The Triple Aim: Care, Health and Cost, Health Affairs, Vol. 27, Number 3 (2008); p Movement in Payment Structures From Volume to Value 4
5 Population Health the health outcomes of a group of individuals, including the distribution of such outcomes within the group (Kindig and Stoddart 2003) One Definition of Population Health Management A population health management program strives to address health needs at all points along the continuum of health and well being through participation of, engagement with and targeted interventions for the population. The goal of a population health management program is to maintain or improve the physical and psychosocial well being of individuals through evidence based, cost effective and tailored health solutions. Source: Care Continuum Alliance, Outcomes Guidelines Report, Vol. 5, The Continuum of Care 5
6 Health is more expansive than Healthcare People believe personal and social behaviors shape health most Source Edelman Health Barometer 2011 Population Health Management Framework Source: Care Continuum Alliance, Outcomes Guidelines Report, Vol. 5, PHM Objectives in each of 6 Steps Example Provider Organization Source: A Population Health Guide for Primary Care Models Population Health Alliance publication 6
7 HIT Framework Regional Data Liquidity ACOs, HIEs, RHIOs* Systems and Person Level Databases EHR, Lab and Claims Processing Systems* Rules Engines, Decision Support Tools, Intervention Level Databases* Infrastructure and Services Home Health Hubs, PHR, Monitoring Devices* Communication Enabling Devices End User Medical Devices Cell Phones, Smart Phones, IVR, ipads, Personal Computers, Digital TVs* *Examples only, not meant to be all inclusive Source: Care Continuum Alliance, Outcomes Guidelines Report, Vol. 5, Touch the most people or the most cost? 4% 13% 60% Cost Complex Case Management High complexity patients Chronic Condition Management High risk patients 43% 40% (% of Population) 20% Cost 20% Cost Selt treatment Patients with moderate risk Wellness & Prevention Patients with low risk Source: Kaiser Permanente and La Fe Hospital data Can the Healthcare System fix this? 7
8 Some Other Issues Just 38% of US Hospitals and health systems indicated that population health tools were in place in their organization. (1) Are Providers the Right Leaders for Population Health? Total Population Health versus Population Medicine (Kindig) The Long Tail of Risk (1) 26 th Annual HIMSS Leadership Survey leadership survey The Next Phase of Population Health Engaging a population not a slam dunk 8
9 Assessment Mobile Technology Gathering real time data on an individuals health and activity Stratification Machine Learning and Big Data integrating social data with clinical and claims Not just stratified on clinical risk, but on behavior to create an impactable risk measure, in order to answer: Who is more likely to accept a home visit for an assessment Who is more likely to sign up for hospice Likelihood of hospitalization or 30 day readmit Interventions This area has incredible potential when leveraging big data machine learning and behavioral economics, but lagging the assessment and stratification innovations Examples: Using mobile technology for Geo fencing for a recovering alcoholic the app automatically calls their sponsor Avatar based counseling Gaming and gamification Tele monitoring Face to face 9
10 Creating Communities of Health Blue Zones Clinton Health Matters Initiative The Way to Wellville Prevention Partners Summary Population Health is part of the solution Early financial savings on improving the operations of the health care system True Population Health is much broader than just care Over the longer term total population health will have a large impact on providers and their success FRED GOLDSTEIN FGOLDSTEIN@ACCOUNTABLEHEALTHLLC.COM 10
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