Population Health Data and Measurement for Health System Planning and Policy Making

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1 Population Health Data and Measurement for Health System Planning and Policy Making Dr. Cory Neudorf Assistant Professor, University of Saskatchewan Chief Medical Health Officer, Saskatoon Health Region May 28, 2013

2 The Triple Aim 1. Improve population health 2. Enhance the patient and provider experience 3. Constrain cost growth

3 Current state Overarching aim: Constraining cost, closely followed by Enhancing the provider experience, and then Enhancing the patient experience (when it gets votes) With the occasional nod to population health,

4 Current state: a focus on costs Why is healthcare costing more and more? healthcare wages rising faster than the average wages, expensive drugs / small marginal return, Unnecessary diagnostic tests, Increasing public and provider expectations for intervention Is there a Healthcare spending crisis? Sustainability of the publicly funded system questioned, but alternatives can cost even more. By what definition? Numerator vs. denominator issues; healthcare as a cost or an investment? Before we measure our performance in achieving the triple aim, we need to reset our sights!

5 Aims out of balance: Cost Experience Cost Population Health

6 Aims out of balance: Experience Experience Cost Population Health

7 Aims out of balance: Population Health Experience Cost Population Health

8 Pursuing the triple aim: Measuring progress, performance and outcomes in balance! Need to have all three aims in balance, and protect that balance, then decide how big the funding pot is that we are prepared to give to decide on the size of the target (amount of total funding we are prepared to spend in balance)

9 Balancing the aims: Then deciding on total investment Experience Cost Population Health

10 What does this look like? Health should lead by example in our policies, balancing fiscal responsibility, patient and staff needs and social responsibility to achieve better health for all: e.g. What if salaries in healthcare were at least the level of the living wage, not just minimum wage? (vs pressure to contract out to lower labor costs without an assessment of the effect on employees lives) What if health worker pay across all disciplines stopped increasing faster than the rest of the market? What if physicians were more responsible in ordering tests and drugs, being aware of the opportunity costs on the rest of the healthcare system from unnecessary testing? What if we funded the system starting with evidence-based preventive and primary care, adding interventional care according to how much society is willing to pay, including advances in new drugs, equipment and tests What if we monitored and evaluated health spending as an investment in society s health and well-being based on outcomes and evidence?..etc

11 Population health data for health system Levels of use: planning and decision-making 1. At the program/department level: For planning and monitoring quality of disease prevention and health promoting programs and services 2. At the system planning / quality improvement level: For planning and monitoring quality of treatment and rehabilitative programs and services 3. At the Senior Leadership / Strategic level For planning and prioritizing health system programs and services Neudorf C. Integrating a population health approach into healthcare service delivery and decision-making. Healthcare Management Forum. 2012: 25(4)

12 Population Health Monitoring Activities Activity Purpose Format / Infrastructure requirements Health status monitoring and selected topical in depth reports for monitoring the health of the population and recommending areas of relative need for program and policy change Reports, web resources Population Health analyst capacity (Unit, Observatory) Health system performance monitoring to monitor quality of care across all dimensions, and ensuring a balance between needs of the patient, providers, and population at the best value for money Quality reports, performance dashboards, indicators and targets Health equity audits - to ensure no sub group is being left behind in our efforts above Audit tool and resource kit on how to apply it, data stratified by SES, gender, ethnicity, age, etc Health (and health equity) impact assessment of health and other policies - to ensure we are not compromising our standards and ethics in an effort to pursue any one of the triple aims out of balance, or sacrificing health on the altar of healthcare Health (Equity) Impact Assessment tools, and training as to their systematic use by senior management and funders

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15 Population Health Monitoring Activities Activity Purpose Format / Infrastructure requirements Health status monitoring and selected topical in depth reports for monitoring the health of the population and recommending areas of relative need for program and policy change Reports, web resources Population Health analyst capacity (Unit, Observatory) Health system performance monitoring to monitor quality of care across all dimensions, and ensuring a balance between needs of the patient, providers, and population at the best value for money Quality reports, performance dashboards, indicators and targets Health equity audits - to ensure no sub group is being left behind in our efforts above Audit tool and resource kit on how to apply it, data stratified by SES, gender, ethnicity, age, etc Health (and health equity) impact assessment of health and other policies - to ensure we are not compromising our standards and ethics in an effort to pursue any one of the triple aims out of balance, or sacrificing health on the altar of healthcare Health (Equity) Impact Assessment tools, and training as to their systematic use by senior management and funders

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19 Population Health Monitoring Activities Activity Purpose Format / Infrastructure requirements Health status monitoring and selected topical in depth reports for monitoring the health of the population and recommending areas of relative need for program and policy change Reports, web resources Population Health analyst capacity (Unit, Observatory) Health system performance monitoring to monitor quality of care across all dimensions, and ensuring a balance between needs of the patient, providers, and population at the best value for money Quality reports, performance dashboards, indicators and targets Health equity audits Health (and health equity) impact assessment of health and other policies - to ensure no sub group is being left behind in our efforts above - to ensure we are not compromising our standards and ethics in an effort to pursue any one of the triple aims out of balance, or sacrificing health on the altar of healthcare Audit tool and resource kit on how to apply it, data stratified by SES, gender, ethnicity, age, etc Health (Equity) Impact Assessment tools, and training as to their systematic use by senior management and funders

20 HCEA cycle Analyse disparities in access and outcome by various dimensions (gender, geography, age, ethnicity) Compare with measurement of relative need or morbidity to determine if inequities exist Prioritize areas for quality improvement (areas of greatest concern or greatest potential gains to be made) Triangulate results from the literature, quantitative analyses and focus groups, surveys on ways to remove barriers for patients, providers and system issues that may be responsible for inequities Initiate QI projects and evaluate impact on reducing the gaps

21 Health Care Equity Audit: Immunization Measure Impact and Amend intervention Problem Low Immunisation rates Core Neighbourhood Implement Phone based reminder system for parents Lit Review Of evidence and best practice +Parent survey

22 Population health data use and challenges Population Health Data Use Challenges and solutions Health system performance indicators e.g. -avoidable (preventable, treatable) mortality or PYLL, -life expectancy or HALE, -stratification of many access and outcome indicators by social determinants of health Target programs and services to sub group needs and incorporate prevention and promotion components in all parts of the health system. Community needs assessments, eg for use in community oriented primary care Population Health data use required for health system strategic planning process (environmental scanning, department planning) for accreditation - Health administrative data not routinely stratified by SDOH - Population health indicators such as PYLL, avoidable mortality and HALE not routinely produced at RHA level - Ask stratification questions (on SDOH and health behaviours) to patients in all areas of care and treatment to allow for healthcare equity assessment and providing health promotion services in all parts of the system. See example in Toronto hospitals - Most primary care not set up in this manner - Templates of standard information requirements needed - Capacity for providing data on catchment populations lacking in most jurisdictions - Variability in capacity to acquire and use this information in all parts of the health system

23 Population health data use and challenges Population Health Data Use Challenges Incorporate population health and prevention concepts into criteria used in prioritization processes for investment or reductions Use Population health forecasting tools (e.g. Micro simulation modeling, trend analysis, projections) for long term planning and deciding about relative investments and opportunity costs - Relative weighting of competing criteria can bias against prevention initiatives even when included in criteria - Unlinked planning and budget cycles work against best laid plans to invest in prevention and promotion - Lack of capacity in most RHAs to use these tools - Often not user friendly for decision makers - Lack of awareness about their utility and availability Apply population health perspectives to health system problems - Not all senior leadership teams include a population health specialist - Not all population health specialists are trained to think system wide

24 From: Tian, Y Evaluating the Effectiveness of Contact Tracing on Tuberculosis Outcomes in Saskatchewan Using agent Based Modeling

25 Population health data use and challenges Population Health Data Use Challenges Incorporate population health and prevention concepts into criteria used in prioritization processes for investment or reductions Use Population health forecasting tools (e.g. Micro simulation modeling, trend analysis, projections) for long term planning and deciding about relative investments and opportunity costs - Relative weighting of competing criteria can bias against prevention initiatives even when included in criteria - Unlinked planning and budget cycles work against best laid plans to invest in prevention and promotion - Lack of capacity in most RHAs to use these tools - Often not user friendly for decision makers - Lack of awareness about their utility and availability Apply population health perspectives to health system problems - Not all senior leadership teams include a population health specialist - Not all population health specialists are trained to think system wide

26 Individual and Population / Social level questions Smoking Individual How can we stop these individuals smoking? Population / Social How can we change the social & economic environment so it discourages smoking? Childhood Obesity How can we encourage obese children to lose weight? What social and economic factors mean our community has higher rates of childhood obesity than others? Depression How do we best counsel teenagers with depression? Why have rates of teenage depression gone up in our community in the last 10 years? What can be done to change this across the community? Homelessness How can we provide a home to a homeless person? How can we design a housing system which ensures no one is homeless? Drug Use How can we educate people to use substances responsibly or abstain? What legislation and policies can we adopt to reduce harm from drugs? After Tesh, 1988 Hidden Arguments, as presented by Fran Baum

27 Next steps Improve healthcare collection, monitoring, reporting and use of population health data by the whole health system (relatively small investments in analytic capacity and data systems) for planning and evaluation Broad application of all elements of health promotion by Public Health (and board/administration support even when doing so gets uncomfortable!) Incorporate more health promotion / prevention in primary care (individual, group and population based) Adopt health promoting hospitals standards in our acute care centres * Advocacy for improvements in social determinants of health and health equity by health system leaders and providers A society (or health system?) is judged on how it treats its most vulnerable see WHO Europe project on integrating health promotion into hospitals and health services at: data/assets/pdf_file/0009/99801/e90777.pdf