A Tale of Two Health Systems

What does “population health” mean to you?

If you are a health care provider in a clinical setting, such as an emergency department or specialty practice, it probably means the health status and outcomes of a group of individual patients being treated for various medical conditions.

If you are a public health professional within the government public health system, population health might have another meaning: the health of populations across an entire geopolitical jurisdiction seen through the prism of disease prevention and health promotion strategies.

The difference between these two perspectives speaks to the fragmented system of health improvement in our country, and how each community sees the “patient” differently. Clinicians tend to think of patients as the individuals they are treating for a specific medical condition. Public health providers, however, are likely to focus their efforts not only on the individual, but also on the family and the community, with the added dimension of the “upstream” determinants of health, including the social, environmental, and behavioral factors that play a role in both the disease process and disease prevention.

A unified approach of these two perspectives is required to achieve the vision of a society of all people living long, healthy lives, as set out by the US Department of Health and Human Services’ Healthy People 2020 initiative. This is precisely the idea behind the Measure Application Partnership  (MAP), convened under the auspices of the National Quality Forum (NQF), a public-private partnership of stakeholder groups that review health performance measures for potential use in federal public reporting and performance-based payment programs. MAP’s Population Health Task Force, which I chair, is charged with identifying a “family” of aligned measures that span programs and care settings, and which relate to the triple aim of improving the overall quality of care, reducing the cost of care, and supporting proven interventions to address the behavioral, social, and environmental determinants of health. This vision was laid out by HHS in its 2012 report to Congress, National Strategy for Quality Improvement in Health Care.

Here is how it might look in practice. A group of hospitals conducts a community assessment in a particular geopolitical area based on the family of aligned measures selected by the NQF. Public health and medical record databases are correlated to produce a snapshot of such health indicators as diabetes, obesity, smoking rates, and hypertension. The clinical care community implements evidenced-based strategies targeting sub-populations of at-risk patients requiring more focused medical and pharmacologic interventions. In parallel with these efforts, the governmental public health community begins to work on the social, economic, environmental, and behavioral determinants of these health conditions.

One of the challenges the task force faces is that clinical, evidence-based measures of health determinants are more advanced than those underlying or intensifying predispositions to particular diseases or conditions. For example, we have good studies on the efficacy of administering beta-blockers to a patient undergoing heart failure, but we have much to learn about effective environmental, behavioral, and social interventions that could prevent the cardiac episode in the first place.  Another challenge is funding.  Historically, the public health sector has had to function on a very tight budget, receiving far less support than its clinical care counterparts. This has meant that, for instance, many county health departments have had to limit themselves to simply treating patients after the fact, often forfeiting important initiatives as obesity prevention programs. And while clinical-care data collection has made important strides due to a focus on patient safety and reducing hospital costs, a similar emphasis on measuring the effectiveness of public health performance is only now emerging around such topics as obesity prevention, tobacco control, and infectious disease.

HHS has given NQF more than200 measures to review for possible use in 20 federal health care programs. Aligning these measures into “families” reflecting quality of care, cost of care, and health improvement for entire populations is a daunting task. But it also provides an opportunity for the clinical care and public health communities to learn from each other and apply new insights to improving the health of their sub-populations. Linking health behaviors and clinical preventive services within the context of social and physical environments, and recognizing the importance of social and cultural factors will certainly help us better measure health disparities and health equity at the total population and subpopulation levels. 

The findings of the MAP Population Health Task Force will be included in the MAP Families of Measures Report delivered to HHS this summer. If successful, we will have helped create a framework for a sense of shared responsibility that brings together both the clinical care and public health communities. This would represent a small, but potentially important step toward integrating a fragmented health care system for the benefit of individuals, families, and entire communities.