Population Health in the Affordable Care Act Era
by Michael A. Stoto, Ph.D.
February 21, 2013
2 Population Health in the Affordable Care Act Era
The phrase “population health” is increasingly used by researchers, practitioners, and policymakers in health care, public health, and other fields. Although their understanding of this phrase differs,
many see attention to population health as a potent opportunity for health care delivery systems, public health agencies, community- based organizations, and many other entities to work together to improve health outcomes in the communities they serve. To explore these possibilities and to identify the organizations’ potential contributions and role in advancing the evidence base for population health policy and practice, AcademyHealth is convening an exploratory meeting to identify specific activities, programs, and partnerships to develop and/or pursue to support research and translation activities in this area.
As a starting point for the discussion, this background paper draws on a scan of the policy, practice, and research environment to identify the many distinct but overlapping meanings of population
health, identify their commonalities, and suggest a research agenda for the field and opportunities for AcademyHealth. I hope that all meeting participants see their own ideas about population health represented in this paper while discovering other interpretations and perspectives. Comments are, of course, welcome, especially regarding any misinterpretations and missing activities.
Differences and Commonalities in the Definition of Population Health Population health was defined by Kindig and Stoddart (2003) as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” I have emphasized the word “outcomes” to make the point that the definition focuses on the implicit goal of improving health outcomes. Jacobson and Teutsch (2012) propose a similar goal, with the term “total population health” defined by geographic areas.
Berwick and colleagues (2008) identify “improving the health of populations” as one element in the Institute for Healthcare Improvement’s (IHI) Triple Aim for improving the U.S. health care system (the other two elements call for improving the individual experience of care and reducing the per capita costs of care for populations). Similarly, “better health by encouraging healthier lifestyles in the entire population, including increased physical activity, better nutrition, avoidance of behavioral risks, and wider use of preventive care” is one of three elements of the Center for Medicare & Medicaid Innovation’s mission. This formulation suggests that population health is instrumental as a means to improving the health care system rather than the end goal.
Dunn and Hayes’s (1999) definition focuses on measurement, not only of health outcomes but also of the factors that influence them:
“The health of a population as measured by health status indicators and as influenced by social, economic and physical environments, personal health practices, individual capacity and coping skills, human
biology, early childhood development, and health services.”
Young’s (2005) definition identifies population health as a “conceptual framework for thinking about why some populations are healthier than others,” as well as the policy development, research agenda, and resource allocation that flow from it. The “health in all policies” approach, which encourages policymakers to weigh the health implications of policies that are not normally considered health related (Bostic 2012), is consistent with this definition of population health.
Some view “population health” as a more modern version of “public health,” which itself may be a goal (improving the health of the public), an instrument (governmental public health agencies), a measurement
system, and a conceptual framework that undergirds a profession and
a scientific field. Population health differs from public health, at least
perceptually, in at least two respects. First, it is less directly tied to governmental
health departments. Second, it explicitly includes the health
care delivery system, which is sometimes seen as separate from or even
in opposition to governmental public health.
The different concepts of population health fall along a spectrum,
depending in large part on where one starts. At one extreme, the
focus is on health outcomes in populations defined by geography or
similar factors. County health officers, for instance, are interested in
the “total population health” (borrowing from Jacobson and Teutsch
2012) of the county they serve. These outcomes are determined
by various factors, including services that the health department
provides. This perspective is reflected in the County Health Rankings
as well as in the National Association of County and City Health
Officials’ (NACCHO) Mobilizing for Action through Planning and
Partnership (MAPP) model. At the other extreme, “population
health” refers to accountability for health outcomes in populations
defined by health care delivery systems such as health plans or
Accountable Care Organizations (ACO).
Recognizing this accountability leads providers to address upstream
factors such as health promotion and care coordination that influence
health outcomes in “their” population. Similarly, Chang (2012)
describes the potential for population health integrators, which are entities
that serve a convening role and work intentionally and systemically
across various sectors to achieve improvements in health and well-being
for an entire population in a specific geographic area. “Population
management” of patients with one or more chronic diseases is a related
concept. In this use, population health improvement emphasizes the
central role of the primary care provider, a fully engaged and activated
patient, and care coordination (Nash 2012).
Despite the above differences, the concepts embody a number of commonalities
in what might be called the population health perspective.
First, population health is seen as more than the sum of individual
parts or a cross-sectional perspective. Upstream factors are included
in the measurement of population health, for instance, not just health
outcomes. The goal of reducing disparities and inequities—explicit
in Kindig and Stoddart (2003) and implicit in other definitions—is
another example of population health’s holistic focus.
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Population Health in the Affordable Care Act Era
Second, the population health perspective requires the consideration
of a broader array of the determinants of health than is
typical in either health care or public health. This is illustrated by
the elements of the IHI composite model (Stiefel and Nolan 2012)
reproduced in Figure 1. In particular, it is important to note the
emphasis on health promotion and disease prevention as well as on
interventions focusing on upstream factors rather than outcomes.
Unlike some models of public health, however, Stiefel and Nolan’s
perspective recognizes the role of health care and of personal prevention
services as part of the population health production system.
Third, the population health perspective recognizes that responsibility
for population health outcomes is shared but that accountability is diffuse.
Shared responsibility arises from the many upstream factors that
influence population health and the opportunities to address them.
Diffuse accountability, on the other hand, reflects the reality that,
although there are many possibilities for upstream interventions, the
entities that take them on vary from community to community. To
improve population health, communities must establish and nurture
partnerships that include but go beyond state and local public health
agencies and health care delivery systems. And this broad system of
partners must share data and adopt a systems focus that identifies
accountability for and measures contributions to population health
outcomes (IOM 1997, 2010, 2012).
Taken together, these characteristics point to the importance of
an epidemiological approach to managing population health that
includes measuring inputs and outcomes, understanding how
they are related, and setting priorities that consider population
health production function. As a result, measurement is a fundamental
aspect of the population health perspective. Expanding on
Stiefel and Nolan’s (2012) point in the new IHI white paper titled
“A Guide to Measuring the Triple Aim,” health care organizations,
public health departments, social service entities, school systems,
and employers must cooperate because no single sector alone has
the capability for successfully pursuing the improved health of a
population; indeed, such cooperation requires an integrator that
accepts responsibility for the health of the population. With an
appropriate governance structure, the integrator should lead the
establishment of a clear purpose, the identification of a portfolio
of projects and investments to support that purpose, and the creation
of a cogent set of high-level measures to monitor progress.
The set of measures should operationally define each dimension
of population health. Yet, measurement of the factors that influence
population health outcomes is challenging and an area where
research is needed.
Phy sical
Environment
Medical
Care
Socioec onomic
Factors
Mortality
Health and
Function
Resilience
Well-Being
Dise ase
and Injury
Prevention and
Health Promotion
Upstream Individual Intermediate S t a t e s of Health Quality
Factors Factors Outcomes of Life
Genetic
Endowment
Spirituality
Behavioral
Factors
Physiologic
Factors
Equity
Interventions
C
M
Y
CM
MY
CY
CMY
K
Figure 1. IHI Population Health Composite Model
Source: Adapted from Stiefel M, Nolan KA. Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper.
Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. (Available on www.IHI.org)
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Population Health in the Affordable Care Act Era
Population Health in the Affordable Care Act
The passage of the Patient Protection and Affordable Care Act
(ACA) addresses population health in four ways. First, provisions to
expand insurance coverage (the individual mandate, Medicaid expansions,
state insurance exchanges, support for community health
centers, for instance) aim to improve population health by improving
access to the health care delivery system, which is a critical component
of a community’s population health production system.
Second, other provisions aim at improving the quality of the care
delivered (National Strategy for Quality Improvement, CMS Center
for Medicare and Medicaid Innovation, and establishment of the
Patient-Centered Outcomes Research Institute).
Third, less well-known provisions of the ACA seek to enhance
prevention and health promotion measures within the health care
delivery system. Perhaps the biggest change is the promotion and
implementation of ACOs to incentivize providers to take responsibility
for population health outcomes. Also included are the expansion
of primary health care training, requirements that private
health plans and Medicare provide specific preventive services recommended
by the U.S. Preventive Services Task Force without cost
sharing, that Medicare provide for an annual wellness visit, and that
Medicaid expand the provision of preventive services for children,
as is currently the case, to adults.
Fourth, the final set of provisions aims at promoting communityand
population-based activities, including the establishment of the
National Prevention, Health Promotion and Public Health Council,
which has already produced the mandated National Prevention Strategy
(DHHS 2011) as well as a new Prevention and Public Health Fund
(authorized at $1 billion in fiscal year 2012) and funding for Community
Transformation Grants. The ACA also provides incentives for
workplace wellness programs in the form of grants to small businesses
to develop comprehensive wellness programs and insurance discounts
for employees participating in wellness plans.
Community Health Needs Assessments
The ACA also adds a new IRS requirement that has the potential
to leverage the strengths and resources of both the health care
and public health systems to create healthier communities (Kuehnert,
2012). First, hospitals must conduct a Community Health
Needs Assessment (CHNA) once every three years. These reports
must describe the community served, identify existing health care
resources, and prioritize community health needs. Hospitals must
also develop an implementation strategy to meet the needs identified
through the CHNA.
Similarly, the Public Health Accreditation Board (PHAB) calls on
health departments seeking accreditation to participate in or conduct
a collaborative process resulting in a comprehensive Community
Health Assessment. Other PHAB standards require that health
departments conduct a comprehensive planning process resulting in
a “community health improvement plan,” assess health care service
capacity and access to health care services, identify and implement
strategies to improve access to health care services, and use a performance
management system to monitor achievement of organizational
objectives.
Thus, although they use different terminology, both the IRS requirements
and the PHAB standards similarly call for two different
sets of population health measures: (1) measures of population
health outcomes for which healthcare providers, public health
agencies, and many other community stakeholders share responsibility,
and (2) performance measures capable of holding these same
entities accountable for their contributions to population health
goals. (This distinction was articulated in Improving Health in the
Community (IOM, 1997).
The challenge of managing a shared responsibility, however, is that
given the broad range of factors that determine health, no single
entity can be held accountable for health outcomes. Identifying
accountability for specific actions is an essential component of both
the Community Health Improvement Plan required by the IRS and
the comprehensive planning process in the PHAB standards. To
address this, Improving Health in the Community (IOM, 1997)
suggests that a Community Health Improvement Process (CHIP)
identifies specific activities to be conducted by entities in the community
(public health, health care providers, employers, schools,
and so on) that contribute to overall community health goals.
Moreover, communities should develop a set of valid and actionable
performance measures to ensure that these entities are held
accountable for their activities.
Both improvement plans and their associated performance measures
must be tailored to a community’s health needs, the resources
that are available, and the actions that healthcare providers, health
departments, and other entities are willing to take and be accountable
for. For the Public’s Health: The Role of Measurement in Action
and Accountability (IOM 2010) lays out a very useful “Framework
for Accountability” and suggests specific measures and the
stakeholders (or accountable entities) associated with them. This
approach can be a useful starting point for non-profit hospitals
looking for measures of their contributions to the community to
begin the implementation strategy required by the IRS regulations,
as well as health departments seeking measures for their community
health improvement plans as part of PHAB accreditation.
A Research Agenda for Population Health
As a starting point for discussion, this environmental scan suggests
four areas where research and measure development are needed to
advance the practice of population health.
First, additional research is needed to provide evidence establishing
that upstream interventions (as opposed to changes in personal risk
factors) have a positive influence on health outcomes. For example,
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Population Health in the Affordable Care Act Era
the relationship among physical activity, obesity, and diabetes is
reasonably well established. As both health care and public health
increasingly emphasize evidence-based practice, policymakers and
managers need to know, for instance, whether providing sidewalks
and recreation facilities leads to more physical activity and less
obesity and eventually improved health outcomes and even reduced
health care costs. Decision makers also need to know what works
for whom in what context given the wide variations in U.S. communities
and populations (Bethell 2009). Health researchers typically
assess health risks at the individual level with epidemiological
studies and the impact of patient-level interventions in randomized
clinical trials (RCT), but new methods need to study the impact
of upstream population-level interventions on population health
outcomes. Without the ability to randomize at the individual level,
new methods must be capable of rigorous analysis of natural and
quasi-experiments and other observational approaches and qualitative
and mixed-methods approaches such as realist evaluation.
Adopting the population health perspective surfaces a number of
important conceptual issues in measurement that must be addressed
and clarified. Organizations such as the Agency for Healthcare
Research and Quality (AHRQ) and the National Quality Forum
(NQF) rely on well-developed concepts of quality and performance
measurement for health care service providers, but efforts to translate
such concepts to population health settings are just beginning. One
aspect of this involves the identification of the relevant “denominator,”
for instance, going from patient encounters in a fixed time period
to enrolled populations to geographically defined populations. More
conceptually, in the context of shared responsibility for population
health outcomes, measures that clarify accountability for actions are
needed (IOM 1997, 2010). In measuring health outcomes associated
with health care organizations, methods for and the appropriateness
of risk adjustment is reasonably well understood. How do these issues
play out in the context of shared responsibility for population health?
Appropriate measures of health disparities, and of success in reducing
disparities, are also needed (Kindig, booklet).
The converging interest of health care providers in addressing population
health and of official health departments in engaging with
providers also raises a number of practical measurement issues.
One issue is the challenge of overlapping population definitions.
How should populations be defined to encourage collaboration between health care providers and public health when a metropolitan area accounts for several ACOs or ACOs cover several political
jurisdictions? Similarly, recognition of a shared interest in population
health, and the encouragement provided by the Office of the
National Coordinator for Health IT’s “meaningful use” standards,
often requires merging existing electronic data in different formats
from providers and public health sources (IOM 2012). This in turn
surfaces a number of complex data governance issues (ownership,
privacy, confidentiality and so forth) that must be addressed.
The final research opportunity that I would highlight derives
from the confluence of the new IRS requirements for non-profit
hospitals and the development and implementation of the PHAB
standards. Together, these requirements provide an important
opportunity to operationalize the types of partnerships and collaboration
needed for population health. Many communities in the
United States are currently engaged in these activities, and no doubt
some hospitals and health departments have found ways to collaborate
effectively. Research is needed, however, on how to measure
population health in this context and to identify effective models
for collaboration to improve population health.
About the Author
Mike A. Stoto, Ph.D., is a professor of Health Systems Administration
and Population at Georgetown University and a senior scholar
in residence at AcademyHealth.
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