‘Population Health’ shifting healthcare’s focus upstream
By Ed Lane
Dr. Robert J. Esterhay, chair of the Department for Health Management and Systems Sciences in the University of Louisville School of Public Health and Information Sciences, has been involved with healthcare informatics for more than 35 years. His medical school thesis in 1969 – prior to personal computers and the Internet – involved computer-assisted learning using computer-simulated patients for training medical students and faculty.
Dr. Robert Esterhay
In the mid-1970s, he led an early implementation of an electronic medical record information system at the University of Maryland Cancer Center and in the mid-1990s headed a nationwide implementation of an electronic medical record system in 60 long-term acute care hospitals and 300 nursing homes for Kindred Healthcare (formerly Vencor). Esterhay was also instrumental in creating a comprehensive cancer database that continues to be used today. He is a member of the Kentucky TeleHealth Network Board and served as the first co-chair of the Kentucky e-Health Board.
Esterhay describes why and how U.S. medical providers are aligning into networks
Ed Lane: “Population Health” is a new academic and health industry textbook that took more than 21 months to complete using the efforts of a coordinating editorial team and a group of authors from the healthcare, public health and academic communities. As one of its executive editors, could you briefly explain the meaning of the term “population health” and how this shift in perspective affects the nation’s health and wellness?
Robert Esterhay: Not everyone agrees on the meaning of “population health.” If you talk to experts, you will get different definitions. In our book, the editors created a summary of different definitions created by healthcare experts. The conclusion I reached is that population health is a complex ecosystem that involves at least four overlapping components. The first part is consumers or patients. The second part is the healthcare system, with which we’re very familiar and is the focus of the Affordable Care Act (ACA). The third part is the traditional role of public health in the education and safety of our communities. The fourth part is the social policies that influence how this ecosystem operates and interacts with itself.
EL: How do local public health departments and officials enact health-related initiatives to protect individuals?
RE: The traditional departments of health worry about clean water, clean air, restaurant inspections – what would be called traditional public health services. In the past they’ve provided immunizations. Even immunizations today, many of them are no longer done by health departments; they’re done in physicians’ offices or in hospital settings or pharmacies. Pharmacies will also remind you, depending on your age, whether your immunizations are up to date. Health departments no longer provide primary care. The health department’s other big role is educating a population about getting flu shots, exercising, eating correctly and so forth. So the role of the traditional public health department is changing.
EL: One fact in “Population Health” is that in 1900 the world’s population was about 1 billion, while today it’s 7 billion and still growing. What difference do these population shifts make in healthcare?
RE: Poverty is one of the most significant factors with respect to the health of a community or a population. For instance, Louisville has a West End where people are poor, as opposed to the people who live in the East End. People in Louisville’s West End don’t live as long as those in East Louisville. To reflect back upon the world, every community has a West End. In fact, in parts of the world, when you go to a large city, it is only the West End.
If you look at West Africa where Ebola is a problem, those are really poor countries. They don’t have the infrastructure. They don’t have roads and hospitals and healthcare people to provide enough care and support. When the president sends in the military, that’s the only large, mobile group that can get in there quickly and set up hospitals and start to compensate for the lack of infrastructure in West Africa. Every community, for the most part, has a West End, and many global cities are only a West End.
EL: What have we learned from the efforts to create state health information exchanges to collect and share medical data?
RE: We’ve learned that 75 percent of state health information exchanges do not have a sustainable business model and therefore will fail. We’ve seen many of them already shut down and close; others have been moved into other parts of a state’s organization just to keep them going, or they have become Medicaid-only. In Kentucky, the lack of a sustainable business model is a challenge. Kentucky’s health information exchange will have to start charging for its operation, either some sort of membership fee or fees based on transactions. The exchange will end up competing with the private sector, which is building health information exchanges for Accountable Care Organizations. State exchanges won’t be able to compete with the private sector, which is moving much faster.
EL: KentuckyOne Health, which owns Jewish Hospital, St. Mary’s HealthCare, and the Saint Joseph Health System as well as partnering with the UofL Hospital’s James Graham Brown Cancer Center, recently announced that it is operating at a deficit of $200 million a year.
RE: I recall when Norton Healthcare acquired hospitals from Hospital Corporation of America in Nashville; after the acquisition, it took Norton a while to dig out of its debt. It’s also going to take KentuckyOne a while to achieve operational savings. It took Norton several years to improve its bottom line, and KentuckyOne will likely take a similar amount of time.
EL: Humana and Anthem BlueCross BlueShield are two of the largest insurers here in Kentucky. How well are those firms managed?
RE: Humana and Anthem are rapidly adapting to the changes in the healthcare market. They are trying to put the needs of the customer or consumer first. Other large insurance companies like United Healthcare also are consumer-focused and trying to get people more engaged in their own health information. Managing a person’s personal health information, aggregating all the information and monetizing these services will create new businesses, new ways of thinking and new opportunities.
EL: How is the Affordable Care Act causing changes with new programs that affect how we access, pay for and assess the quality of healthcare services in the United States?
RE: Most people need to realize that the ACA is predominantly about insurance reform. It has not very much to do with healthcare itself. And it’s being implemented over a period of time; it’s very complex, and people don’t understand all the pieces and parts.
Consumers are happy with some benefits of the ACA: You can’t be denied coverage if you have an existing precondition; your child can remain on your insurance plan up to the age of 26; and some wonderful prevention and screening coverages are provided. There’s a lot that people don’t like about the ACA: Consumers are upset with the individual mandate; basically if you don’t have insurance coverage you’re going to pay a penalty or a fee.
The Supreme Court upheld the legality of the mandate. The mandate resulted because healthcare costs are exploding at a tremendous rate. In retrospect, when the cost of healthcare gets to a point people cannot tolerate, then the federal government creates legislation to do something about it. Over a long period of time, you can see it’s a cycle, like a sine wave. Costs go up, the government responds, the government does something and the cost of care comes down a little bit. But what people don’t understand is that, overall, the cost of care continues to increase no matter what. The challenge is, can the rate at which costs are escalating be decreased?
As part of the ACA, the Center for Medicaid and Medicare Services (CMS) set up an innovation center with the idea of creating accountable care organizations and how providers charge patients for their care. The idea is to move from paying a fee for each provided service into what’s called bundled pay. Healthcare providers achieve efficiencies by bundling all the costs of an episode of care, which actually brings down the cost of that care. It’s very difficult for large businesses to figure out how to do bundled payments based on an entire episode of care over time. It’s very challenging for the healthcare business environment to figure out how to move from service reimbursement to bundled. Most everyone is still using fee-for-service compensation.
EL: Recent national news is covering the Ebola epidemic in Africa and incidents of U.S. healthcare workers being infected. This very dangerous communicable disease and related media hype have the American public concerned about a major epidemic in the United States. How concerned should Americans be in regard to an Ebola outbreak?
RE: It’s unlikely there will be an outbreak of Ebola in this country. The people who get Ebola are healthcare workers, and the healthcare workers who most frequently get Ebola are nurses, because they are the ones taking care of the sick. As you mentioned, the news media hyped Ebola, got the public fearing it, and some very inappropriate things have been done because people are frightened. A person’s chance of being struck by lightning is actually greater than the chance of contracting Ebola in the United States right now. You’re much more likely to die from influenza, and yet a significant number of people don’t get their flu shots.
EL: According to the Centers for Disease Control (CDC), approximately 36,000 people in the United States die of flu each year.
RE: Yes. Influenza and Ebola are totally different. You can’t even compare them. The media doesn’t make a big deal about 30,000 people dying from flu. People are not afraid of flu because they know what happens to people who have flu. The American public doesn’t react to flu the same way it is currently reacting to Ebola. It’s really amazing.
EL: What are the stated goals of “Healthy People 2020”?
RE: The goals of “Healthy People 2020” are quite different from the Affordable Care Act. The 2020 goals are basically saying that this is where we are now statistically with respect to heart disease or Type 2 diabetes in this country, and this is what we should try to achieve by 2020. Those become measures of indicators of population health.
In addition to looking at health statistics, the other question raised in that 2020 report is the whole idea of looking at the social determinants of health: having a job, a good education, transportation, those criteria that actually say more about a person’s health than all the healthcare services in the world. Remember, in many other countries that don’t have an expensive healthcare system, people live longer and are healthier than people in the United States, which is ranked around 34th on the list with respect to health indicators. Those countries don’t have an expensive healthcare system and yet they do better than we do. Now why is that?
EL: Because some Americans are living in poverty?
RE: Yes. The United States has a very large population that lives in poverty. When you look at healthcare averages, you’re not looking at the distribution of population and what’s really going on. Averages don’t give you a true picture. Ron Crouch, who wrote the chapter on demographics, pointed out that, yes, Americans are living longer, and the U.S. population is becoming more diverse, and it’s distributed in an interesting way. If you look at a spatial map of the United States and look at the distribution of the population, it’s amazing that it’s not uniform. Poverty in America is increasing, the middle class is declining in size, and there are tremendous implications for healthcare services when you look at these data.
EL: One of the other sections in the book discusses the mechanisms that are needed to control and lead a network.
RE: There’s a book that we reference in Chapter Two, which Dr. Judah Thornewill and I wrote. In fact, we created a course called Network Leadership. Network leadership is very different than organizational leadership. When you are in charge of a network, you behave differently. You just can’t demand people to do things like you can if you’re the leader of an organization. You have to understand that there’s an interplay of power, control, money and trust. And unless you’re trusted in a network, you really can’t achieve much.
In the book that Mike Leavitt and Rich McKeown wrote called “Finding Allies and Building Alliances,” they make the point that if you want to create an alliance, which is a network, the best way to do it is if there’s a common problem that’s causing everyone pain – and if everyone realizes that they can’t solve the problem themselves but have to work together to solve it. And what makes that work often in a community is someone who has – we call them a convener of stature, or a convener of importance. Somebody whom the community respects and to whom people will listen.
EL: You mention in the book having many links within a network in order to build trust and leadership.
RE: Leaders have to build relationships. It’s all about relationship building. You have people who can build relationships very well within an organization; you also have people who can bridge and build relationships with the external community. It’s really about building the social capital that’s required in a community to get large projects done, that will have significant impact on the community. Health fits into that category; population health fits into that category.
You can destroy trust in less than half a second by saying something that undermines everything you’ve tried to accomplish. You have to realize as leader of a network that you can destroy trust. What takes years to build can be destroyed in an incredibly short period of time.
EL: Two facts in the book stood out in terms of demographics. One was fertility rates are declining worldwide, and the other was that population growth is not due to increased fertility but to increased longevity.
RE: Right. The U.S. “population pyramid” (oldest age cohorts at the top, youngest at the bottom) doesn’t look like a pyramid anymore; it looks like a box or a trapezoid at best. In terms of world population, the UofL School of Public Health is in negotiations to establish a program with the University of Lahore in Pakistan and will create a satellite campus 8,000 or so miles away. Pakistani students will earn a University of Louisville degree, a master’s in public health. That’s underway. You look at the population pyramid of Pakistan and compare it to the United States, and they have what looks like a pyramid because they don’t live as long and their fertility rate and childbirth rates are far greater in comparison to the United States. So Pakistan has a true age pyramid. Their biggest challenge is child and maternal health. In the United States, our biggest healthcare challenge isn’t child and maternal health; it’s our aging population.
EL: Is there a differential in the U.S. population growth rate of different races?
RE: As pointed out in the book, most of the birthrates are higher in the immigrant population that have come to our country, and that rate is much higher than it is for the population that’s been in this country for generations. So if you’re looking at race – the immigrant population and the poor population – the fertility rates are greater than they would be in the corresponding white population. There is a definite difference.
EL: “Population Health” says, “The current system of healthcare cannot continue to focus on caring for people after they are ill. The system must focus on disease prevention, chronic disease management, and health outcomes for individuals, communities and populations.”
RE: I’ve criticized that our healthcare system deals with sickness and not with being well. You can’t really do anything about a lot of the chronic diseases like Type 2 diabetes unless you go upstream. There’s not enough money on the planet to deal with Type 2 diabetes downstream, where you have all the consequences of the disease. The only way you can tackle the problem is looking upstream. What does that mean? You start with kids – they’re overweight and not getting enough exercise. In fact, a lot of kids now have Type 2 diabetes, which is frightening. The only way you can deal with downstream problems, which are so expensive, is to invest money upstream to encourage kids to eat and exercise properly. If you take a systems thinking approach and you think about dealing with the upstream problems, which relate to poverty, not having a good education or a job, not living in a neighborhood where it’s safe to walk, run, play and get exercise, all of those things lead to downstream problems.
EL: Is there a good strategy in place at this time to reduce chronic diseases?
RE: We need to do a lot of work. Under the ACA, there are certain things that are covered: screenings, certain prevention things are covered and provided. Large companies offer programs of exercise and eating wisely. Many large corporations will incentivize their employees by providing opportunities to get exercise, maybe even a coach or trainer. Large businesses realize that it’s a business decision to have healthy, happy employees rather than having disgruntled employees who miss a lot of work and mess up production lines. It’s been a while, but the case has been made that an employer that invests in having a healthy workforce will do better than one that doesn’t.
EL: Will Accountable Care Organizations (ACOs) be compensated for keeping people from getting chronic disease?
RE: It’s tough, because an ACO has to realize it’s responsible for the patient when the patient’s not in the hospital. That’s a different way of thinking. It’s tough because the ACO needs to know about the people receiving coverage. How do they live? What do they eat? Do they exercise? And if the insured do not sign on for the wellness effort, how can the ACO be paid in terms of how costs are going to be kept down when, in fact, its insured are staying in the hospital longer than planned and the ACO ends up paying for it?
EL: And the insured pay for it, too, because they are less healthy.
RE: Yes. So it’s a really tough road to go down. Most people don’t understand that before an ACO can be implemented, it must create a clinically integrated network. It’s a precursor to your ACO to have all the providers that competed for money come together and say, “We’re going to do this together, and we may not make as much money, but we’ll continue to make money, and so I’ll do this for less (money) if you can guarantee that I’m going to continue to be able to provide these kinds of services.” And all of that negotiation that takes place between physicians and specialties is a tough thing to accomplish.
EL: One other key to making the ACO functional is to have good data, because if you don’t have data, how do you know whether you’ve done a good job?
RE: You have to have useful healthcare data, not just “big data.” A lot of people have big data that’s junk.
EL: Is defining data a critical issue?
RE: That’s a very good question. Most of the operations data that hospitals utilize are called administrative data. There are different kinds; the biggest category is the claims data, which are the codes providers submit to get reimbursed. Each code is worth something; so much money per service provided. On a massive scale, around the clock, 24/7, codes are going to the sources of money; and once the code for service is exchanged, the provider gets reimbursed. That’s the basis.
There’s a movement of information and money that most people don’t understand, that when an employer provides a benefit to an employee, they have negotiated with a provider how much it will be compensated. They say, these are the names of the people, and this is what’s going to be covered. Well, what’s covered also gets further negotiated in terms of what’s on the (prescription drug treatment) formulary. The formulary is probably going to contain more generic drugs than brand-name drugs because they’re cheaper. Or there are going to be certain procedures that are negotiated: What procedures are covered at what rate, and what formulary is being used, and which drugs? You have a tremendous amount of information being moved electronically these days and funds being electronically deposited. It’s amazing that it works.
EL: According to the book, 25 percent of all Medicare payments are spent on end-of-life care, along with a lot of private money. Current end-of-life treatments often do not enhance, and sometimes even detract from, a patient’s quality of life. As the baby boomers age, can end-of-life care be improved and costs lowered?
RE: Some states are trying to create what are called standing orders, where the individual can say at the end of my life, these are the things I want done and these are the things I don’t want done. That will be an enormous move in the direction of reducing unnecessary end-of-life expenses.
EL: Malaria infects 500 million people each year. Typhus caused millions of deaths in the 20th century alone. Bubonic plague killed 75 to 200 million people in the 14th century; the third pandemic in 1850 spread to all inhabited continents, killed 12 million people, and didn’t taper off until 1950. Smallpox, now successfully eradicated, is credited with the deaths of millions. The Spanish Flu of 1918 infected one-third of the world’s population and killed 100 million. What is the probability that a major pandemic will occur in the future?
RE: There will always be something new in terms of a health threat, and technological progress often leads to unintended consequences. An airplane can move Ebola across an ocean in a matter of hours. We’ve proved that. We also have 24/7 news coverage, so we can frighten anybody we want to in the world instantaneously by people making inappropriate comments for whatever reasons. We have seen what fear can do; fear can be spread in a dramatic fashion and probably can even be made worse by whatever the situation is.
President Roosevelt said, “The only thing we have to fear is fear itself.” Fear is a terrible thing. Fear is a tremendous challenge with which healthcare has to deal. People understand the power of fear and use it in ways that are very destructive. Fear is not a virus; fear is a psychological thing. New healthcare threats will emerge. It will never end. Healthcare can respond so much faster these days with its technology, information and communication capabilities.
EL: How will the quality of healthcare in the U.S. change during the next 25 years?
RE: It’ll be different. Healthcare has its own economy, and in the United States, based on how we have a free-market system, it will morph and it will change – just like IBM (first) built mainframe computers and they went through a metamorphosis, a transformation, a change, and that IBM today is basically a consulting company. They still exist, it’s still called IBM, but what they do is quite different. Our healthcare system will end up the same way.
How it operates today will be dramatically different than how it operates in the future. I would hope that it would be more devoted to health and wellness and less to diagnoses and dealing with complications of end-stage disease and the expense associated with that. But not until the marketplace figures out how to engage consumers in their own health information and how to live healthier and better lives, and until the private sector can figure out how to make a business out of all of that and how to make money out of all that – I think in 25 years it’ll get there. It might even get there a lot sooner.