Population Health

Want to improve public health? Start with housing.

A well-worn axiom says that “hope is not a plan.” Indeed, hope alone is such a hands-up abdication of planning that editor Thomas Mowle was inspired to use the phrase as the title of his 2007 book of essays on the war in Iraq, which says something.

Still, if we play with syntax and add a few words, we can say that every successful plan should offer a measure of hope—hope for success, an improved reality, greater opportunity.

With the twin American scourges of homelessness and addiction, hope starts with a plan that includes housing—a refuge, even if it’s just a 50-square-foot wooden box.

“Housing is one of the best-researched social determinants of health, and selected housing interventions for low-income people have been found to improve health outcomes and decrease health care costs,” writes Lauren Taylor in Health Affairs.

Perhaps, then, housing is a key component in the overall explanation for why health and life expectancy have been declining in America the last few years. When workers making minimum wage—more than 20 million people and roughly 30 percent of all hourly, non-self-employed workers over 18—can afford a modest one bedroom home in only twelve counties in the country, it’s near impossible to argue that the gap between wages and housing costs does not create profound desperation and instability.

That despair, in turn, worsens public health in myriad ways. People with no hope turn to drugs and alcohol, battle depression, eat poorly, work three jobs to exhaustion and injury, battle chronic pain with no viable options, sleep too little, etc. And in worst case scenarios, they end up on the street with few if any possible good outcomes.

Is it the housing as an end that creates better public health outcomes? Not really. No one who lacks adequate housing or has to move frequently is clamoring for a 7,000-square-foot home.

Instead, it’s the benefits housing provides that support a healthier, more sustainable life. As an essential social determinant of health, well-built and well-conceived housing is one corner of foundation supporting four interconnected quality of life pathways: stability, quality and safety, affordability, and community. If any of these pathways are lacking in the housing options available, housing potentially becomes a negative social determinant of health.

For example, consider the tiny homes many cities are now building to try and grapple with the problem of homelessness. Initially, it seems like any kind of lockable structure is an improvement on doorways, park benches and even shelters. But in some cities, tiny houses don’t come with heat, electricity and plumbing, effectively making clusters of houses a small step up from homeless encampments. As social determinants of health, they still register a negative, leaving America far from realizing the goal of housing as net positive for all citizens.

Of course, housing is only one social determinant of health, which collectively are generally lumped as social and environmental factors (20 percent), genetic fortune or misfortune (30 percent), and individual behavioral choices (40 percent).

The final 10 percent is healthcare, and maybe that percentage seems a little light, given how much attention we pay to the healthcare system. Still, think about the ability of healthcare to balance all other social determinants—diet, housings situation, employment status, mental status—when they’re decidedly or even predominantly negative.

It’s not hard to see why clinicians resent being held responsible for the fire after the house is engulfed in flame.

And what, if anything, can healthcare do about these social determinants over which they have no control? In short, look for solutions and shortcuts.

Comprehensive medical records, interoperable systems, healthcare data exchanges and the like can together enable hospitals and clinicians to circumvent the complications created by a transient life. But healthcare providers and organizations can also address social determinants of health more directly.

“The health care sector should continue to explore the extent to which home interventions, such as the well-studied community asthma initiatives, can make financial sense among other patient populations,” says Health Affairs writer Taylor. “Given the shift toward accountable care models and other value-based payments, the financial incentives for health care systems to take broader responsibility for social determinants of health (including housing) are likely to increase.”

And that’s the added factor that may motivate healthcare organizations as much as anything else. Housing makes communication with patients more reliable, which cuts down on the costs of care and lends stability that enables accountable care. Really, all social determinants on the positive side of the ledger decrease healthcare costs, but stable housing makes the others that much more likely.

The social determinants of health are also lurking in the national discussion of universal healthcare. At times, the nation and the industry seem caught up in discussions of payment models, insurance deductibles and technological advancements. Maybe we miss the fact that having affordable healthcare is better than not having it in the same way that having a 200 square-foot house with locks is better than living on the streets, even if we can agree that such basic standards are not enough.

Using social determinants, we could improve the health of many Americans without ever specifically addressing a medical record or length of stay. And until we do see patients as a complex amalgamation of influences, we can’t be surprised that specific therapies out of context have negligible impact on overall public health.

Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

Insuring America and The Expanded Role of Medicaid

The expansion of Medicaid and insurance subsidies through the ACA meant 20.4 million more people had health insurance in 2016 than in 2010. According to the non-partisan Congressional Budget Office, somewhere just north of 20 million Americans would lose health insurance in the various repeal-and-replace scenarios that have been floated of late and rejected, for now. That number jumps to 30 million-plus if Obamacare is simply repealed.

What all proposed ACA-repeal legislation has in common is deep cuts to Medicaid. Indeed, the group most affected by any of the bills is poor Americans who receive Medicaid support.

“Federal Medicaid spending would be reduced by 26 percent by 2026, largely because of the phase out of federal Medicaid expansion funding, but also because of the imposition of per capita caps or block grants,” writes Health Affairs blogger Tim Jost in analysis of one legislative proposal, the Better Care Reconciliation Act released by the Senate budget committee on July 20. “The CBO projections of loss of coverage remain substantially unchanged from the earlier analysis … The number of the uninsured would increase by 19 million by 2020 and 22 million by 2026.”

In some instances, replacement legislation in Congress divides state and national politicians of the same party. Half of the states that took expanded Medicaid dollars have Republican governors. Total enrollees in ACA insurance marketplaces are highest in Republican controlled legislative districts.

“We are now able to provide health insurance to 700,000 people,” said Ohio Governor John Kasich, who maneuvered around his state legislature in 2013 to expand Medicaid. “Let’s just say they just got rid of it, didn’t replace it with anything. What happens to the 700,000 people? What happens to drug treatment? What happens to mental health counseling? What happens to these people who have very high cholesterol and are victims from a heart attack? What happens to them?”

As chief executives of state governments, Kasich and other governors are directly responsible for state management, a direct responsibility that members of Congress do not share. Ohio is in the eye of the opiate addiction storm—the most devastating substance abuse epidemic in American history—and badly needs the expanded Medicaid dollars.

The fundamental issue with Obamacare repeal is the expansion of so-called entitlements, the social safety net and federal spending. Once a social program is established and benefits are extended, it is extremely difficult to pull them back. If social security is the third rail of politics, expanded Medicaid may soon become rail 3A.

Why is there even a discussion of Medicaid contraction when there is clearly so much need? Because, for many, such handouts do not reflect how a nation built on a culture of independence and self-sufficiency should function. Because the perception of some is that programs like Medicaid create dependence and limit freedom.

"When the Democrats built Obamacare, they built a Berlin Wall to keep the American people inside,” wrote Utah Senator Mike Lee, a leading opponent of the ACA. “The Consumer Freedom Amendment I'm offering will tear that wall down and allow the American people to connect with willing insurers to buy the policy that is right for them."

But Lee’s proposal, while submitted with honorable intent, still leaves a massive gap between the availability and affordability of health insurance. It may give some Americans freedom of choice, but it does not alleviate the Berlin Wall of poverty and poor health, to use Lee’s analogy. It holds the line ideologically while doing little to address the underlying problem.

And it defines ‘freedom of choice’ only in terms of what citizens are not coerced into buying. Many Americans do not feel free to search the labor market for a new job because they risk losing health insurance. Many hospitals are not free to deny service to those without health insurance.

The uninsured who must ultimately go to the ER for treatment are often not free to pay for both medical care and food. Insurance consumers are not free to pay a lower premium bill because they don’t like that prices have been driven up by the uninsured. As every other industrialized nation has proven, costs per citizen are significantly lower when everyone is part of the same risk pool.

Some would have us believe that the 3 percent of citizens paying more for insurance thanks to Obamacare are the only ones impacted. Certainly, their hardship deserves attention. But don’t the millions who can’t get insurance without the ACA deserve notice as well? And what of the Americans who ultimately pay for those that choose not to have insurance and get hurt? Costs accrue, regardless, and someone will pay for them.

That problem is a healthcare system that routinely leaves those most vulnerable at risk. Medicaid expansion was one solution to that problem. It is an imperfect solution, to be sure, with legitimate liabilities, but at least it is a starting point for ensuring all Americans are covered.

“Sickness is costly, it shrinks the workforce and makes it less produc­tive,” write Walter McClure, Alain Enthoven, and Tim McDonald in the Health Affairs Blog. “Good health, like education, expands the workforce and makes it more productive … Good public investment programs infeas­ible in the private sector, such as universal public education, return far more to national prosperity than they cost in taxes. If both sides of the aisle will work together to do it right, universal health coverage is just such an opportunity.”

American healthcare has crossed the Rubicon and must find ways to extend insurance coverage, not retract it. The costs of the uninsured seep into the healthcare system anyway, as do the costs to society of addiction and mental illness when intervention comes far too late.

We should not cling to the ACA because it was passed by Democrats, nor should we oppose other ideas because they come from Republicans. I am not saying that free-market solutions are off the table and we must look to big government to save us.

But we must pursue ideas that expand healthcare availability. Healthcare costs threaten to bankrupt the country and lack of care is destroying lives in record numbers. For now, Medicaid expansion is one way to extend coverage and improve lives—to invest in the health and productivity of our people. It should not be viewed as the end game, but until we can improve on it in a way that makes insurance more broadly available, we cannot eliminate it either. 

Irv Lichtenwald is president and CEO of Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Population Health

Do we have to define population health to make it useful?

Maybe the initial challenge of population health is deciding exactly what that phrase means.

Well before it became a catchphrase in health IT, population health was the province of academics who devised predictably academic definitions like “… the aggregate health outcome of health-adjusted life expectancy (quantity and quality) of a group of individuals, in an economic framework that balances the relative marginal returns from the multiple determinants of health.”

Originally created by and revisited in a Health Affairs blog post by Population Health Sciences Professor David Kindig, this definition may help with understanding, but it makes specific application outside of academics kind of problematic. Today, there are many more minds working on population health matters, which has created what Kindig admits is “a conflicting understanding of the term today.”

Which version of the “conflicting understanding” a person subscribes to seems largely determined by prevailing questions. Are we trying to track the health of people in a geographic area? Is the primary concern the health of a particular ethnic group? Is economics the challenge in growing a client base enough to scale the costs of population health? Are we trying to track spreading disease?

Because the end goal determines where boundaries are drawn around subjects, the answer is ‘Yes’ to these and almost all population health objective questions.

The Affordable Care Act (ACA) and Accountable Care Organizations (ACOs) have made it more expensive to readmit patients soon after treatment, so the bottom line comes into play regardless of which question is being asked. But the spread of technology like electronic health records (EHRs) and other applications also makes it possible to use data in a variety of ways, perhaps many of which we have yet to discover and define.

“A critical component of population health policy has to be how the most health return can be produced from the next dollar invested, such as expanding insurance coverage or reducing smoking rates or increasing early childhood education,” Kindig writes.

More bang for the buck—everyone wants it.

“To do population health, insurers must have a critical mass of members in each of several high-cost diseases: diabetes, heart disease, cancer, behavioral health,” says Indianapolis Business Journal reporter JK Wall. “Otherwise, it will be too expensive to hire the clinical staff to develop the necessary clinical protocols, to staff the high-touch patient intervention programs and to develop the data analytics and customer engagement technology seen as vital for doing effective population health on a large scale.”

Wall adds that much of the insurers’ population health strategy is driven by two facts: The ACA squeezes per-patient profit margins, and maintenance of many diseases is expensive.

If you are a physician or hospital administrator, you will be concerned with chronic disease in a defined population from a causes-and-treatments, as well as a financial perspective. To that end, hospitals are frequently using remote patient monitoring and analytics as embedded components in the care process, writes reporter Jessica Davis in Healthcare IT News.

But even while much data is being gathered, there is a gap between the data we can compile and knowing what to do with it.

"Analytics provides a huge opportunity, but we lack the data science and medical algorithms," says Gregg Malkary, managing director of Spyglass Consulting Group. "We don't really know how to translate certain data because medical science is immature."

A high-profile example of what Malkary describes is the failure of Google Flu Trends (GFT), the company’s effort at tracking search data and alerting public health officials of flu outbreaks before the Centers for Disease Control could know about them.

“When Google quietly euthanized the program … it turned the poster child of big data into the poster child of the foibles of big data,” write political science professors David Lazer and Ryan Kennedy in Wired.  “But GFT’s failure doesn’t erase the value of big data … The value of the data held by entities like Google is almost limitless, if used correctly.”

Google’s adventure becomes a lesson for those that come after, adding to acquired knowledge and contributing to later success. In many ways, that same ethic is at the heart of the optimism surrounding all these piles of data we are starting to acquire. Right now, the rhetoric is ahead of the reality, but the gap between the two is closing rapidly enough that there is reason to believe the use of big data in population health will become common.

But do we still need an accepted definition to work from?

Actually, according to Kindig, we need two.

While population health is often viewed as a mostly clinical measure, Kindig feels the terms population health management or population medicine better describe this physiological aspect of group wellness.

“The traditional population health definition can then be reserved for geographic populations, which are the concern of public health officials, community organizations, and business leaders,” he says, and which factor in contributors like education, employment and other non-clinical issues.

Geography on one side and whatever the determinant is—ethnicity, education, diet—on the other. It may not get us down the path to universal understanding, but it does provide the kind of flexibility that will probably come in handy as we look for new ways to analyze mounds of data in search of healthier populations.  

Richard Sullivan is chief operations officer for Medsphere Systems Corporation, the solution provider for the OpenVista electronic health record.

Category: Population Health

Can effective healthcare IT reduce hospital costs?

The focus of federal efforts to incentivize healthcare IT adoption has primarily been on electronic health records (EHRs), which are oriented around hospitals and physician offices. Moving forward, EHRs will remain the anchor technology as data from other devices and applications flows in and becomes both available and comparable.

It’s become readily apparent that healthcare IT is much broader than EHRs alone. Increasingly, healthcare IT is a web of interconnected devices and applications that can feed data to the EHR. So, instead of focusing intently on how healthcare IT can alter inpatient safety and quality, we’re better off looking at technology as all the tools patients and doctors can use to maintain and improve health.

Why might this shift in focus be important? One obvious reason is that hospital and emergency care are expensive. The average cost for a single inpatient day in the United States is more than $2,200. The average cost of an ER visit is about the same—$2,168—without being admitted.

The better reason is that hospital visits often mean something has gone wrong. Sure, some hospital stays or visits are required because life is messy and people get in accidents. But others are the product of preventable scenarios. Instead of focusing on crisis-scenario work, perhaps there is wisdom in focusing on the more mundane tasks technology can perform to keep people out of the hospital.

How, specifically, can we use IT to make patients better shepherds of their own care?

  • Identify at-risk patients. Age, ethnicity, health history, gender, geographic location and other population health data give healthcare professionals a pretty good idea of who will get sick. Obviously, primary care providers also have a significant role to play when it comes to identifying potential health problems and engaging the patient in a plan to avoid them.

    When it comes to at-risk patients, technology is essential but not sufficient on its own. A better approach might be a care management scenario that combines big data analytics, the collaboration of multiple providers,  and human insight. 

  • Monitor patients’ vitals and welfare. For a while now, wearable devices have given healthcare the ability to track patients outside of the hospital and clinic. That tracked data can be relayed wirelessly back to the EHR and is available to physicians when they check patient status.

    Remote patient evaluation is also available more directly via telehealth. Through remote consultations and evaluations, a physician can usually determine whether a patient should come to the hospital or is fine at home. As is often mentioned, telehealth offers great potential in terms of treating patients in remote areas where hospitals and specialists are few. 

  • Remind patients of appointments. No-show rates for patients vary wildly—anywhere from 5 percent to 55 percent—with similarly varying impact on patient health. Sometimes a patient misses a cardiac stress test and shortly thereafter suffers a heart attack. Other times a routine checkup is missed with no physical fallout.

    The point is that patient portals and regular communication provide services both banal—the patient is simply reminded that they have an appointment—and potentially essential in the case of a cardiac diagnostic. Regular communication in advance of a test is an opportunity to provide patients with reassurance and more information on the potential benefits of attending the appointment.

  • Empower them to manage their own care. Especially regarding behavioral health, technology enables patients to learn self-management techniques that improve coping skills and ideally prevent incidents requiring hospitalization. Support for self-directed or self-managed care comes from Health and Human Services, the Centers for Disease Control and Stanford University Medical School, among others. For self-directed care objectives, mobile phone applications can remind people to take medications, track heart rates, help with stress and anxiety, and improve thinking skills, to name but a few benefits.

    It’s limiting, however, to think of self-managed care as essentially behavior health-related. All patients can benefit from technological assistance with taking medications regularly, improving dietary choices, monitoring blood pressure and getting some exercise. All of these daily activities could help keep someone out of the hospital.

  • Provide educational information. The internet is a jungle of information, some of it benign and some much less so. Hospitals and practices can direct patients toward reliable sources and can provide their own via PDF documentation and the patient portal. In fact, the internet is both an animating and potentially complicating factor in patient care, requiring providers, perhaps especially nurses, to evaluate information patients bring to appointments and correct as necessary. 

Of course, the ultimate focus in reducing hospital admissions is on patient health and welfare, but the corollary is runaway health costs in the United States and the need to wrestle them into submission. Once hospital admissions take place, things get expensive, making just about all efforts leading up to the hospital visit more attractive and cost effective.

The federal government (CMS, HHS) has made reducing hospital readmissions a primary objective and a criterion impacting hospital reimbursements. But there can’t be a readmission if admission is avoided in the first place. Moving forward, integrated, aware health systems will focus as much on preventing hospital visits as they will on making sure patients don’t come right back.

D'Arcy Gue is Director of Industry Relations for Medsphere Systems Corporation. 

Subscribe to Population Health