Population Health: The Unfinished Journey With David Kindig

Environment

• What happens outside the clinic is as or more important than what happens inside, a concept not widely embraced in health care in the 1960’s and 1970’s.

Population Health – general

• Everything Kindig has done in population health research and advocacy has its origins in the Evans-Stoddart 1990 paper “Producing Health, Consuming Health Care” – -i.e., it takes more than disease management and more than medical care to produce health.
• Population health needs a clear outcome measurement definition – -not enough to be just a study of determinants. This led to the initial “health adjusted life expectancy definition.”
• Kindig defined population health as a health outcome concept, some combination of mortality and morbidity/functional status as well as disparity or equity differences across subgroups.
  • It implicitly recognizes that such outcomes are produced by multiple determinants, not just medical care.
• Population health management refers to health outcomes of enrolled clinical populations, but often limited to health care quality.
• There is a beginning appreciation in the first decade of this century that population health is more than health care, yet the full appreciation for the social determinants is slow in coming. It is hard for most to understand how the social determinants “get under the skin”.

Incentives

• Financial incentives are critical but can be overdone such as fee-for-service, and the idea of capitation changes the incentive orientation.
  • “Why not financial incentives for health outcomes instead of simply health care/services?”
• Grants are not enough for major change. For something so major, ongoing formulas like crop subsidies and graduate medical funding (GME) funding are needed.

Pay for Population Health

• The fundamental assertion of Kindig’s book Purchasing Population Health: Paying for Results is that population health improvement needs appropriate financial incentives designed for this outcome.
• Measures, financial incentives, coordination across sectors – – important concepts are key challenges for a pay for population health model, as well as the importance of a common language and understanding across disciplines.
• Complex ideas such as paying for population health take time to gain broad understanding.

Investments 

• An “investment balancing function” across determinants is critical – one that encompasses fairness.
• One key take-away continues to surface – the challenge of balancing investments across determinants.
• We need much more research on relative cost effectiveness, so cross sectoral investment benchmarks can be set.
• There is promise in community multisectoral partnerships including business as well as government, non-profits like United Way, health care and public health, but need core resources to function effectively.

County Health Rankings Model

• The County Health Rankings model – three main points:
  • Clearly derived from original Evans and Stoddart 1990 and 2003 articles
  • Separated outcomes from determinants
  • Needed to estimate weights in order to rank…e.g., 20% health care weight -driving home that more than health care is needed
• In the second decade, new disseminations were needed for population health concepts. A blog and the Roundtable for Population Health Improvement associated with the National Academies for Sciences, Engineering and Medicine (NASEM) were created, which reached a wider, diverse audience.

Equity

• Population health equity is crucial and complicated.
• There are twin goals of population health – raise the mean; close the gaps. Having equal but very low outcomes is not acceptable; it’s not equitable – not fair and just.
• The balance of outcomes we desire reflects value choices for individuals and jurisdictions.
• No single group characteristic or health outcome represents the whole picture of health inequalities in a population.
• Addressing racism is central and essential to addressing black, indigenous, Asian and Latinx inequities, but there is a counterpart history of poor white classism that persists today as well. It is not well understood and needs policy attention as well.
•  Absolute numbers are as important as high rates.  Can understanding burden and rate – can this lead to more common ground – e.g., black/white, urban/ rural – on equity policy and investment?

Miscellaneous

• Excessive health care expenditures are the perfect storm of American culture… wanting more of everything now, greed in medicine, fascination with technology, etc. As Starr said in the Social Transformation of Medicine, professional power gets medical care expansion without controls.