Population Health

I’ve been wanting to write about “Population Health” for some time now. It is a huge new trend that has risen under the radar of almost the entire population. Nearly every medical school now has a Department of Population Health or a Center for Population Health. Thomas Jefferson University has an entire school devoted to the subject — The Jefferson School of Population Health, founded in 2008.

The concept is kind of creepy, but it is getting even creepier. The Institute for Healthcare Improvement (IHI), Don Berwick’s old outfit, recently announced a conference on “Population Management” to be held September 28 to October 1 this year. Enrollment will cost $4,950 per person, so you know it’s a very big deal.

One of the reasons it is hard to write about this is there is no settled definition of what it is. A paper written in 2003 by David Kindig and Greg Stoddard in the American Journal of Public Health took a stab at it. They write –

Although the term “population health” has been much more commonly used in Canada than in the United States, a precise definition has not been agreed upon even in Canada, where the concept it denotes has gained some prominence.

They proceeded to define it as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” They go on to explain –

We support the idea that a hallmark of the field of population health is significant attention to the multiple determinants of such health outcomes, however measured. These determinants include medical care, public health interventions, aspects of the social environment (income, education, employment, social support, culture) and of the physical environment (urban design, clean air and water), genetics, and individual behavior.

In other words: Everything under the sun.

Such an all-inclusive definition is not very helpful, so people keep trying. Ten years later Michael Stoto gave it a shot in a paper published by Academy Health, “Population Health in the Affordable Care Act Era.” This paper spends half its space explaining some of the different definitions currently in use. The balance of the paper is suggesting to researchers how they can tailor their projects to take advantage of funding opportunities presented by ObamaCare.

The same year the Robert Wood Johnson Foundation published a series of blogs by Nicholas Stine and Dave Chockshi on Population Health that started with one that attempted to define it. They interviewed 17 “leaders” of the population health movement and found that each one has a different definition.

Now this is very peculiar. Vast resources are being invested into something that cannot be defined. What’s going on here?

It is chilling. First, it seems to be a raw power grab. The Kindig/Stoddard definition would place virtually every human activity under the management of “population health” experts — food, education, the arts, architecture, even “individual behavior” — all must bend to the demands of the new “population health” system. Add in Don Berwick’s concept of “population management” and we get a tiny elite anointed to manage the behavior of the entire population, all in the name of improving their health whether they want it or not.

Clearly these people are bored with the idea of treating one patient at a time. That is far too messy, and actual people are not very pleasant to deal with. It is much more grandiose and ego-enhancing to “treat” and control the activities of the ENTIRE POPULATION! This impulse is identical to that of Progressives who are in love with “the people,” but don’t much care for actual persons.

Even more chilling is the realization that in dealing with the health of a “population,” the needs of any individual are simply unimportant. Things become measured by averages. The average result will improve if we eliminate the outliers who bring down the average. This is sometimes known as thinning the herd. If we could rid ourselves of those people with serious disease, we would have a much healthier population, on average.

This calculation becomes even more compelling when costs are considered, as Kindig and Stoddard write –

In our view, a population health perspective also requires attention to the resource allocation issues involved in linking determinants to outcomes. Part of the study of population health involves the estimation of the cross-sectoral cost-effectiveness of different types and combinations of investments for producing health.

This is how the sickest people get left behind. Spend a little bit of money on “preventive care” to improve the health of the majority by a small margin, but forget about expensive organ transplants. The result is an improvement in the health of the population at very low cost.

The mathematics of population health drive these conclusions. And the current adoration of Zeke Emmanuel and Peter Singer suggests that this is exactly what lies ahead as long as we keep empowering the elite rather than the people.

Comments (42)

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  1. Mindy K. says:

    I wonder if the distribution of vaccines has any ties to the population health concept. Perhaps it was the unofficial start of the movement?

  2. Kent J. Lyon, M.D. says:

    Dr. Goodman: The vision of these self-anointed (see Thomas Sowell’s book, The Vision of the Anointed) experts is to manage the human population in a similar way to the management of the Elk herd of the Yellowstone. I would suggest a book: “Playing God in Yellowstone” that describes how such an approach works with a population that is the model for Zeke Emanuel’s and Pete Singer’s vision of healthcare.
    The point is that humans are viewed by these gentlemen, as well as our President, and “Pragmatists” after Richard Rorty, as simply another species, and a dangerous and damaging one at that, essentially an “invasive” species that must be controlled so the rise of sea levels can be curtailed and the planet begin to heal. Their ethics, if such a term can be applied to their perverse thinking, are sordid, indeed. It won’t be just leaving behind a segment of the population–it will be active culling of the herd when the range is overgrazed.

  3. Big Brother says:

    Yes…. I like the sound of this “Population Management”

  4. mitch says:

    where is the line? at what point do the needs of the one no longer outweigh the needs of the many (or vice versa)

  5. H D Carroll says:

    Thoughts of “1984” and “Anthem” stream through my head. It also reminds me of the basic question I want to ask health care “progressives”: Since it is clear that some doctors are better than others, in a system where everyone is supposed to have equal access (and financing), who gets to see those particular doctors? Their answer would typically be, in the name of true equality, “If everyone can’t see those doctors, then no one gets to see those doctors,” and the race to the bottom begins. Except, presumably, for the elites who make sure that ‘they’ get to see those better doctors because ‘they’ will be controlling the system. Did I include “Animal Farm” in my list?

  6. N-R says:

    I think Dr. Goodman is taking the term too literally here. While i do have concern for a one-size-fits-all treatment model (remember that all healthcare is local) its scaremongering for no good reason to suggest the “thinning of the herd” without any facts to support that statement. He uses the lack of a concrete definition to propose his own one, but it is far too literal. In statisitics, a population can signify any pre-determined group or sample size. Ie a population can be a college campus used to extrapolate outcomes to similarly sized college campuses in other states. Or using a sample population of elderly women to determine best practice osteoporosis therapy. The population is predefined depending on the needs of the researcher. It isnt literally the ENTIRE POPULATION! of the nation.

    • R. a. Gardiner says:

      So why don’t they say that?

    • Morris Bryant, MD says:

      No, healthcare is not all local. One look no further than the VA, where the fact that medicine is practiced one patient at a time is totally lost. I am not saying there are not some good people trying, but just look what top down authoritarian, institutional structure has accomplished with “the population.”

  7. Matthew says:

    “This is how the sickest people get left behind.”

    It is kind of the same with ObamaCare. They try to offer plans to everyone, but make it expensive and provide narrow physician networks. Yes everyone gets insurance, but very few get any sort of care.

    • Thomas says:

      And in population health, it seems everyone gets the same care, whether they are sicker or healthier. Its too much of a one size fits all model.

    • Erik M says:

      It is not “like Obamacare”… this IS Obamacare. When the government is trying to put everyone into the same box (insert your favorite pun about death panels here) then we end up with socialized medicine that is not good for anyone. Thank you Greg for the article!

  8. Roger Waters says:

    Ok, Greg, excellent compilation of ideas here. That said, industry use has imbued population health with two very distinct meanings.

    On the one hand, it is taken to mean managing the health of a large, capitated population so as to pool resources and buffer large losses caused by persons who turn out to be sicker or have accidents. This is the traditional role of health insurance, and is based on insurance principles of underwriting and risk management. But, since health insurance was outlawed in the ACA because we cannot underwrite and perform other insurance activities – instead we have devolved into “pre-paid medical” plans, this definition no longer applies (although some are trying to shift the principle to providers assuming risk, ala ACO, it is a different kind of risk they are assuming and a perversion of the original concept).

    The other meaning is public health and public health surveillance. This is perhaps closer to the meaning of the term created by ACA (as the authors were all career government/political operatives, most of whom were not familiar with how the private sector works) and includes epidemiology and other functions of traditional government health services. And, of course, we know how well government performs health services when they attempt to extend beyond epidemiological studies and disease surveillance – witness the VA health system.

    As it turns out, and this is a common occurrance with government defined programs, the private sector has left both definitions behind as “old school,” and is innovating with services that focus on the individual consumer as a “market-of-one,” and bring “personal health management” into the context of the individual. BTW, “personal health management” is a copyrighted phrase you shall hear more about in the future as the private sector creates services attractive to the individual consumer. Unless, of course, government intervenes and over-regulates with “smart regulations” and other such nonsense.

    BTW, what IS a “smart regulation” anyway?!?

  9. Buddy says:

    You know their is trouble with this when no health care expert can provide a definition of it that are close to each other.

    • Perry says:

      I think that’s the most critical point, Buddy. In terms of Evidence-Based Medicine we use populations to determine what is the best route to go for say, low back pain. Most patients don’t need MRIs or narcotics or exhaustive investigation, all well and good. However, if the physician detects any red flags, other options need to be pursued. I’m fine with guidelines as long as they are just that, guidelines, giving the physician room to adjust the treatment or diagnostics as needed. The bottom line is, you can’t treat everyone the same, otherwise why bother having doctors?

  10. George Sack says:

    The “Population Health” notion is nebulous but there is nothing confusing about the far earlier term of Public Health – encompassing areas such as water supply, sanitation, vaccines, etc. All globally effective in reducing frequency and burden of disease.

    • Devon Herrick says:

      A few years ago I testified before a Congressional Committee on the difference between public health and why most health care cannot be considered a public good. I explained the fallacy of how over time the public health mission of preventing Cholera and immunizing school kids against infectious diseases somehow was expanded to include a mandate forcing everyone to have comprehensive health insurance.

      At its core, medical care is a very private good. In economic terms, it is both rival and exclusive. Over the past century, the entire field of medicine has been co-opted by an elite group that determines what medicine is legal, who is allowed to administer it, and how it’s allocated and distributed among the population.

  11. John Fembup says:

    “In other words: Everything under the sun.”

    And the moon. Don’t forget the moon.

  12. Gordon Green says:

    I think N-R has it exactly right. Sometimes we use the term “community health,” and then go on to define the community of which we speak: infants, farmers, women over 50, kids in a classroom, etc. In the case of “population health,” let’s state clearly which population is under discussion.

  13. Elizabeth A. Reid, MD says:

    Jung understood this concept long ago. In The Undiscovered Self, he wrote eloquently about the need for the individuals to beware of the power of the elite group who would see them as numbers. Decades later we are well into the world of statistical man that he warned about, with the Emmanuels and Singers leading the way in medicine. Statistics obviously are useful in medical care, but Jung’s worry about the types of people who see people as data points is valid. The leaders who emerge are the ones willing to avert their eyes from the results of dehumanization.

  14. Dan says:

    The Triple Aim (from which population health comes in Don Burwick’s Health Affairs article) has two other prongs, which you seem to be missing. The first is improving patient experience of care. Popln management is the second part.

    By focusing on the individual, we still only meet the needs of those who have taken their healthcare into their own hands. Without community education, vast groups of people will be overlooked as doctors just await those who know and understand the healthcare system to come to their offices.

    • Roger Waters says:

      Wow, you are old school. The internet, for one example, is all about empowering the individual with information and recommendations. The ability to reach and impact the individual using this and other “new” technologies makes aggregate population views not only out-of-date, but dangerous as the old approaches treat the individual like everyone else and fail to recognize individual genotypic and phenotypic variation. It is all about focusing on the individual, as a “market-of-one,” especially if they have not taken care of themselves or have chronic conditions or disease – so we can better understand their individual problems and help them, individually and personally. Think “personalized medicine.”

  15. Uwe Reinhardt says:

    This is a good post, Greg, because it challenges people who engage in loose talk about “population health” (a) without defining it and (b)( without proposing how to measure it and (c) telling what policy implications follow from it.

    Greg criticizes the concept of “population health” for the same reason that I vehemently criticize the economist’s notion of “economic efficiency” and the redistributive policies that follow from from it. I call ti cattle-farm economics.

    Economists try to maximize “social welfare” just as the health wonks try to maximize “population health.”

    It is natural, for example, for economists to argue that the sum of QALYs (quality-adjusted life years) producible with a given population be maximized for a given budget. Surveys of citizens, on the other hand, show that they want budgets spend so as to alleviate the distress of the sickest people. This leads to vastly different allocations of resources.

    It is a murky area.

    • John R. Graham says:

      When people are surveyed, they say they want to alleviate the distress of the sickest people. When they go to the voting booth, that is not what they vote for. They vote for middle-class entitlements.

      Woe unto the politician who governs according to the altruistic statements of the people!

    • Devon Herrick says:

      Surveys of citizens, on the other hand, show that they want budgets spend so as to alleviate the distress of the sickest people…

      I suspect their actions would be very different when people are spending their own money rather than voicing their opinions on collective spending policies.

      If you were polling seniors, I also suspect that their opinions on collective policy is a self-interested opinion.

      i.e. they will tell you… “I believe society should do everything possible to save the life of a deathly-ill senior because someday that deathly-ill senior could be me!”

      • John R. Graham says:

        It’s much like when they survey people who agree that the government is too big and spending too much money. Then go down the list and ask citizens what to cut.

        Their answers will barely cut one penny on the dollar.

    • Earl Grinols says:

      Uwe,
      Thanks for your post. I was about to make a similar comment about the rancher’s concern for his cattle’s health. The rancher, of course, always views himself as the member of a superior species. Cattle are just cattle and need the rancher’s concern.

  16. William Palmer says:

    Maybe it’s a backup Gramsci plan in case anthropogenic global warming doesn’t pan out?
    Telling people how to live needs some flimsy logic like “this area in LA has too much childhood suicide; we need more psychologists in the school system.”

  17. Devon Herrick says:

    Enrollment will cost $4,950 per person, so you know it’s a very big deal.

    Greg, why don’t you and Uwe attend this conference (at your own expense of course) and report back to us on the proceedings?

    • Uwe Reinhardt says:

      What conference is that, Devon? Seems like a good deal — cheap, by health care standards.

      Greg and I could charge it to the NCPA, because it would make us better contributors, inching ever closer to guru Goodman.

    • Greg Scandlen says:

      Even if it were free I wouldn’t attend. Having a dozen people all congratulating each other on how smart they are has limited entertainment value.

      • Devon Herrick says:

        Greg:
        I already know what the conference presenters will say! The following is a preview:

        1) As their standards of living rises, citizens in both developed and developing countries have been packing on the pounds! The cause is largely unknown, but it may be a function the rising efficiency of food production and the sedentary nature of 21st Century jobs. Paradoxically, the poor in rich countries are the most overweight; excess body weight begins to fall as individuals in rich countries’ income and educational attainment rises.
        The following is our recommendations:

        1) We should apply for grants to write white papers that recommend rich countries ban the purchase of sugary drinks from their generous food-assistance programs and from schools.

        2) We should apply for grants to write white papers that encourage poor people (and everyone else) to eat more vegetables.

        3) We should apply for grants to fund white papers that advise health departments to force fast food restaurants to post calorie counts on menus. And browbeat restaurateurs if they serve the fatty food customers actually want to eat rather than heavily promote (and subsidize) meals that consist of leafy green vegetables and salads that their customers don’t want to eat.

        Finally, 4) we should recommend a calorie tax to fund Healthy Eating Educational Initiatives. The accumulated tax funds — which will be immense — can be used to fund grants to community health academics to write white papers on how healthy eating contributes to community health.

        • Greg Scandlen says:

          Maybe you should apply for a grant to write a white paper about this.

        • wanda j. Jones says:

          Then, someone is going to publish regulations limiting our intake of Mexican food because of the lard and pork, or our intake of grilled beef because of the carcinogens in the grill marks, then Japanese food because of the excess sodium in the soy sauce. we are close to regulations against wild tuna and salmon.

          There should be an overall law limiting the passage of laws of this kind.

          Federal regulators have no common sense counter-force. Let’s pray for public health professionals to have the strength to revolt.

          Wanda Jones
          San Francisco

  18. L. BRODY says:

    IS POPULATION MEDICINE A VARIANT OF EZEKIEL’S “COMPLETE LIFE SYSTEMS”?

  19. James Gaulte says:

    A commentary in the November 13,2013 issue of JAMA by former President of ACP, Dr. Harold Sox, makes it frighteningly clear that the ACP brainchild of “Medical Professionalism in the New Millennium, A physician’s Charter” is a precursor to the adoption of the Population Medicine Approach . He said:
    “..the physician has an ethical imperative to balance the needs of the the individual with the needs of society. With this foundational principle of the population health approach,the Charter, in effect calls on clinicians to allocate resources.

    I expressed my grave concerns about this approach in this blog commentary.http://mdredux.blogspot.com/2014/05/former-president-of-american-college-of.html
    but I found it so antithetical to traditional medical ethics that that I struggled to adequately convey that thought.

  20. Bruce W. Landes, MD says:

    Interesting perspective Greg (the author) and all. Also interesting that just today, HealthLeaders Media put out one of their “Spotlights” on Population Health. (Sorry about thee length of the URL)

    http://list.fortisbusinessmedia.com/track?t=v&enid=ZWFzPTEmbXNpZD0xJmF1aWQ9MjY1MTMwMCZtaWQ9MTAwNzYwNSZtc2dpZD02NDQwMDAmZGlkPTMwNzQwMCZlZGlkPTMwNzQwMCZzbj0xNjg2ODIzMCZlaWQ9bGFuZGVzYndAYW9sLmNvbSZlZWlkPWxhbmRlc2J3QGFvbC5jb20mdWlkPTFfNjgyNDMmcmlkPTY4MjQzJmVyaWQ9NjgyNDMmZmw9Jm12aWQ9JnRnaWQ9JmV4dHJhPQ==&&&2020&eu=500&&&#

    You will find multiple interviews with true leaders from around the country who have been growing their organizations for years. There is a similar pattern that will emerge but no two are alike because they are being grown organically from the bottom up by health care providers and not by insurers, governments, hospital administrators, think tanks, or even economists. It’s taken 35 years but in this case physicians are stepping up and taking back control of health care or at least having a real role instead of a symbolic one.

    It’s really about vertical integration, but trying to take a thousand siloed regional businesses into a Kaiser-Permanente-like structure takes a long time. And because these entities are consolidating organically, they will include local resources that will vary quite a bit at first from one location to another.

    Unless one integrated organization takes the whole health care dollar and the whole risk associated with that dollar, then you have what we have now – every organization tries to grab as much of the dollar as they can and plays hot potato with the risk. That is why ACOs are failing and will fail.

    I find it interesting that, of the 114 original Medicare ACOs from the first year, only 54 hit their targets. And of those 54, only 29 received bonuses. And 21 of those 29 ACOs that received bonuses were physician-led. What’s the p-value on that?

    Please check out the link, I think perusing it gave me a better grasp of what “Population Health” means.

  21. William Palmer MD says:

    Greg, it’s easier to describe what Population Health is not:

    I’ll guess nothing about THC and its effect on fertility rates.

    Probably nothing on single parent families.

    Certainly nothing about tax rates and clinical depression.

    Almost surely there will be no talk about the political vs. business consumers of prostitute services, college loans and divorce rates, vaccine take-up and new age music, welfare and morbidity statistics, and heat spells vs cold spells…which are more dangerous? And lastly, which college major leads to longer life and lower debt?

    …these will all not be in the syllabus.

  22. wanda j. Jones says:

    All–This is a topic that will not go away and that deserves our considered discussion and communications.

    First: Do we think that Population Health is to be led from the top or from the local area, that should encompass the main parties that affect healthcare as it deals with the population at all its levels: the individual, family, employee, and customer–the “earner” of the healthcare dollar, then the purchaser, business or government; then the health plan, then the provider, from the most immediate unit of care to the next level, or clinical service or program, then the next level, or the organization that finds and manages a whole delivery system in the local area.

    Then, do we think that improvements in the health of the population can be achieved by asking for reports of “outcomes” within a financial incentive approach? What’s wrong? Few policy people ask for information about the “input”–how sick were people when they presented to the health system, then what change in their health status was achieved? Finally, why are financial incentives allocated to the provider and none to the customer/patient?

    But all this measurement frenzy should be toned down; it is probably impossible to identify all the factors that affect health status of individual patients or groups. Who is going to interpret these data? What do they know? How much fudging went on? How much does it cost to acquire, interpret and publish detailed health outcomes data?

    In my own practice, for four decades, I have taught “Population-based Planning” for providers, so they can address health problems for people who have similar conditions and who may or may not even be in the health system. If this is done well, there should be a diminution of unaddressed health problems, but as excellent this approach can be, it cannot deal with culturally-determined health behaviors very well.

    One of the things I find most disturbing about Obamacare is that the founders seem to believe that healthcare can be standardized and designed into “protocols.” The logic hierarchy I support is: individuals; cohorts of people with similar conditions; risk groups, or people who are not yet sick but have known risk factors; target groups, or those people who use the healthcare system in the same way; and “Populations” or groups of people defined by geography, employment or other gross indicators.

    It seems that different commentators or professionals or organizations find it most comfortable to deal with a subset of these classes, while being more or less allergic to the implication for other levels.

    ACO’s are a pitiful reflection of top-down policy-making.

    I advocate private sector healthcare redesign without a so-called partnership with the government.

    Wanda J. Jones, President
    New Century Healthcare Institute
    San Francisco

    • John R. Graham says:

      Thank you. I think we are experiencing another aspect of the problem that our ability to measure things is outpacing our ability to do anything about it.

      Nationalizing “population health” (except with respect to things like not letting bird flu come ashore) is fraught with the perils of central planning.

      How may times have I had conversations with someone from a county I’ve never visited start telling me about the health of the population in his county, and telling me things about his county that I would have no idea about.

      These issues are far too local to make general statements about how to solve them.

  23. William Palmer MD says:

    You can tell what population health is about by inserting almost any other noun.

    Population housing

    Population nutrition

    Population transportation

    Population clean water

    Population entertainment

    Population suffrage

    These make it very clear what is being discussed: someone is trying to find groups and classes that are not doing so well so that they can be turned into voters.

    Hi Wanda, you know me from days of yore. Congratulations.