The Affordable Care Act, Population Health Management, & a More Robust Research Agenda for Hospitals

Richard A. Skinner, Ph.D. – Senior Consultant   Harris Search Associates -  2018

Legal and political challenges to the Affordable Care Act (ACA) continue, but health care providers and especially hospitals are already deep into the Act’s implementation. Change of the kind and scope called for by ACA is complex. Here I explore how one of the key components for improving American health care may tax even the best-intentioned motives of those organizations that will be held accountable by the Act.

Writing well in advance of ACA’s enactment, Berwick, Nolan and Whittington (2007) noted:

Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Preconditions for this include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an “integrator”) that accepts responsibility for all three aims for that population. The integrator’s role includes at least five components: partnership with individuals and families, redesign of primary care, population health management, financial management, and macro system integration.

The “population health management” component will likely entail the integrator obtaining or developing a more robust research capacity with which to assess and demonstrate the efficacy of efforts made by both the integrator and its partner organizations to improve the health status of a given population. Unless the integrator is prepared to assume sole responsibility for the health status of the selected population (a risky venture if done alone), other organizations are likely to play roles. The kinds of organizations that could be called upon to play those roles may be quite different than the integrator. The partner organizations may, in turn, generate very different kinds of data that nevertheless have to be incorporated into the population health management model the integrator adopts.

A recent Xerox Corporation "white paper" entitled "How social factors shape population health: Integrating the non-medical sources of health issues," depicts the challenge an integrator faces by noting that studies reveal as much as 60 percent of the factors that account for population health are social, environmental or behavioral in nature and "outside" what happens in a doctor's office or a hospital.

Beyond hospital.jpg

Consider the case of a hospital that is home to a medical school but not affiliated with a research university. Located in what were the early and therefore are now older rings of suburbs that grew up as residents left urban areas in the 1960s, - 70s and -80s, the hospital has seen its catchment area change. The residents are older persons, long-term residents as well as a younger but less-affluent cohort who more recently gained homeownership in aging suburbs. Whereas the former still rely on established religious and civic organizations, the latter often seek to create their own but necessarily newer institutions. 

Older residents have little or no contact with schools, but the younger residents have substantial contact via their children of school age. However, the information collected by schools is not typically seen as having a direct or immediate effect on health and well-being and may therefore not contribute a great deal to an understanding of impacts on an identified population served by the local hospital.

VFWs’ and American Legion posts’ memberships have dwindled in number, while cultural organizations that serve immigrants are less apt to acquire, maintain, or analyze information that could be used to assess whether and which of their actions actually do what was intended, that is, contribute to the health and well-being of the populations they serve.

Public health agencies are more likely to have information about population health, but such data are usually aggregate measures and as such difficult to associate with individual patient well-being.

Employers often collect data on workplace accidents and injuries and frequently use very visible signage such as “413 consecutive work days without an accident” to instill an awareness of job safety in employees. Tying such data, again in their aggregate form, to individual well-bring is problematic, although correlating them with overall measures of population health can help descriptively.

Public safety agencies collect reams of data on incidents such as fire, acts of violence, and the like but linking them to individual or collective population health seldom rises to the level of causal inference.

But even if sources and kinds of data are overcome, the local hospital institutional research function will be hard-pressed to sort out the relative contributions of agencies outside the hospital to population health. Understanding precisely the effects of actions taken by health-care providers within the hospital with members of the selected population is a daunting task as is: extending it to the actions taken by “external” agencies and organizations compounds the challenge.

And yet, few would question that a hospital – no matter how connected to its catchment area and regardless of the strength of coordination with various other agencies – can alone effect the kinds of change in health that America needs and Americans deserve. A system of care that focuses so much on treating illness and injury at the expense of promoting health and preventing sickness and impairment is already acknowledged to be one that even an affluent society will struggle to afford. At the same time, hospitals will need to change in profound ways if they are to join forces with other organizations to establish a new kind of health care system.

That change will include expanding the research capacity of hospitals well beyond the functions they now carry out in clinical and laboratory studies and assessments and beyond the quality of care measures that are produced as a result of care practices and protocols, most of which take place within or at the direction of health-care professionals who work in hospitals. The “brave new world” of the Affordable Care Act includes hospitals needing to embrace and understand better the work done by their societal partners who, together, seek to manage the health of a population. That research capacity seldom exists in most hospitals, yet it will be needed and needed sooner rather than later.

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