Population health management – Coming soon to a province near you?

Brian N. Jobse, PhD, Isra Levy, MBBCh, MSc, and Owen Adams, PhD

 

ARTICLE

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Internationally, two trends in health care are becoming increasingly well established. One is the growing recognition that health care is just one determinant of health status. Prevention and health promotion have a large role to play by affecting the social determinants of health and the sectors that represent them. The second trend is experimentation with approaches to systems funding that aim, increasingly, to share risk and benefits between funders and providers. Together, these trends form the impetus for what is becoming known as population health management (PHM). Canada has been a pioneer in developing the concepts, but international experience suggests that it has been a laggard in implementing them. In moving forward, critical success factors for Canada include health information management, multisectoral collaboration, and clinical leadership.

 

KEY WORDS: determinants of health, health care system funding, health information management, multisectoral collaboration, clinical leadership, system integration

 

A Canadian perspective

 

A large majority of Canadians continue to see health care improvement as a primary concern for government.1 Escalating costs, at least partly attributable to an aging population and a greater burden of chronic disease,2,3 demonstrate the need for change, but policymakers struggle to introduce effective innovation. Where should we turn for inspiration? The health system is obviously an important input with regard to individual health, but the 2009 Canadian Senate Subcommittee on Population Health Final Report highlights that 75% of health is attributable to other determinants.4 Long before this report, Canadians were playing a large role in the development of this line of social inquiry,5 but the implementation of public health measures and the integration of these concepts into health care have been limited. Top

 

Understanding and accepting the social determinants of health in a society is an area in which Canadians have had important impacts on the development of population health models. Key to this work is acceptance of the 1946 World Health Organization constitutional statement that “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”6

 

The record of the Canadian perspective and input begins with the Lalonde Report of 1974 entitled “A new perspective on the health of Canadians,”5 which described the factors of health as human biology, lifestyle, the organization of health care, and the social and physical environments in which people live. The upstream determinants of health, and health promotion as a tool to impact these determinants, were central themes.

 

The Epp Report of 1986, entitled “Achieving health for all,”7 continued in this vein by highlighting preventable disease, stress, and chronic conditions as major challenges to health. Of importance, this report also emphasized the social support, from both government and community, needed to facilitate healthy outcomes.

 

Further elaboration on the Lalonde framework was provided in 1990. In “Producing health, consuming health care,” Evans and Stoddart8 advanced the Lalonde model to describe the interaction between social, environmental, and biological elements of health, their relation to general health and, ultimately, the overall well-being of an individual. Effectively, the authors position health care, and the associated costs, within the social feedback cycles that describe our society. Top

 

If Canadians were at the forefront in building these foundational ideas, why haven’t they been more effectively implemented in the decades since? Although the Public Health Agency of Canada currently provides a framework for a population health management (PHM)-style approach, there is little evidence of an implementation strategy. Increased provincial reliance on regional health authorities is an example of the shift toward management of geographically defined populations, a stance that reflects a core consideration of PHM approaches. However, there seems to be little acknowledgement of PHM as an option in Canadian health systems. A universal access-based system should surely favour adopting methods to impact the social determinants of health; so, why then, is PHM currently a foreign concept best exemplified south of the border?

 

Defining population health management

 

PHM can be narrowly interpreted as the use of patient-level socioeconomic and geographic data to direct health resources and assess key population-level outcome indicators, such as life expectancy. Ideally, PHM is a strategy whereby population health status is improved by accounting for multiple determinants. Again, the current health care system is an important but relatively small contributor to life-long health. Top

 

As an approach to health system integration and improvement, PHM is arguably the contemporary extension of population health concepts that were shaped in Canada,5,7,8 but are rapidly being adopted elsewhere, especially in the United States. For example, a PubMed search for “population health management” at the time of the writing of this article yielded 130 results, of which only 11 date before 2010 and only two have a Canadian connection. Although publications on this subject are described in various ways, the message remains that PHM is taking off in the United States while it seems there is little momentum in Canada.

 

Risk sharing

 

There are two dimensions to provider risk sharing. The first is managing risk by contracting to provide all necessary care for an individual for a fixed rate of payment for a specified time. The second is sharing risk between the funder and provider by agreeing to share in savings or losses if care is provided at a return either less or more costly compared to some predetermined benchmark (e.g., growth rate in the previous year’s costs). Top

 

Integrated delivery systems

 

Integrated delivery systems typify risk-sharing behaviour and have been evolving over the last several decades. A number of US health care providers neatly illustrate this model; perhaps the best example is Kaiser Permanente, which boasts operating revenues and population served not dissimilar to those of the Ontario Ministry of Health and Long-Term Care.9 This health care provider was founded on the experience that charging individuals a flat yearly rate for health care services reduces financial barriers to care and leads to increased use of health interventions, limiting the scope and cost of long-term morbidities. Population health information, then, became a great commodity in a competitive market, as resource development could be directed toward limiting upstream negative determinants.

 

Associated providers, generally led by physicians, are incentivized by capitated budgets and shared savings arrangements to create efficiency and reinforce population well-being.9 This, in turn, encourages continued service use as a result of greater user satisfaction. This model also encourages fast integration of new technologies and concepts to improve efficiency and user experience. Today, the assorted entities that make up the Kaiser Permanente (working cooperatively) have created a single integrated electronic record system with online access for users.9 As such, population health data are readily available to inform best practices, identify problems, and lead to tailored solutions. Top

 

In brief, Kaiser Permanente represents the most established case of a large-scale PHM approach, demonstrating the potential for application elsewhere. It is important to note, however, that Kaiser had the opportunity to develop slowly and represents a model of efficiency in a competitive market more so than it does a model dedicated to the social determinants of health. That said, the example stands as evidence for the success of preventative PHM.

 

Emergence of accountable care organizations

 

The Triple Aim framework, developed by Berwick, Nolan, and Whittington with the Institute for Healthcare Improvement (IHI) in 2008,15 succinctly describes the core concepts of PHM as they relate to service providers: improving the experience and quality of care, improving the health of populations, and reducing the per capita cost of health care. Since 2010, Whittington and colleagues16 have provided an update of Triple Aim framework practices based on experience from IHI collaborations aiming to reorient health care delivery systems toward PHM approaches. Top

 

The proliferation of accountable care organizations (ACOs) in the US also falls into this time frame, following the Patient Protection and Affordable Care Act of 2010, which proved to be a major driver for PHM implementation. Within this legislation, a shared savings plan for the Medicare program was established that rewards ACOs that are able to lower their growth in health care costs while meeting specified quality standards. ACOs can accept either one-sided (shared savings) or two-sided (shared savings or losses) risk-sharing models.17

 

Overall, ACOs have experienced fairly profound success in improving quality of care and most of the original participant organizations have opted to continue on under ACO frameworks.18 It should also be noted that the track record for cost savings is much less conclusive.18,19 Several of the obvious issues may not apply to the Canadian context, but it is becoming clear that appropriate incentivization across the various aspects of health care provision are necessary to engender success.18 Top

 

It is also becoming apparent that physician and clinical leadership have a very large role to play in the success of PHM approaches to health care.20 Physician involvement in redesigning health systems and overcoming resistance to change, both financial and procedural, is undoubtedly an important facet of the successful transition to a new paradigm. As evidenced by ACOs, the growing trend to share risks between funders and care providers is likely key to creating momentum toward the goal of health care improvement.

 

Limited Canadian exploration

 

Of relevance to this discussion are the projects supported by the Canadian Foundation for Healthcare Improvement,21 indicating, in similar fashion to the comparable examples south of the border, that the change to PHM is a complex realignment that requires concerted and sustained efforts along multiple social trajectories.22 Various other Canadian ventures into PHM approaches to solving various pressing societal health concerns are detailed in a 2014 report from the Canadian Institute for Health Information.23 A further article from this organization describes the options, benefits, misconceptions, and pitfalls of implementing ACO-style health system management in Canada, using Ontario as a case study.19 Ontario is also currently working toward reducing expenditures by increasing service integration through community “health links,” an emulation of the PHM paradigm without the population health feedback to truly assess impact. Despite these examples and some positive momentum toward PHM ideologies, there is currently no large-scale (provincial) example of a fully integrated PHM-oriented health care network in Canada. Top

 

Critical factors for implementation

 

Instead of the generally accepted view that the health care system is the main mode of disease and illness treatment, the PHM paradigm integrates health care as only one (albeit a pivotal) determinant of individual well-being and population health outcomes. As such, PHM frameworks require health care systems to engage with individuals and their communities, work with governments and population health agencies to intersect emerging issues, and develop multidisciplinary and inter-sectoral collaborations to provide a higher standard of care. The PHM approach acknowledges that relevant and timely information is critical to decision-making and, therefore, requires measurement of outcomes at the population level, whether that population is large or small.

 

Interest in PHM continues to develop, as evidenced by a broadening body of Canadian academic literature revolving around the social determinants of health and aimed at policymakers.24 The chaotic state of the diverse terminology and confusion regarding roles and responsibilities25 requires delineation of what is likely necessary to achieve success of implementation in a large-scale context, such as an entire provincial health care system. The three following concepts, therefore, are critical to the successful establishment of PHM in Canada. Similar to the IHI’s Triple Aim, all three facets are contingent on one another, helping to explain why progress in this area has been slow without a concerted effort by policymakers, population health agencies, and the medical community. Top

 

Information management

 

Health data are integral to care delivery, research, and policymaking. Electronic health records are currently in varying states of implementation across Canada, but, although progress in adoption has been steady,26 integration of records across health care environments is limited.27

 

A single, compulsory set of standards for all health-related services allows any provider to quickly understand the history and needs of a patient and to better communicate treatment options and other lifestyle recommendations. With regard to population health, an integrated health records system allows for the necessary research to assess population outcomes, appropriately use limited resources, and mobilize stakeholders.23

 

Patient engagement is also served by the accessibility of a system-wide electronic platform. Not only can this platform serve as an educational repository and a source of public health information, but it can also enable online provision of services, especially where access to appropriate expertise is an issue.9 Citizen engagement in the health care system should not be underestimated, as it has the potential to effect change in a broader, societal sense. Information management is a key to this endeavour, empowering patients by allowing greater access to the tools and understanding required to impact their health. Top

 

Multisectoral collaboration

 

In the wider societal sense, cooperation between governments, public health agencies, the health system, and many other stakeholders is necessary to facilitate any PHM-style approach. Collaboration with social services and education sectors are evident connections, but other sectors that could affect long-term health trends include agriculture, transportation, and land use, just to name a few. Governments should aim to facilitate knowledge-sharing among all levels and districts, but especially between public health and health sectors.28 Top

 

The 2009 final report of the Senate Subcommittee on Population Health4 positions the necessary outlook as a “whole-of-government” approach, with direct involvement of the Prime Minister in a Cabinet committee overseeing participation of various departments and agencies encompassing education, finance, employment, health, and the environment. A health lens in all policies, and across all departments, is seen as a necessary point of view to facilitate the transition to a population health model. Because health and the economy are inextricably linked,4,8 the role of politicians in adopting this model is clear; investment and advocacy for population health must become the norm to increase well-being and enhance economic productivity in the long term.

 

The framework for incentivization of PHM approaches will also be an evolving issue to be negotiated among health care professionals, stakeholders, and policymakers; medical leadership will be vital to this process, as the funding formulas for various services and regions will require different solutions that speak to both the professional performance of health care providers and the implementation of public-health-derived measures of success. Top

 

From the standpoint of cooperation within and between health sectors, PHM methodology requires an individualized, patient-focused standard that aims to address health concerns through integrative needs assessment and delivery. As such, the onus is on primary care to ensure that individuals receive support, resources, and referrals to a broader range of services than is traditionally available.

 

This, in turn, relies on cooperation outside the primary care setting to ensure integrated delivery. Further, outreach and collaboration require local relationship building to successfully affect upstream determinants of health, thereby reducing costs related to chronic and complex diseases.

 

Examples of this kind of outreach are becoming more common, with work by HealthPartners standing out as an early effort to create sustained partnerships between health, education, non-profits, and government by adopting a community business model.29 The organizational shift by this non-profit health insurance/integrated delivery provider has provided the means and motivation for a health system to influence upstream determinants in the local community. It is clear from this example, and others, that a positive impact is possible, but questions around incentives and a continuing policy-driven effort remain. Top

 

Clinical leadership

 

A critical point in the development of PHM is that medical practitioners need a greater voice in their areas of expertise and that those areas represent a dynamic, shifting landscape of problems, needs, and solutions.30 “Chief population health officer” is an emerging role in the US, speaking to the expertise needed to design and implement population health strategies. This position is often integrated into clinical executive bodies and is likely vital to creating an environment that facilitates sustained progress.31

 

From a ground-level standpoint, however, clinicians are ultimately in the best position to make changes reflecting both increased quality of patient care and efficiency within their practices. The current CanMEDS framework from the Royal College of Physicians and Surgeons of Canada addresses many concepts needed in this endeavour.32 Within the Leader role, a key competency is to engage in the stewardship of health care resources. Within the Health Advocate role, an enabling competency indicates that physicians should improve clinical practice by applying a process of continuous quality improvement to disease prevention, health promotion, and health surveillance activities.32 Top

 

Successful implementation must also look to enable the diversification of systems to better empower service providers given their particular populations, environments, and challenges.23 It follows that, given the latitude to problem-solve, the appropriate leadership structure, and the incentive to produce greater population health (not just the absence of disease), health care systems will adapt to better account for the well-being of the individuals with whom they interact. The strength of US examples provides some validation of this stance, although an emphasis on funder–provider agreement to public betterment seems an implicit warning if the long-term success of such a paradigm shift is the goal.

 

The need for clinical leadership also extends beyond particular areas of expertise and into the broader policymaking environment. There is no doubt that the experience and drive exists for this venture in the Canadian context; thus, enabling leadership on both provincial and national stages is primarily an issue of building appropriate venues and opportunities to allow the medical community to truly take part in the restructuring of health systems.30 Unifying the profession behind shared values of conduct as well as a modern ethical framework is a first step toward providing the landscape for clinical leadership.33 As medical associations, both new and old, take on greater roles in health advocacy, members will need to be more willing to participate in forums establishing direction and policy positions. Top

 

Implications for physicians

 

Without the ability to prioritize patient health and population health concurrently, real positive progress within the Canadian health system will continue to be elusive. Dynamic situations, such as the modern health system, require communication, willingness to implement new ideas, disruptive innovation, and the perspective that no one framework is infinitely applicable. Above this, consensus and commitment to a strategic direction will shape the effectuality of implementation. Top

 

The foregoing suggests three key implications for physicians and medical organizations in engaging in PHM approaches. First, physicians can get involved in reform and transformation initiatives. If nothing else, physicians should realize their potential for leadership, as they can both champion efforts towards reform and impact the transformation of patient care. Second, physicians can play a key role in establishing intersectoral collaboration and partnerships, both through their workplaces and through the medical associations to which they belong. Finally, physicians need to facilitate the development of timely, population-based data systems integrating individual clinical records, indicators of the social determinants of health, and information from other parts of the health and social services delivery system.

 

The health system, as a whole, stands at an important crossroads between the status quo and a fundamental shift in societal impact. Physicians can ensure that they, and patients, are best represented by becoming informed and active in the restructuring process, wherever opportunities arise and at all levels of governance.30 Provinces are moving ahead with health system reforms, but many physicians do not seem to be engaged in the process and, instead, are only reacting to policy decisions.

Establishing leadership goes hand in hand with determining direction. It may be of import to the discussion to consider that medical ethics is generally concerned not only with the well-being of any patient in their role within the health care system, but also in their well-being in a broader societal context. Physicians who hold to this view should consider the ramifications of any particular style of delivery. Although PHM appears to promise greater financial sustainability for the health care system, it also speaks to the ethical values rooted in medical practice and the societal values that led to the creation of a universal access system in Canada. Top

 

Canada has been a leader in the development of the population health perspective, the impact of lifestyle on well-being, and the multiple determinants of health. There is a growing interest in PHM for all of the reasons already described, the examples and comparisons necessary to conceptualize an approach of this style in the Canadian context have been detailed,9 and the framework for application to the Canadian health system continues to develop.19 It is also noteworthy that Accreditation Canada has introduced standards for population health and wellness.34

 

In realigning the delivery of health care, emphasis on improvement in health outcomes may be what is needed in Canada as both the driving impetus for change and the evaluation tool to make change possible.35 However incentivization is conceived, the US experience would suggest that a focus on outcomes, with risk–benefit sharing of costs, will be necessary to decrease the rates of preventable disease and health system use, ultimately reducing costs and increasing prosperity.8 Health really does matter for the well-being of society and the economic outlook of the future, but, to improve the health of Canadians beyond what has been achieved to date, there is a need to look past today’s work in managing costs toward the long-term benefits of understanding true population health status outcomes. Top

 

Glossary

 

Public health – “Public health is the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society.”10

Population health – “The health outcomes of a group of individuals, including the distribution of such outcomes within the group.”11 (Generally taken to refer to a geographic population.)

Population health management – The application of population health concepts and measurements in reference to specific patient populations.12

Population health approach – An approach “that aims to improve the health of the entire population and to reduce health inequities among population groups.”13

Social determinants of health – The conditions in which people are born, grow up, live, work, and age, and the systems put in place to deal with illness.14 Top

 

 

References

1.Priorities, values, and leadership: Canadian public opinion. Toronto: Ipsos Canada; 2017.

2.National health expenditure trends, 1975 to 2016. Ottawa: Canadian Institute of Health Information; 2016.

3.How healthy are Canadians? A trend analysis of the health of Canadians from a healthy living and chronic disease perspective. Ottawa: Public Health Agency of Canada; 2017.

4.A healthy, productive Canada: a determinant of health approach. Ottawa: Standing Senate Committee on Social Affairs, Science and Technology; 2009.

5.Lalonde M. A new perspective on the health of Canadians: a working document. Ottawa: Government of Canada; 1981. Available: https://tinyurl.com/o5jum8w (accessed Aug. 2017).

6.Preamble to the constitution of WHO as adopted by the International Health Conference, New York, 19-22 June 1946. Geneva: World Health Organization; 1946.

7.Epp J. Achieving health for all: a framework for health promotion. Ottawa: Health and Welfare Canada; 1986. Available: https://tinyurl.com/y7un8nvl (accessed Aug. 2017).

8.Evans RG, Stoddart GL. Producing health, consuming health care. Soc Sci Med 1990;31(12):1347-63.

9.Townsend M. Learning from Kaiser Permanente: integrated systems and healthcare improvement in Canada. Ottawa: Canadian Foundation for Healthcare Improvement; 2014.

10.Acheson D. Public health in England: the report of the Committee of Inquiry into the Future Development of the Public Health Function. London: Her Majesty’s Stationery Office; 1988.

11.Kindig D, Stoddart G. What is population health? Am J Public Health 2003;93(3):380-3.

12.Kindig D. What are we talking about when we talk about population health? Bethesda, Md.: Health Affairs Blog; 2015. Available: https://tinyurl.com/y8p3zn5t (accessed Aug. 2017).

13.What is the population health approach? Ottawa: Public Health Agency of Canada; 2012. Available: https://tinyurl.com/y7s2cwxu (accessed Aug. 2017).

14.Commission on the Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization; 2008.

15.Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood) 2008;27(3):759-69.

16.Whittington JW, Nolan K, Lewis N, Torres T. Pursuing the Triple Aim: the first 7 years. Milbank Q 2015;93(2):263-300.

17.Accountable care organizations: what providers need to know. Baltimore: Centers for Medicare & Medicaid Services; 2016.

18.Blackstone EA, Fuhr JP Jr. The economics of medicare accountable care organizations. Am Health Drug Benefits 2016;9(1):11-9.

19.Huynh TM, Baker GR, Bierman A, Klein D, Rudoler D, Sharpe G, et al. Exploring accountable care in Canada: integrating financial and quality incentives for physcians and hospitals. Ottawa: Canadian Foundation for Healthcare Improvement; 2014.

20.Colla CH, Lewis VA, Shortell SM, Fisher ES. First national survey of ACOs finds that physicians are playing strong leadership and ownership roles. Health Aff (Millwood) 2014;33(6):964-71.

21.Farmanova E, Kirvan C, Verma J, Mukerji G, Akunov N, Phillips K, et al. Triple Aim in Canada: developing capacity to lead to better health, care and cost. Int J Qual Health Care 2016;28(6):830-7.

22.Law MM, Kapur AK, Collishaw NE. Health promotion in Canada, 1974-2004: lessons learned. Ottawa: Canadian Medical Association; 2004.

23.Huynh TM. Population health and health care: exploring a population health approach in health system planning and decision-making. Ottawa: Canadian Institute for Health Information; 2014.

24.Lucyk K, McLaren L. Taking stock of the social determinants of health: a scoping review. PLoS One 2017;12(5):e0177306.

25.Cohen D, Huynh T, Sebold A, Harvey J, Neudorf C, Brown A. The population health approach: a qualitative study of conceptual and operational definitions for leaders in Canadian healthcare. SAGE Open Med 2014;2:2050312114522618.

26.A conversation about digital health: annual report 2015-2016. Toronto: Canada Health Infoway; 2016.

27.Chang F, Gupta N. Progress in electronic medical record adoption in Canada. Can Fam Physician 2015;61(12):1076-84.

28.Neudorf C. Integrating a population health approach into healthcare service delivery and decision making. Healthc Manage Forum 2012;25(3):155-9.

29.Isham GJ, Zimmerman DJ, Kindig DA, Hornseth GW. HealthPartners adopts community business model to deepen focus on nonclinical factors of health outcomes. Health Aff (Millwood) 2013;32(8):1446-52.

30.Van Aerde J, Dickson, G. Accepting our responsibility: a blueprint for physician leadership in transforming Canada’s health care system (white paper). Ottawa: Canadian Society of Physician Leaders; 2017.

31.Punke H. Health system C-suiters, meet the chief population health officer. Becker’s Hosp Rev 2014;Mar. 14. Available: https://tinyurl.com/ltlzkcd (accessed 10 Aug. 2017).

32.Frank JR, Snell L, Sherbino J (editors). CANMEDS 2015 Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015. Available: file://E:/Downloads/canmeds-full-framework-e.pdf (accessed 10 Aug. 2017).

33.Buckley JB, Bernard A, Gruenwoldt E, Bensimon CM, Blackmer J. Medical professionalism and physician leadership: the time for action is now. Can J Physician Leadersh 2017;3(5):85-90. Available: https://tinyurl.com/mp3pdl2 (accessed Aug. 2017).

34.Population health and wellness. Ottawa: Accreditation Canada; 2017.

35.Wise A. A health outcomes fund for Canada: how paying for outcomes could improve health and deliver better value for money. Toronto: MaRS Centre for Impact Investing; 2017.

 

Authors

Brian Jobse, PhD, is a medical scientist and health policy analyst, currently working with the Canadian Medical Association while pursuing a master’s degree in public policy at Carleton University, Ottawa.

 

Isra Levy, MBBCh, MSc, FRCPC, FACPM, is the medical officer of health in Ottawa; before that he was director of health programs at the Canadian Medical Association.

 

Owen Adams, PhD, is the chief policy advisor at the Canadian Medical Association, Ottawa.

 

Correspondence to: owen.adams@cma.ca

 

This article has been reviewed by a panel of physician leaders.

Top

 

A large majority of Canadians continue to see health care improvement as a primary concern for government.1 Escalating costs, at least partly attributable to an aging population and a greater burden of chronic disease,2,3 demonstrate the need for change, but policymakers struggle to introduce effective innovation. Where should we turn for inspiration? The health system is obviously an important input with regard to individual health, but the 2009 Canadian Senate Subcommittee on Population Health Final Report highlights that 75% of health is attributable to other determinants.4 Long before this report, Canadians were playing a large role in the development of this line of social inquiry,5 but the implementation of public health measures and the integration of these concepts into health care have been limited. Top

Internationally, two trends in health care are becoming increasingly well established. One is the growing recognition that health care is just one determinant of health status. Prevention and health promotion have a large role to play by affecting the social determinants of health and the sectors that represent them. The second trend is experimentation with approaches to systems funding that aim, increasingly, to share risk and benefits between funders and providers. Together, these trends form the impetus for what is becoming known as population health management (PHM). Canada has been a pioneer in developing the concepts, but international experience suggests that it has been a laggard in implementing them. In moving forward, critical success factors for Canada include health information management, multisectoral collaboration, and clinical leadership.

 

KEY WORDS: determinants of health, health care system funding, health information management, multisectoral collaboration, clinical leadership, system integration

 

A Canadian perspective

 

A large majority of Canadians continue to see health care improvement as a primary concern for government.1 Escalating costs, at least partly attributable to an aging population and a greater burden of chronic disease,2,3 demonstrate the need for change, but policymakers struggle to introduce effective innovation. Where should we turn for inspiration? The health system is obviously an important input with regard to individual health, but the 2009 Canadian Senate Subcommittee on Population Health Final Report highlights that 75% of health is attributable to other determinants.4 Long before this report, Canadians were playing a large role in the development of this line of social inquiry,5 but the implementation of public health measures and the integration of these concepts into health care have been limited. Top

 

Understanding and accepting the social determinants of health in a society is an area in which Canadians have had important impacts on the development of population health models. Key to this work is acceptance of the 1946 World Health Organization constitutional statement that “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”6

 

The record of the Canadian perspective and input begins with the Lalonde Report of 1974 entitled “A new perspective on the health of Canadians,”5 which described the factors of health as human biology, lifestyle, the organization of health care, and the social and physical environments in which people live. The upstream determinants of health, and health promotion as a tool to impact these determinants, were central themes.

 

The Epp Report of 1986, entitled “Achieving health for all,”7 continued in this vein by highlighting preventable disease, stress, and chronic conditions as major challenges to health. Of importance, this report also emphasized the social support, from both government and community, needed to facilitate healthy outcomes.

 

Further elaboration on the Lalonde framework was provided in 1990. In “Producing health, consuming health care,” Evans and Stoddart8 advanced the Lalonde model to describe the interaction between social, environmental, and biological elements of health, their relation to general health and, ultimately, the overall well-being of an individual. Effectively, the authors position health care, and the associated costs, within the social feedback cycles that describe our society. Top

 

If Canadians were at the forefront in building these foundational ideas, why haven’t they been more effectively implemented in the decades since? Although the Public Health Agency of Canada currently provides a framework for a population health management (PHM)-style approach, there is little evidence of an implementation strategy. Increased provincial reliance on regional health authorities is an example of the shift toward management of geographically defined populations, a stance that reflects a core consideration of PHM approaches. However, there seems to be little acknowledgement of PHM as an option in Canadian health systems. A universal access-based system should surely favour adopting methods to impact the social determinants of health; so, why then, is PHM currently a foreign concept best exemplified south of the border?

 

Defining population health management

 

PHM can be narrowly interpreted as the use of patient-level socioeconomic and geographic data to direct health resources and assess key population-level outcome indicators, such as life expectancy. Ideally, PHM is a strategy whereby population health status is improved by accounting for multiple determinants. Again, the current health care system is an important but relatively small contributor to life-long health. Top

 

As an approach to health system integration and improvement, PHM is arguably the contemporary extension of population health concepts that were shaped in Canada,5,7,8 but are rapidly being adopted elsewhere, especially in the United States. For example, a PubMed search for “population health management” at the time of the writing of this article yielded 130 results, of which only 11 date before 2010 and only two have a Canadian connection. Although publications on this subject are described in various ways, the message remains that PHM is taking off in the United States while it seems there is little momentum in Canada.

 

Risk sharing

 

There are two dimensions to provider risk sharing. The first is managing risk by contracting to provide all necessary care for an individual for a fixed rate of payment for a specified time. The second is sharing risk between the funder and provider by agreeing to share in savings or losses if care is provided at a return either less or more costly compared to some predetermined benchmark (e.g., growth rate in the previous year’s costs). Top

 

Integrated delivery systems

 

Integrated delivery systems typify risk-sharing behaviour and have been evolving over the last several decades. A number of US health care providers neatly illustrate this model; perhaps the best example is Kaiser Permanente, which boasts operating revenues and population served not dissimilar to those of the Ontario Ministry of Health and Long-Term Care.9 This health care provider was founded on the experience that charging individuals a flat yearly rate for health care services reduces financial barriers to care and leads to increased use of health interventions, limiting the scope and cost of long-term morbidities. Population health information, then, became a great commodity in a competitive market, as resource development could be directed toward limiting upstream negative determinants.

 

Associated providers, generally led by physicians, are incentivized by capitated budgets and shared savings arrangements to create efficiency and reinforce population well-being.9 This, in turn, encourages continued service use as a result of greater user satisfaction. This model also encourages fast integration of new technologies and concepts to improve efficiency and user experience. Today, the assorted entities that make up the Kaiser Permanente (working cooperatively) have created a single integrated electronic record system with online access for users.9 As such, population health data are readily available to inform best practices, identify problems, and lead to tailored solutions. Top

 

In brief, Kaiser Permanente represents the most established case of a large-scale PHM approach, demonstrating the potential for application elsewhere. It is important to note, however, that Kaiser had the opportunity to develop slowly and represents a model of efficiency in a competitive market more so than it does a model dedicated to the social determinants of health. That said, the example stands as evidence for the success of preventative PHM.

 

Emergence of accountable care organizations

 

The Triple Aim framework, developed by Berwick, Nolan, and Whittington with the Institute for Healthcare Improvement (IHI) in 2008,15 succinctly describes the core concepts of PHM as they relate to service providers: improving the experience and quality of care, improving the health of populations, and reducing the per capita cost of health care. Since 2010, Whittington and colleagues16 have provided an update of Triple Aim framework practices based on experience from IHI collaborations aiming to reorient health care delivery systems toward PHM approaches. Top

 

The proliferation of accountable care organizations (ACOs) in the US also falls into this time frame, following the Patient Protection and Affordable Care Act of 2010, which proved to be a major driver for PHM implementation. Within this legislation, a shared savings plan for the Medicare program was established that rewards ACOs that are able to lower their growth in health care costs while meeting specified quality standards. ACOs can accept either one-sided (shared savings) or two-sided (shared savings or losses) risk-sharing models.17

 

Overall, ACOs have experienced fairly profound success in improving quality of care and most of the original participant organizations have opted to continue on under ACO frameworks.18 It should also be noted that the track record for cost savings is much less conclusive.18,19 Several of the obvious issues may not apply to the Canadian context, but it is becoming clear that appropriate incentivization across the various aspects of health care provision are necessary to engender success.18 Top

 

It is also becoming apparent that physician and clinical leadership have a very large role to play in the success of PHM approaches to health care.20 Physician involvement in redesigning health systems and overcoming resistance to change, both financial and procedural, is undoubtedly an important facet of the successful transition to a new paradigm. As evidenced by ACOs, the growing trend to share risks between funders and care providers is likely key to creating momentum toward the goal of health care improvement.

 

Limited Canadian exploration

 

Of relevance to this discussion are the projects supported by the Canadian Foundation for Healthcare Improvement,21 indicating, in similar fashion to the comparable examples south of the border, that the change to PHM is a complex realignment that requires concerted and sustained efforts along multiple social trajectories.22 Various other Canadian ventures into PHM approaches to solving various pressing societal health concerns are detailed in a 2014 report from the Canadian Institute for Health Information.23 A further article from this organization describes the options, benefits, misconceptions, and pitfalls of implementing ACO-style health system management in Canada, using Ontario as a case study.19 Ontario is also currently working toward reducing expenditures by increasing service integration through community “health links,” an emulation of the PHM paradigm without the population health feedback to truly assess impact. Despite these examples and some positive momentum toward PHM ideologies, there is currently no large-scale (provincial) example of a fully integrated PHM-oriented health care network in Canada. Top

 

Critical factors for implementation

 

Instead of the generally accepted view that the health care system is the main mode of disease and illness treatment, the PHM paradigm integrates health care as only one (albeit a pivotal) determinant of individual well-being and population health outcomes. As such, PHM frameworks require health care systems to engage with individuals and their communities, work with governments and population health agencies to intersect emerging issues, and develop multidisciplinary and inter-sectoral collaborations to provide a higher standard of care. The PHM approach acknowledges that relevant and timely information is critical to decision-making and, therefore, requires measurement of outcomes at the population level, whether that population is large or small.

 

Interest in PHM continues to develop, as evidenced by a broadening body of Canadian academic literature revolving around the social determinants of health and aimed at policymakers.24 The chaotic state of the diverse terminology and confusion regarding roles and responsibilities25 requires delineation of what is likely necessary to achieve success of implementation in a large-scale context, such as an entire provincial health care system. The three following concepts, therefore, are critical to the successful establishment of PHM in Canada. Similar to the IHI’s Triple Aim, all three facets are contingent on one another, helping to explain why progress in this area has been slow without a concerted effort by policymakers, population health agencies, and the medical community. Top

 

Information management

 

Health data are integral to care delivery, research, and policymaking. Electronic health records are currently in varying states of implementation across Canada, but, although progress in adoption has been steady,26 integration of records across health care environments is limited.27

 

A single, compulsory set of standards for all health-related services allows any provider to quickly understand the history and needs of a patient and to better communicate treatment options and other lifestyle recommendations. With regard to population health, an integrated health records system allows for the necessary research to assess population outcomes, appropriately use limited resources, and mobilize stakeholders.23

 

Patient engagement is also served by the accessibility of a system-wide electronic platform. Not only can this platform serve as an educational repository and a source of public health information, but it can also enable online provision of services, especially where access to appropriate expertise is an issue.9 Citizen engagement in the health care system should not be underestimated, as it has the potential to effect change in a broader, societal sense. Information management is a key to this endeavour, empowering patients by allowing greater access to the tools and understanding required to impact their health. Top

 

Multisectoral collaboration

 

In the wider societal sense, cooperation between governments, public health agencies, the health system, and many other stakeholders is necessary to facilitate any PHM-style approach. Collaboration with social services and education sectors are evident connections, but other sectors that could affect long-term health trends include agriculture, transportation, and land use, just to name a few. Governments should aim to facilitate knowledge-sharing among all levels and districts, but especially between public health and health sectors.28 Top

 

The 2009 final report of the Senate Subcommittee on Population Health4 positions the necessary outlook as a “whole-of-government” approach, with direct involvement of the Prime Minister in a Cabinet committee overseeing participation of various departments and agencies encompassing education, finance, employment, health, and the environment. A health lens in all policies, and across all departments, is seen as a necessary point of view to facilitate the transition to a population health model. Because health and the economy are inextricably linked,4,8 the role of politicians in adopting this model is clear; investment and advocacy for population health must become the norm to increase well-being and enhance economic productivity in the long term.

 

The framework for incentivization of PHM approaches will also be an evolving issue to be negotiated among health care professionals, stakeholders, and policymakers; medical leadership will be vital to this process, as the funding formulas for various services and regions will require different solutions that speak to both the professional performance of health care providers and the implementation of public-health-derived measures of success. Top

 

From the standpoint of cooperation within and between health sectors, PHM methodology requires an individualized, patient-focused standard that aims to address health concerns through integrative needs assessment and delivery. As such, the onus is on primary care to ensure that individuals receive support, resources, and referrals to a broader range of services than is traditionally available.

 

This, in turn, relies on cooperation outside the primary care setting to ensure integrated delivery. Further, outreach and collaboration require local relationship building to successfully affect upstream determinants of health, thereby reducing costs related to chronic and complex diseases.

 

Examples of this kind of outreach are becoming more common, with work by HealthPartners standing out as an early effort to create sustained partnerships between health, education, non-profits, and government by adopting a community business model.29 The organizational shift by this non-profit health insurance/integrated delivery provider has provided the means and motivation for a health system to influence upstream determinants in the local community. It is clear from this example, and others, that a positive impact is possible, but questions around incentives and a continuing policy-driven effort remain. Top

 

Clinical leadership

 

A critical point in the development of PHM is that medical practitioners need a greater voice in their areas of expertise and that those areas represent a dynamic, shifting landscape of problems, needs, and solutions.30 “Chief population health officer” is an emerging role in the US, speaking to the expertise needed to design and implement population health strategies. This position is often integrated into clinical executive bodies and is likely vital to creating an environment that facilitates sustained progress.31

 

From a ground-level standpoint, however, clinicians are ultimately in the best position to make changes reflecting both increased quality of patient care and efficiency within their practices. The current CanMEDS framework from the Royal College of Physicians and Surgeons of Canada addresses many concepts needed in this endeavour.32 Within the Leader role, a key competency is to engage in the stewardship of health care resources. Within the Health Advocate role, an enabling competency indicates that physicians should improve clinical practice by applying a process of continuous quality improvement to disease prevention, health promotion, and health surveillance activities.32 Top

 

Successful implementation must also look to enable the diversification of systems to better empower service providers given their particular populations, environments, and challenges.23 It follows that, given the latitude to problem-solve, the appropriate leadership structure, and the incentive to produce greater population health (not just the absence of disease), health care systems will adapt to better account for the well-being of the individuals with whom they interact. The strength of US examples provides some validation of this stance, although an emphasis on funder–provider agreement to public betterment seems an implicit warning if the long-term success of such a paradigm shift is the goal.

 

The need for clinical leadership also extends beyond particular areas of expertise and into the broader policymaking environment. There is no doubt that the experience and drive exists for this venture in the Canadian context; thus, enabling leadership on both provincial and national stages is primarily an issue of building appropriate venues and opportunities to allow the medical community to truly take part in the restructuring of health systems.30 Unifying the profession behind shared values of conduct as well as a modern ethical framework is a first step toward providing the landscape for clinical leadership.33 As medical associations, both new and old, take on greater roles in health advocacy, members will need to be more willing to participate in forums establishing direction and policy positions. Top

 

Implications for physicians

 

Without the ability to prioritize patient health and population health concurrently, real positive progress within the Canadian health system will continue to be elusive. Dynamic situations, such as the modern health system, require communication, willingness to implement new ideas, disruptive innovation, and the perspective that no one framework is infinitely applicable. Above this, consensus and commitment to a strategic direction will shape the effectuality of implementation. Top

 

The foregoing suggests three key implications for physicians and medical organizations in engaging in PHM approaches. First, physicians can get involved in reform and transformation initiatives. If nothing else, physicians should realize their potential for leadership, as they can both champion efforts towards reform and impact the transformation of patient care. Second, physicians can play a key role in establishing intersectoral collaboration and partnerships, both through their workplaces and through the medical associations to which they belong. Finally, physicians need to facilitate the development of timely, population-based data systems integrating individual clinical records, indicators of the social determinants of health, and information from other parts of the health and social services delivery system.

 

The health system, as a whole, stands at an important crossroads between the status quo and a fundamental shift in societal impact. Physicians can ensure that they, and patients, are best represented by becoming informed and active in the restructuring process, wherever opportunities arise and at all levels of governance.30 Provinces are moving ahead with health system reforms, but many physicians do not seem to be engaged in the process and, instead, are only reacting to policy decisions.

Establishing leadership goes hand in hand with determining direction. It may be of import to the discussion to consider that medical ethics is generally concerned not only with the well-being of any patient in their role within the health care system, but also in their well-being in a broader societal context. Physicians who hold to this view should consider the ramifications of any particular style of delivery. Although PHM appears to promise greater financial sustainability for the health care system, it also speaks to the ethical values rooted in medical practice and the societal values that led to the creation of a universal access system in Canada. Top

 

Canada has been a leader in the development of the population health perspective, the impact of lifestyle on well-being, and the multiple determinants of health. There is a growing interest in PHM for all of the reasons already described, the examples and comparisons necessary to conceptualize an approach of this style in the Canadian context have been detailed,9 and the framework for application to the Canadian health system continues to develop.19 It is also noteworthy that Accreditation Canada has introduced standards for population health and wellness.34

 

In realigning the delivery of health care, emphasis on improvement in health outcomes may be what is needed in Canada as both the driving impetus for change and the evaluation tool to make change possible.35 However incentivization is conceived, the US experience would suggest that a focus on outcomes, with risk–benefit sharing of costs, will be necessary to decrease the rates of preventable disease and health system use, ultimately reducing costs and increasing prosperity.8 Health really does matter for the well-being of society and the economic outlook of the future, but, to improve the health of Canadians beyond what has been achieved to date, there is a need to look past today’s work in managing costs toward the long-term benefits of understanding true population health status outcomes. Top

 

Glossary

 

Public health – “Public health is the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society.”10

Population health – “The health outcomes of a group of individuals, including the distribution of such outcomes within the group.”11 (Generally taken to refer to a geographic population.)

Population health management – The application of population health concepts and measurements in reference to specific patient populations.12

Population health approach – An approach “that aims to improve the health of the entire population and to reduce health inequities among population groups.”13

Social determinants of health – The conditions in which people are born, grow up, live, work, and age, and the systems put in place to deal with illness.14 Top

 

 

References

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2.National health expenditure trends, 1975 to 2016. Ottawa: Canadian Institute of Health Information; 2016.

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4.A healthy, productive Canada: a determinant of health approach. Ottawa: Standing Senate Committee on Social Affairs, Science and Technology; 2009.

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17.Accountable care organizations: what providers need to know. Baltimore: Centers for Medicare & Medicaid Services; 2016.

18.Blackstone EA, Fuhr JP Jr. The economics of medicare accountable care organizations. Am Health Drug Benefits 2016;9(1):11-9.

19.Huynh TM, Baker GR, Bierman A, Klein D, Rudoler D, Sharpe G, et al. Exploring accountable care in Canada: integrating financial and quality incentives for physcians and hospitals. Ottawa: Canadian Foundation for Healthcare Improvement; 2014.

20.Colla CH, Lewis VA, Shortell SM, Fisher ES. First national survey of ACOs finds that physicians are playing strong leadership and ownership roles. Health Aff (Millwood) 2014;33(6):964-71.

21.Farmanova E, Kirvan C, Verma J, Mukerji G, Akunov N, Phillips K, et al. Triple Aim in Canada: developing capacity to lead to better health, care and cost. Int J Qual Health Care 2016;28(6):830-7.

22.Law MM, Kapur AK, Collishaw NE. Health promotion in Canada, 1974-2004: lessons learned. Ottawa: Canadian Medical Association; 2004.

23.Huynh TM. Population health and health care: exploring a population health approach in health system planning and decision-making. Ottawa: Canadian Institute for Health Information; 2014.

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25.Cohen D, Huynh T, Sebold A, Harvey J, Neudorf C, Brown A. The population health approach: a qualitative study of conceptual and operational definitions for leaders in Canadian healthcare. SAGE Open Med 2014;2:2050312114522618.

26.A conversation about digital health: annual report 2015-2016. Toronto: Canada Health Infoway; 2016.

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28.Neudorf C. Integrating a population health approach into healthcare service delivery and decision making. Healthc Manage Forum 2012;25(3):155-9.

29.Isham GJ, Zimmerman DJ, Kindig DA, Hornseth GW. HealthPartners adopts community business model to deepen focus on nonclinical factors of health outcomes. Health Aff (Millwood) 2013;32(8):1446-52.

30.Van Aerde J, Dickson, G. Accepting our responsibility: a blueprint for physician leadership in transforming Canada’s health care system (white paper). Ottawa: Canadian Society of Physician Leaders; 2017.

31.Punke H. Health system C-suiters, meet the chief population health officer. Becker’s Hosp Rev 2014;Mar. 14. Available: https://tinyurl.com/ltlzkcd (accessed 10 Aug. 2017).

32.Frank JR, Snell L, Sherbino J (editors). CANMEDS 2015 Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015. Available: file://E:/Downloads/canmeds-full-framework-e.pdf (accessed 10 Aug. 2017).

33.Buckley JB, Bernard A, Gruenwoldt E, Bensimon CM, Blackmer J. Medical professionalism and physician leadership: the time for action is now. Can J Physician Leadersh 2017;3(5):85-90. Available: https://tinyurl.com/mp3pdl2 (accessed Aug. 2017).

34.Population health and wellness. Ottawa: Accreditation Canada; 2017.

35.Wise A. A health outcomes fund for Canada: how paying for outcomes could improve health and deliver better value for money. Toronto: MaRS Centre for Impact Investing; 2017.

 

Authors

Brian Jobse, PhD, is a medical scientist and health policy analyst, currently working with the Canadian Medical Association while pursuing a master’s degree in public policy at Carleton University, Ottawa.

 

Isra Levy, MBBCh, MSc, FRCPC, FACPM, is the medical officer of health in Ottawa; before that he was director of health programs at the Canadian Medical Association.

 

Owen Adams, PhD, is the chief policy advisor at the Canadian Medical Association, Ottawa.

 

Correspondence to: owen.adams@cma.ca

 

This article has been reviewed by a panel of physician leaders.

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