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Provider Opportunities for Population Health Improvement



November 5th, 2013

Significant changes in the health care sector have been set in motion or accelerated by the Affordable Care Act.  For health care providers, much of this activity has focused on improving patient care and lowering costs.  There are also numerous opportunities through the Affordable Care Act for health care providers to improve population health, either the population cared for by a provider or the broader geographic population.

Provider engagement in population health improvement is critical because quality of life and functional status are ultimately what matter to people.  These outcomes are directly affected by the prevalence of unhealthy behaviors and the incidence of disease.  In addition, the high and rising prevalence of chronic diseases, which is exacerbated by unhealthy behaviors, is perhaps the single most important factor in the growth of health care costs. Thus, an effective strategy to improve health outcomes and ensure long-term sustainable health care cost reductions is for providers to help individuals be as healthy as possible in their homes and communities.

Community Transformation grants.  For example, communities across the country are working together through the Community Transformation Grant program created by the Affordable Care Act to support community health and reduce chronic disease risk factors.  Grantees are engaging partners from multiple sectors, including health, education, transportation, and business, as well as faith-based organizations.  Several grantees are partnering directly with providers to not only expand delivery of clinical preventive services but also to increase referrals for patients to programs offering smoking cessation, physical activity, and increased availability of healthy food.  This is an important opportunity for providers to have the health education they offer during an office visit become further reinforced in a community setting.

Community health needs assessments.  As a second example, under the Affordable Care Act, charitable hospitals are conducting community health needs assessments, and adopting implementation strategies addressing these needs, once every three years.  In conducting a needs assessment, a hospital may consider input from a broad range of persons located in or serving its community, including health care providers and public health stakeholders.   Given their patient care experience, hospital medical staffs themselves have a unique understanding of the health needs of the population they serve and can play a leadership role in developing a hospital’s implementation strategy to reduce the population’s disease burden.  These activities have the potential to result in measurable improvements in the health of communities across the country.

Public health/provider partnerships.  More broadly, there is a genuine desire among non-health care stakeholders to partner with health care providers to improve population health.  For example, one idea stemming from the Institute of Medicine’s 2012 report Primary Care and Public Health: Exploring Integration to Improve Population Health is for state and local public health departments and primary care practices to collaborate to improve health outcomes and reduce costs.  Providing surveillance data, initiating community-wide prevention interventions, and providing referrals to tackle unhealthy behaviors are all ways public health entities can support health care providers in their efforts to improve health status.  In a notable development, the Association of State and Territorial Health Officials (ASTHO) has recently launched a Primary Care and Public Health collaborative that includes provider organizations and professional societies in support of integration efforts across many of these areas.

Partnering with community-based organizations.  Another set of partners for health care providers are community-based non-profit organizations that deliver evidence-based prevention and wellness programs in such areas as disease self-management, fall prevention, and mental health.  For example, the U.S. Administration for Community Living has supported the translation of Stanford University’s Chronic Disease Self-Management Program  to over 140,000 participants through community-based organizations (e.g., senior centers, social service agencies, faith-based organizations).  This program has been shown to improve symptoms, prevent exacerbations of illness, and decrease emergency department visits.  

Another example is the Centers for Disease Control & Prevention’s efforts to scale up the evidence-based Diabetes Prevention Program.  Community-based organizations such as the YMCA are helping to translate the program into the community by working with health care providers to identify pre-diabetics in their practices who might benefit from the intensive lifestyle intervention. The Centers for Medicare & Medicaid Services (CMS) is supporting this effort through an award to test and evaluate the delivery of the program to 10,000 pre-diabetic Medicare beneficiaries in 17 communities across the country.

It should also be mentioned that CMS is more broadly supporting clinical-community linkages through the second round of the Health Care Innovation Awards.  In this funding opportunity, population health has been identified as one of four categories to test new care delivery and payment models to improve quality and reduce program expenditures under Medicare, Medicaid, and the Children’s Health Insurance Program.

The U.S. Department of Health & Human Services’ National Quality Strategy has three aims: better care, healthy people/healthy communities, and affordable care for all.  All three are equally necessary, and each should be pursued vigorously.  Taking advantage of new opportunities to improve the underlying health status of the population has been and will be both professionally and personally rewarding to providers. Moreover, while reforms in the delivery of and payment for care will continue in coming years, changing the paradigm of paying providers solely to take care of those who are sick to one in which they are paid to ensure people are healthy is an idea whose time is coming.

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3 Responses to “Provider Opportunities for Population Health Improvement”

  1. John Raser Says:

    Lee, I’m disheartened by your response. It’s true that in serving patients, we must be focused on their individual needs. But the article is referring to work outside of the clinic. As a young family doctor at a FQHC, I started showing up to public health related coalition meetings and events in my free time, and quickly found myself a valued contributor to exactly the efforts mentioned in the article. Financial pressures do exist, but there are opportunities through academic roles, grants, or community based research funding to be paid at least partially to do some of this work. That said, we as physicians are reimbursed quite well. With income expectations moderated, most of us can find free time to pursue non-clinical work that we know is essential to the futures health of our patients, our neighbors, and ourselves.

  2. Sneha Gupta Says:

    hey leetocchi,
    I also agree with your views.

  3. leetocchi Says:

    You are wrong… The physician must do what is best for each individual patient, one at a time. The current legal and financial structure of medicine will only punish providers who look beyond the patients they are dealing with. Until we discuss those issues your last sentence cannot happen. It is more wishful thinking that providers can focus on lifestyle and societal issues, with the current legal and financial requirments to stay in business.

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