Since the early nineties nothing has challenged physicians grounded in the traditional culture and practice of medicine more than the introduction of the “radical” concept of population health. One could argue that the Affordable Care Act is the legislative expression of the tenets of population health. The reduction of healthcare costs that will lead to sustainability of expanded coverage and the Triple Aim can not be achieved without a robust foundation in the ever expanding understanding and practice of the methodologies of population health. I fear that  one of the most vulnerable targets of the new administration, as it attempts to fulfill its promises to the base that led to its election, will be CMMI, the innovation lab for population health created in concert with the ACA.

Medical Economics has reported a poll of its readers that suggests that 60% were happy about the impact on their practices of the election of Donald Trump. Does that mean that a lot of doctors are celebrating the imminent demise of the ACA and its focus on population health mechanisms? We forget that the majority of practicing physicians work in either privately owned practices or hospitals where they conceptualize their role as the healers of disease and injury and not as practitioners of preventative medicine or population health. I have facetiously said that their primary interest is “repair care”. We have not reached a tipping point where the majority of the industry has accepted that it is their responsibility, indeed that it is in their best interest, to promote the principles of population health.

The ACA was a step away from traditional practice and a step toward practice and care delivery built on principles of population health. Until there was an emphasis on “value” and the goal of universal access there was little or no reason for most physicians or healthcare professionals to think about population health or the sustainability of finance. The financial sustainability of their practices and institutions was a function of revenue and revenue was a function of volume. When you are producing volume the idea of worrying about collective sustainability becomes about as logical as the idea of a coal producer worrying about global warming.

I can remember thinking twenty five or thirty years ago that although public health was an important concern, it was not my concern. My concerns were the patient in front of me. and the problem that they were having that day and the viability of the practice that paid me. My professional responsibility was fixing the problem or answering the question that the patient presented, and not worrying about access or the expense of healthcare.  

In truth I wanted to work in a smaller world where I could focus on delivering good care to sick people. I had joined a group practice to focus on practice, not healthcare economics or the issues of a population. The “social determinants” of health were the responsibility and concern of others, not me. I had enough to do just staying current in my field and providing what I considered to be quality care to my patients.

I felt confirmed in my position because I had the luxury of only listening to those grateful patients who thought I was a wonderful doctor and were delighted to be my primary focus. It was not until I realized that the world I valued was unsustainable that I began to listen to people like Don Berwick who had begun the conversation about quality and safety, the challenges of equity, and giving every person quality care in a way that improved the health of the community using sustainable resources. When my practice’s sustainability was threatened I began to connect the dots and learned that our goal was

Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time…

I needed to be a part of a sustainable effort built on the principles of population health.

I think that many of our colleagues in healthcare today are not far from my mindset of thirty years ago. If they are not comfortable now, they long for that comfort that they think they can remember before all the hostile externalities of healthcare finance seemed to be exacerbated by the passage of the ACA.  I suspect that for many the phrase “Make America Great Again” translates into “turn healthcare and medical practice back to where it was before all these people preaching quality, universal access, healthcare equity, improved outcomes, patient centeredness and other tenets of population health ruined the business and made my life unsustainable.” PCMHs, ACOs, MACRA, Meaningful Use, Big Data, roster reviews, patient advocates, hundreds of quality metrics, preauthorizations, and dysfunctional EHRs have nothing to do with why they went to medical school. Perhaps they believe that the “social determinants of health,” should be managed by social workers, bureaucrats and politicians, and are not their responsibility. There was a time when I would have agreed.

Many in healthcare do not understand what we mean when we begin to talk about population health. For me population health is a collection of concepts, data based tools that require new competencies, and insights that are fundamental to all three legs of the Triple Aim. Success requires facilitating the greater engagement of each individual patient in their own care and more effective interactions between clinicians and systems of care delivery. There is no hope around the efforts to improve the social determinants of health without consensus or “social solidarity” . The beginning premise of improvement in the health of the population is universal access to efficient and effective care.

David Kindig discusses the breadth of the concept and how difficult it is to understand the scope of population health in a posting from HealthAffairs entitled “What Are We Talking About When We Talk About Population Health?” Most important is his emphasis on the relationship between the Triple Aim and population health.

The Triple Aim And Population Health Management

The past six years have seen the prominent development of the Triple Aim, which proposes three linked goals — improving the individual experience of care, reducing per capita cost of care, and improving the health of populations. This framework provided a boost in the use of the term population health.

The sustainable resources that you and your patients need for you to serve them well will be largely determined by your understanding and effective implementation of population health based innovations.

David Nash, MD, MBA is the founding Dean of the Jefferson College of Population Health at the Thomas Jefferson University in Philadelphia and the lead author of Population Health:Creating a Culture of Wellness. Dr. Nash and his collaborators believe that extracting the benefits of a focus on population health is dependent upon a “culture of wellness”.  As I think back on my early practice experience, I realize that when I say we were focused on “repair care” I am indicating that we functioned in a culture that focused on illness. Dr. Nash explains:

The population health movement has gained momentum over the past decade, particularly since the passage of the Patient Protection and Affordable Care Act (ACA) and the subsequent implementation of programs aimed at improving the health of the population. In terms of national statistics, population health remains a daunting challenge: however, some practical application of its tenets ….show great promise. By enveloping population health in an environment that supports its delivery and sustainability, benchmark cultures of health and wellness are appearing throughout the country…

Not long after the election of Donald Trump to be the forty fifth president, I attended a conference on population health in Washington that was chaired by David Nash. The conference, including the keynote address given by Andy Slavitt, the Administrator of CMS and CMMI for the last two years, was greatly different in the context of the election than what anyone was expecting when the conference was scheduled. Slavitt’s speech deserves some review, and I hope that you will take the time to read it. He discussed CMS’s efforts to implement MACRA. He noted that MACRA passed by a 95% bipartisan majority and was unlikely to be repealed. He was concerned that if CMMI was abolished as part of the repeal of the ACA then the implementation of the alternative payment models envisioned in MACRA could be affected. CMMI is the source of innovation and testing of new payment models built on the understanding of value that has evolved from population health as you will read in the section of his speech which I have copied below.

So how do I suggest we tackle the next opportunities?

One. Build from a foundation of progress, not head backwards. There can be no delivery system reform without building on the foundation of reaching universal coverage [all the bolding is from me for emphasis]. That means building on the record 20 million people who have newly found coverage and continuing the security and protections Americans have found, including no-cost preventive care, the elimination of lifetime and annual coverage limits, and the end of pre-existing condition exclusions. If we want to fix how care is delivered, so that we’re providing value, then we must ensure that Americans can afford and access quality care at every point in their lives. If we lose even some of the coverage gains made under the ACA, or leave people in limbo, people will lose access to regular care and we will drive up long-term costs. This doesn’t mean we shouldn’t improve how coverage works in a bipartisan fashion. We must always do that and we should now as new leaders bring new approaches and solicit new ideas.

Two. Insist that modernization of Medicare must actually mean modernization. Progress is achieved by ingenuity, innovation, teamwork, and the use of data and technology, not by changing funding formulas.  

I’ll say this bluntly: MACRA can’t work as well without a CMS Innovation Center that can move quickly to develop and expand new approaches to paying for care. With changes to the Innovation Center, the advanced alternative payment approaches could slow significantly. We will have a much narrower path with fewer specialty options and approaches, which take in patient and physician feedback. Medicare and commercial payers would then fall further out of alignment, and more importantly, less patients would have access to innovative care methods.

Three. Start to demand technology that can exchange data, that supports care, and that is affordable…. For a variety of reasons, EHRs became an industry before they became a useful tool. The technology community must be held accountable by their customers and make room for new innovators and to give clinicians more freedom and more flexibility to focus on their patients, to practice medicine, and deliver better care….

Four. Don’t forget that people are the heart of every policy made. We are on a journey as a nation towards better health for all. Patients. Care givers. Consumers. You know them better than anyone because you care for them. View MACRA as a step in the journey to develop care together.

As we realize that uncontrolled costs threaten the sustainability of our meager progress toward the Triple Aim it becomes clear that applying the principles of population health to reduce the need for costly “repair care” should be our objective. The modification of the ACA was always inevitable.  Our challenge is not to return to “repair care” and its fee for service finance but to use what we have learned from the failures of the ACA and our growing understanding of the power of the principles of population health to make sustainable progress toward

Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time…