February 11, 2019
Population Health And Conventional Demographics: Both In Need Of An Overhaul
By Michael D. Shaw
This column first examined the notion of “population health” back in 2014. A definition of the term was proposed in 2003 by David Kindig MD, PhD, and Greg Stoddart, PhD in a breakthrough article entitled “What Is Population Health?” They proffered this definition:
We propose that population health as a concept of health be defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” These populations are often geographic regions, such as nations or communities, but they can also be other groups, such as employees, ethnic groups, disabled persons, or prisoners.
In no time at all, population health became intimately linked with Accountable Care Organizations (ACOs). These are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to the Medicare patients they serve. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. That is, meeting goals will result in financial rewards.
As it happens, ACOs haven’t quite worked out the way the bureaucrats and experts predicted. In fact, ACOs have led to higher Medicare spending. Need I mention that ACOs were a key provision of Obamacare? Fear not, though, as ACOs are being reformed.
Notwithstanding issues with ACOs, population health favors group parameters over actual health outcomes of the individual. Car enthusiasts are familiar with Corporate Average Fuel Economy (CAFE) standards. Notably, these regulations apply to the entire fleet of cars and light trucks (gross weight up to 10,000 pounds) for a given manufacturer.
Unintended consequences will occur, however. I owned a 1995 Corvette with six-speed manual transmission. This car was equipped with a feature called “1 to 4.” As such, at a certain combination of speed and RPM, a pawl would engage whereby you could only upshift from first directly into fourth gear. This construct created an outrageous safety hazard, especially if you were headed uphill. But, it did help GM with CAFE. Fortunately, this feature could be disabled easily—and was, by nearly every owner.
By the same token, the very nature of medicine requires the physician to apply experiences learned at large, to the individual patient, all the while cognizant of the unique individual responses. A perfect example of groupthink involves skinny type 2 diabetics, being lumped in with all type 2s.
Surely, it is an admirable goal to lower the rates of type 2 diabetes, and getting fat people to lose weight will do wonders from a population health perspective. Yet, this will not help skinny type 2s, who represent—in my judgment—a larger percentage than is currently acknowledged.
This tyranny of the easily-defined group, along with specious conclusions as to its characteristics, is represented in other ways. David Allison, consumer behavior expert, marketing advisor, and the pioneer of Valuegraphics, believes that conventional demographics—as a method of understanding groups of people and target audiences—is seriously flawed. Indeed, he wrote a book entitled We Are All the Same Age Now: Valuegraphics, The End of Demographic Stereotypes.
Results have just been released on a study commissioned by Allison in which 100,000 individuals were surveyed to measure 380 variables about what people value, want, need, and expect from life. Disagreement within conventional demographic age divisions averaged around 80%, while values-based cohorts—within an age group—showed agreement over 75%.
The researchers emphasized that demographics are still the best way to define the constituents of a target audience, but that including a values-based profile to understand and influence audience behavior will lead to much more motivating results.
Moving back to population health, two years ago, clinical psychologist Hilary Hatch opined that “Population health efforts are actually making us dumb, blind and deaf to the patient’s true health needs.” She echoes Allison, noting that…
Population health puts people into categories by conditions (diabetes, hypertension, depression), age, lab results and medical billing data. These categories presume their own importance. When in fact, psychosocial, behavioral, and environmental factors determine individual health far more. Patient goals, preferences and barriers to care tell us what stands between that patient and better health. Without this data, population health efforts are undermined.
But then, isn’t there always a big disconnect between healthcare bureaucrats and those who actually treat patients?