Human-Centered Population Health
What are reasonable aspirations for a human-centered health system? In my forthcoming book, Beyond Quick Fixes (Oxford, 2024), I propose a ten-year, multi-stage plan to transform population health in the US. The plan includes five elements:
- Starting Point (Status Quo): High costs & poor outcomes
- Baseline Initial Success: Information sharing
- Leveraging Baseline: Care coordination across services
- Innovative Leaps: Single payer
- Ultimate Success: Integrated delivery system
The US has the highest per capita costs of healthcare, compared to other OECD countries. We have among the poorest outcomes compared to these countries. This is due, in part, to making much smaller investments in social services. Further, the medical services offered are quite fragmented.
The first step to changing this situation is information sharing. The 21st Century Cures Act requires healthcare providers give patients access to all of the health information in their electronic medical records “without delay” and without charge. This is a great first step. We need all providers, including those providing social services, to have access to patients’ complete health and well-being records.
Assume a patient’s primary care physician (PCP) uses Cerner’s electronic health record (EHR) while the hospital where the patient recently underwent a procedure uses Epic’s EHR, and the patient accesses public social services via his or her city. All of the information generated in the course of using these services should be available to the patient and the providers via a single integrated portal.
Once this baseline is achieved, the next step is care coordination across all population health services. The PCP should interact with the hospital’s specialists, and perhaps be aware that the patient experienced a period of homelessness a few years ago, but recently earned an associate’s degree at the local community college and now has a much better job. The portal just mentioned would provide functionality to help with this coordination.
The overall system needs to evolve towards single payer. Employer-based health insurance has depressed wages as providers charge patients with such insurance more than, for example, Medicare patients. This hidden tax is unfair to these people. Single player does not imply the government takes over healthcare. Unified payments are the key. Kaiser Permanente is a great example of private sector innovation.
The eventual outcome is an integrated delivery system with, for example, the whole population health system using Kaiser Permanente’s business model. There may be many companies involved, as well as government involvement at the local, state, and federal level. However, from the perspective of patients, their families, and front line clinicians, the delivery system would seem to be one integrated system. These stakeholders are much more interested in high quality, affordable services, rather than who owns what.
In a recent piece, Mike Johns, Jim Curran and I outlined population health in terms of human well-being. We began with definitions of well-being, then considered the behavioral and social phenomena that must be addressed. We next addressed the performance challenges faced in the US when trying to assure well-being. We need a national well-being system. Unfortunately, the inherent complexity of the highly fragmented US system seems to preclude the requisite information sharing and care coordination across the stakeholder organizations in the federation that is misnamed as a system.
I am not suggesting an integrated government run system. Recent experiences, reported by The Economist and Wall Street Journal, suggest that health systems operated by governments are by no means panaceas. The government’s role envisioned here includes regulations, standards, and perhaps financial incentives. The private sector can focus on providing efficient and effective services, with frequent innovations due to competitive pressures. The example of Kaiser Permanente provides a compelling illustration.
We reviewed a range of interventions and discussed the role of digital technologies in enabling these interventions. The promise and risks of these technologies were summarized. We next articulated how to gain the upsides and avoid the downsides to assure human well-being in a digital age. Finally, we outlined the management implications of pursuing our recommendations
It is clear that we know how to conceptualize and address human well-being. However, we have difficulty mustering the will, commitment, and resources to plan and act to achieve these ends. Successful execution of the above plan, over a decade or more, will greatly enhance human well-being.
