population health: beyond managing high utilizers david b. coultas, md va portland health care...

POPULATION HEALTH: BEYOND MANAGING HIGH UTILIZERS

David B. Coultas, MDVA Portland Health Care System

Professor, OHSU

• Knowing the health outcomes of group(s) of individuals, including the distribution of outcomes and their determinants.

• Using proactive, evidence-based, cost-

effective population-level interventions to reduce variation/disparities in outcomes and add value to health system and community.

DEFINITION: POPULATION HEALTH

COUNTY HEALTH RANKING MODEL

POLICIES & PROGRAMS HEALTH FACTORS HEALTH OUTCOMES

Physical Environment (10%)• Built environment• Environmental quality

Social & Economic (40%)• Education• Social support• Employment• Income• Safety

Health Behaviors (30%)• Tobacco• Diet & Exercise• Alcohol• Sexual activity

Clinical Care (20%)• Access• Quality

Morbidity-QOL (50%)Mortality (50%)

• Review barriers to improving population health.

• Describe strategies beyond targeting high utilization for improving population health.

OBJECTIVES

• There is wide cultural variation in beliefs about health and disease, which in-turn influences expectations and behaviors concerning health care.

• These variations in beliefs, expectations, and behaviors makes improving population health very complex.

CULTURE OF HEALTH CARE

• Focus on rescue care

• High waste• Low health literacy• Paternalistic• Poor advanced care

planning

• Focus on 1o and 2o prevention (e.g., social determinants)

• Low waste• High health literacy• Shared decision-making• Informed advanced care

planning

HEALTH CARE CULTURE

Current State Future State

• Non-health care social service spending in US 0.9 to 1 vs. 2.0 to 1 in other developed countries

• $10/person/year in evidenced-based community interventions to increase physical activity, improve nutrition, and prevent smoking could save the US more than $16 billion/year within 5 years.

ROI: PUBLIC HEALTH VS. HEALTH CARE

www.healthyamericas.org/reports/prevention08/Prevention08.pdf

Bradley et al. BMJ Qual Saf 2011;20:826-31

• $476 (~18%) - $992 (~37%) billion of spending on health care in US is wasted:– Failure of care delivery– Failure of care coordination– Overtreatment– Administrative complexity– Overpricing– Fraud and abuse

Berwick, Hackbarth. JAMA 2012;307:1513-16.

WASTE IN US HEALTH CARE SYSTEM

CHRONIC CARE MODEL

• Limited health literacy• Lack of empathy• Communication discordance/errors

– Failure to communicate– Biased communication

• Limited informed/shared decision-making

GAPS IN COMMUNICATION

US ADULT HEALTH LITERACY, 2003

DHHS. www.health.gov/communication/literacy/issuebrief/

Proficient 12%

PREVALENCE OF LIMITED HEALTH LITERACY

Berkman et al. Ann Intern Med 2011;155:97

• 80 million with limited health literacy, highest among:– Elderly– Minority– Poor persons– < High school education

COMMUNICATION & SELF-EFFICACY

Communication

Knowledge

OutcomesBeliefs Self-managementbehaviors

Self-efficacy

Skills

SELF-MANAGEMENT

HEALTH LITERACY & ADVANCED CARE PLANNING

Health Literacy

&ACP

Knowledge gaps

DeathUncertaintyPrognosisOptions

FutileCare

Self-efficacy

Fear

CHRONIC CARE MODEL

• Reduce waste• Improve health literacy• Promote informed/shared decision-making• Proactive advanced care planning

IMPROVING POPULATION HEALTH

QUESTIONS?

VALUE

VALUE = OUTCOMES/COSTS