What is Population Health? Understanding the Key Concepts

Chapter 1
What Is Population Health?

George Mayzell
Contents
U.S. International Ranking..................................................................................2
Population Health versus Public Health.............................................................3
Definition of Population Health.........................................................................4
Definition One.................................................................................................4
Definition Two.................................................................................................4
Definition Three..............................................................................................4
Health versus Healthcare Delivery.....................................................................5
Building a Population Health Model................................................................10
Bibliography.......................................................................................................12
The current health delivery system in the United States is not only broken,
but also unsustainable! The system in the United States is not so much a
health system as it is a sickness system. Arguably, the United States does a
pretty good job taking care of patients when they are ill and particularly if
they are well insured and from certain socioeconomic groups.
Despite the commitment of almost 17% of our gross domestic product
(GDP) to healthcare, the United States performs poorly compared to other
developed countries in many critical healthcare determinants, including
life expectancy, one of the most cited healthcare measurements. The U.S.
healthcare system consistently underperforms when compared to other
nations, including Austria, Canada, and France. Comparing the United
States to 11 other countries in the Commonwealth Fund report,1 the United
1
2 Population Health
States ranks last in the areas of quality of care, access to care, care effi-
ciency, care equity, and healthy lives.
U.S. International Ranking

In our current system of healthcare delivery, most of the stakeholders have
an economic incentive to deal with illness. Thus, many of the individuals
who make the majority of decisions for a healthcare delivery model, despite
Downloaded by [The Chinese University of Hong Kong] at 22:50 04 February 2017
personal moralities, are financially incentivized to treat sick patients. The

system is in fact designed for sick care and not preventive care. In most
cases there is no emphasis for payment for wellness or prevention. If there
is return, it is often many years later in the future; therefore, there is little
direct return on investment (ROI) on prevention and wellness in the short
run for payers or employers.
In only four categories, effective care, safe care, coordinated care, and
patient-centered care, the United States ranked fifth.2 There are also dispari-
ties in the quality and access to care based on not having insurance, where
a person lives, and other socioeconomic indicators. The U.S. health sys-
tem has made some strides in quality of life and life expectancy in certain
groups and demographics. Unfortunately, there are still significant opportu-
nities with disparity (Figure 1.1).
Disparities in Quality of Care for Selected Groups

Percent of quality measures for which groups experienced worse, same, or better quality of care:
26%
29%
41% 39% 39%
47%
54% 18%
Better quality of care
39% 61% Same quality of care
45%
Worse quality of care
47%
44%
22% 24%
14% 10%
6%
Poor vs. Black vs. Hispanic vs. AI/AN vs. Asian vs. 65+ vs.
high income white white white white 1844
AI/AN = American Indian or Alaska Native
Figure 1.1 Disparity chart. (Adapted from AHRQ, National Healthcare Disparities
Report, 2011, http://www.ahrq.gov/qual/qrdr11.htm.)
What Is Population Health? 3
The current system of healthcare delivery is clearly unsustainable as more

and more of our GDP is used to treat illness. There is increasing financial pres-
sure on Medicare, expansion of Medicaid, while a large portion of the country
still remains uninsured. In addition, there is increasing transparency in our
delivery model, which exerts pressure on the system to change its paradigm.
Population Health versus Public Health

Population health is all about what happens outside of our current health-
care delivery model. It is all about what happens outside the four walls of
the physicians office, hospital, or diagnostic center. What we have learned
is that simply managing the delivery of healthcare is not enough to provide
health (well-being) at the patient level. There is 85% of health or quality
of life that is not about healthcare delivery, but about other environmen-
tal, behavioral, and socioeconomic factors that contribute to what we call
quality of life. We can no longer wait till people get sick to intervene. Bythe
time people get ill, the medical costs and treatment costs are large and
will continue to destabilize the U.S. economy. By modifying risk factors, or
eliminating them, we can control societys long-term medical costs as well as
improve productivity.
There are important differentiators between population health and public
health, although there are many similarities. Public health is often thought
of as government directed and traditionally has focused on disease survival,
and dealing with communicable diseases and environmental factors, such
as water supply, clean air, and similar problems. Public health traditionally
has focused on public good items such as drinking water safety, etc., relat-
ing to the entire population. The term public health is slowly being replaced
by population health. Population health is a much broader term that covers
not only activities but also a policy-driven approach to health and wellness.
Population health is about healthcare of a group of individuals and invari-
ably drills down to the individual level, looking at improvement of both
health and healthcare. Population health also focuses on individual and soci-
etal risk factors for disease and tends to be more proactive than a traditional
public health model.
The current sickness model will have to move toward a health model
and preventive care model. Health has many different definitions, but it
is not simply the absence of disease. Health is also wellness or a state of
well-being. Healthcare delivery is only a small component of health.
4 Population Health
Much of this new focus will most likely be driven by corporations, large
employers, and governmental payers. These employers will no longer focus
only on their own healthcare costs; they need to start focusing on the total
cost of the employee to the corporation. These costs include things like
presenteeism and absenteeism. These are factors that lead to a productive
workforce and will be critical for the long-term success of any company.
These factors are often more expensive to any company in the long run
than the actual financial costs of healthcare. The costs of absenteeism and
presenteeism have long been underestimated and have not been part of the
healthcare equation in the past. An active and productive workforce is criti-
cal for a competitive U.S. business.
Definition of Population Health

One solution to this unsustainable paradigm of healthcare delivery is to
embrace the concept of population health. There are several different
definitions of population health; and there is no clear agreement on one
definition. However, all of the definitions essentially get you to the same
place. Here are the three following definitions.
Definition One
The distribution of health outcomes within a population to help deter-
mine the influence, distribution policies, and interventions that affect the
determinants.3
Definition Two
A sophisticated care-delivery model that involves a systemic effort to assess
the health needs of the target population and to proactively provide services
to maintain and improve the health of that population.
Definition Three
The Canadian Federal Advisory Committee used the following defini-
tion: Population health refers to health of a population as measured by
health status indicators as influenced by social, economic, and physical
environments; person health practices; individual capacity and coping skills;

human biology; early childhood development; and health services.28
Essentially, population health is the identification of a population and
the responsibility for both the health and healthcare of the population. To
achieve this, one must focus not only on the healthcare delivery model, but
also on the health and well-being of the population. This requires a focus
on wellness, preventive care, and controlling chronic diseases.
Health versus Healthcare Delivery

It is important that we differentiate between healthcare and health. One
definition of health can be controversial and is often a negative in that it
is described as the absence of disease. With population health defini-
tions, health is a positive and includes wellness, prevention, and a sense
of well-being. In addition, as we measure our current definition of health,
it tends to focus on things like disease rates, illness burdens, and medi-
cal cost. In a population health world, the focus is also on well-being,
quality of life, and productivity. One of the challenges is to develop metrics
that can m easure health and wellness accurately. We are used to measur-
ing totalcost of healthcare in specific outcomes of the disease process.
Wemustnowlooktomeasuring quality of life, productivity, and other
health metrics.
The primary determinants of disease are mainly economic and

social, and therefore its remedies must also be economic and
social.
So Michael G. Marmont 2001

Professor, Epidemiology and Public Health
University College London
The health of a population can be measured by health status indicators

and is influenced by social, economic, physical, environmental, and personal
health practices; individual capacity and coping skills; human biology; early
childhood development; and health services and procedures.1 These are
often called healthcare determinants.
It is often hard to differentiate between risk factors and healthcare
determinants. Determinants focus on environmental exposures, including
6 Population Health
hysical and social, while risk factors are often based on lifestyle decisions.
p
Healthcare determinants can be defined as any factor or characteristic that
brings a change in ones health condition. See examples of classic risk fac-
tors in Figure 1.2. Some of the different categories of determinants include
Social determinantsincluding education, economic stability, health

and healthcare, social and community context, and neighborhood
environment
Physical and environmental determinants

Healthcare determinants
Genetic determinants
Behavioral determinants
Biological determinants
Populations can be defined by conditions, geography, political factors,

or physical boundaries. They can be defined as a populations philosophy,
cultural conditions, or a payer source. They can also be defined by a coun-
try or ethnicity, religion, or any other group that has defining characteris-
tics. Thus far, in the United States, it has usually been a payer source from
the standpoint of practicality. This is probably the easiest way of identify-
ing a population that can be monitored and measured. Accountable Care
Organization (ACO) can potentially be seen as a prodrome of a population
health model. This model will have to shift as we move to more holistic
populations.
One of the most critical things to understand about population health
is that it is a very different concept from that of healthcare. When we talk
about health in the United States, we generally think about healthcare and
healthcare delivery models. We talk about a sickness model, and we talk
about the functioning of our hospitals, physicians, and integration of these
parts of the delivery system.
Examples of risk factors

High blood pressure
Inactivity
Obesity
High cholesterol
Stress
Nutrition
Smoking
Figure 1.2 Risk factors of health.

As we move to population health, the concepts are very different. We are

really talking about health. This is a much broader concept than healthcare
delivery. Healthcare delivery is clearly an important part of health; however,
it is a relatively small component. In fact, healthcare delivery is only thought
to be ~10%15% of the determinants of health.4
In Figure 1.3, we can see that healthcare delivery is really only a small
part of what is important. We can see that genetics plays a significant role
at 20%, and, at least until recently, this has been something that had been
impossible to affect. New technologies may put this in a different light.

Environmental causes are an additional 20%, and these fit into some of
the classic public health entities of water, air, and toxins. Finally, the most
significant effect on health is healthy (or unhealthy) behaviors.
Over recent years we have been spending time and energy on healthy
behaviors, but we have rarely focused on a public health venue in any coor-
dinated fashion. Smoking has been an exception, with major public health
focused on education and taxation. More recently, obesity and sedentary
lifestyle have gotten significant attention.
If you look at where we spend time, energy, and resources, we spend
most of our resources on medical services and very little on healthy
behavior (see Figure 1.4). One of the major challenges is the cost of these
unhealthy behaviors and additional negative determinants of health to
Genetic
30%
Social
15%
Environment
5%
Behavior
40% Healthcare
10%
Figure 1.3 The leading determinants of health. (Adapted from McGinnis JM, Williams-
RussoP, Knickman JR. Health Affairs, 2002; 21(2): 7993. Available at http://www.
healthaffairs.org.)
8 Population Health
What Makes Us What We Spend on

Healthy Being Healthy
10% ACCESS TO CARE 88% MEDICAL SERVICES

20% GENETICS 4% HEALTHY BEHAVIORS
20% ENVIRONMENT 8% OTHER
50% HEALTHY BEHAVIOR
Figure 1.4 Health versus healthcare: What makes us healthy? (Adapted from the
Bipartison Policy Center and Boston Foundation/New England Healthcare Institute,
June 5, 2012.)
society in general. Healthcare costs are rapidly rising out of control, and
as we try to get a handle on its drivers, we realize that we cannot do this
through a classic health delivery model. We must start focusing on these
determinants of health. We cannot control the rising cost of healthcare
unless we promote well-being and health.
As we look at Figure 1.5, a high-level view of population health, we can
see a broad view of population health. Healthcare delivery is where we
spend most of our resources, which can be broken down into access and
quality/outcomes. These also include things like cost of care, geographic
availability of clinics, insurance coverage, and others. Quality-based care
looks at evidence-based care, preventive care, and disease management.
On the health side, we have items such as genetics and individual
behaviors. These include obesity, smoking, seatbelts, alcohol, and other
personal choice items. In addition, we also have on the side of health, the
classic p ublic health factors that are environmental. These include envi-
ronmental exposures; social and economic issues, including healthcare
disparity;as well as things like communicable diseases, water, air, and
toxins.
A population health delivery model broadens the traditional medical
delivery system (Figure 1.6). It includes items and processes of integration
that are not often part of our current healthcare delivery model. These items
Health Health delivery
Individuals Environment Access Quality/outcomes
Genetics Socio- Insurance Evidence-

economic based
Behaviors Logistical
Exposure Preventive
Obesity Cost
Disparity Chronic
Smoking
Disease
Management
Health and
well being
QOL
Productive
(work and
home)
Figure 1.5 A high-level view of population health.
and processes include a focus on prevention, wellness, and the population

that typically does not seek healthcare resources. The following items will
be further delineated in future chapters.
Team-based care models

Care coordination, inpatient, and outpatient
Integration of behavioral health
Health risk assessments and their integration into care models
Palliative and end-of-life planning
A primary care network with focus on patient-centered medical homes
and attributes of care
Patient engagement
Health prevention and wellness infrastructure
A metric system that focuses on performance productivity quality life as
well as medical outcomes measurements
10 Population Health
Population Health: Approach
80% members = 20% cost 20% members = 80% cost
Risk Acute Chronic

Healthy Catastrophic
factors illness care
Biometric screening Coaching Access to urgent Case management

Disease management
care
Immunizations Health literacy Pharmacy
Health literacy
Referral management
Travel medicine Lifestyle change management Referral
fitness Rehabilitation
management
Screenings management
Healthy environment
Pharmacy
management Palliative
Lifestyle education
Hospice
Health risk
assessments
Community
integration
Clinical model
Coaching, care management, health literacy
Member portal tools
Integration with community neighborhood
Figure 1.6 Population Health. (Adapted from the Fabius population health model.
Courtesy of Ray Fabius.)
Predictive modeling
Electronic medical records that link to all providers (health informa-
tion exchanges), and connect to mobile health, personal health records,
patient portals, and telehealth/virtual visit technologies
Building a Population Health Model

If you look carefully at where healthcare resources are expended, they
are focused on healthcare delivery and not on health. We spend inordi-
nate amounts of money on caring for the sick and focusing on access to
the delivery of highly technical and high-quality healthcare. However, very
little is spent preventing disease and slowing the progression of disease. As
we look at ourselves compared to other countries, we see that we spend
more than every other developing country on healthcare expenditures as

a percentage of the GDP. At the same time, we spend much less on the
social determinants of health, that is, behaviors and prevention, as a per-
centage of the GDP (Figure 1.7). Population health will shift this resource
utilization to focus on preventing the need for high-dollar expenditures on
healthcare delivery. Admittedly, this is not a quick fix and will take years, if
not decades, to fully change the paradigm. What is clear is that the current
model is unsustainable and the current healthcare trends cannot last. We
must change the way in which we focus on health and healthcare. This will
be difficult and challenging.
40
37.6
Total social service expenditures

34.9
Total health service expenditures

33.6
33.4
33.3
32.8
35
32.2
32.1
30.6
29.3
29.0
28.6
30
27.6
27.0
26.3
26.0
24.9
24.9
24.9
24.2
24.2
23.7
23.7
Expenditures as % of GDP
23.1
25.5
25
22.9
21.1
21.4
20.6
13.3
21.6
23.1
21.1
23.7
19.3
21.8
20.1
18.3
20.8
13.9
20
17.4
15.4
20.4
17.9
16.7
16.9
16.6
15.5
14.3
16.5
17.1
11.6
15
12.1
15.1
12.3
11.0
10.3
13.5
10
5.9
4.5
16
12.2
12.1
11.2
12
10.3
10.4
10.3
10.2
11
5
9.8
9.9
9.6
9.5
9.4
9.4
9.4
9.1
8.9
8.6
8.4
8.3
8.2
7.8
7.1
7.3
6.4
6.2
7
5.8
0
Poland
Sweden
France
Netherlands
Belgium
Austria
United Kingdom
OECD average
Greece
Iceland
Canada
Australia
Spain
Japan
Czech Republic
Slovak Republic
Korea
Mexico
Denmark
Finland
United States
Luxembourg
New Zealand
Ireland
Switzerland
Portugal*
Germany
Italy
Norway
Hungary
*Expenditures for Portugal are from 2004, owing to missing data for 2005
Figure 1.7 Total health-service and social-services expenditures for Organization for
Economic Cooperation and Development (OECD) countries, 2005. (Reproduced from
Average Health and Social Services Expenditures: Associations with Health Outcomes.
With permission from BMJ Publishing Group Ltd.)
12 Population Health
Currently, the payment model does not support preventive health and
population health. As the payment model evolves and our metrics for popu-
lation health become clarified, we will move toward this new model of
delivery. In the interim, we will need to deliver healthcare under both mod-
els of healthcare. This would include our current volume delivery model and
our future value delivery model. It is this middle time period that will be
increasingly challenging over the next many years.
Bibliography
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11countries on measure of access, equity, quality, efficiency, and healthy
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Chapter 1

What Is Population Health?

U.S. International Ranking

personal moralities, are financially incentivized to treat sick patients. The

Disparities in Quality of Care for Selected Groups

The current system of healthcare delivery is clearly unsustainable as more

Population Health versus Public Health

Definition of Population Health

environments; person health practices; individual capacity and coping skills;

Health versus Healthcare Delivery

The primary determinants of disease are mainly economic and

So Michael G. Marmont 2001

The health of a population can be measured by health status indicators

Social determinantsincluding education, economic stability, health

Physical and environmental determinants

Populations can be defined by conditions, geography, political factors,

Examples of risk factors

Figure 1.2 Risk factors of health.

As we move to population health, the concepts are very different. We are

impossible to affect. New technologies may put this in a different light.

What Makes Us What We Spend on

10% ACCESS TO CARE 88% MEDICAL SERVICES

Health Health delivery

Individuals Environment Access Quality/outcomes

Genetics Socio- Insurance Evidence-

Figure 1.5 A high-level view of population health.

and processes include a focus on prevention, wellness, and the population

Team-based care models

Population Health: Approach

80% members = 20% cost 20% members = 80% cost

Risk Acute Chronic

Biometric screening Coaching Access to urgent Case management

Coaching, care management, health literacy

Member portal tools

Integration with community neighborhood

Building a Population Health Model

more than every other developing country on healthcare expenditures as

Total social service expenditures

Total health service expenditures

Transformation Center, The Scalable Population Health Enterprise. Generating

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