Healthcare in America, just another Seldon Crisis?

When heard they were making a movie of Isaac Asimov's fantastic Foundation series, I decided it was time to reread them.  You see, as a child, my father had the brilliant idea to make reading a book of his choosing part of my monthly allowance.  Half actually.  Plenty of 28th-31sts were spent cramming in some of the best sci fi, personal philosophy, negotiation, interpersonal relations, investment and management books you could find in the mid 80s and early 90s.  It was his intention that not only do I get to learn things he considered crucial to a successful life, but that by having me read them, he would get a free rereading as I summarized my findings.  The pain of cramming also taught me about procrastination. Genius parenting.

The Foundation series, consisting of 7 books written out of order between 1942 and 1992 (the first was written was Asimov was 22!), that chronicle a future galaxy on the decline.  I won't dare do the entire series justice, but the books begin with the establishment of the Foundation on a remote planet that faces a series of existential threats.  More a collection of short stories, each story ends with an astounding resolution of each crisis.

I bring this up as I was reading this recent piece by Dave Chase the describes the disastrous effects of rising health care costs on Americans, to the tune of $1,000,000 lost per family over a lifetime with little to show for it.

For a brief moment I envisioned our current health care fiasco as nothing more than a Seldon crisis, resolved through bold and decisive action, and look forward to when the victors are hailed as heroes and we move on to the next larger, more complex catastrophe threatening our survival...

The "Population" part of Population Health

So I tried to skip over the Population part of Population Health Management yesterday, but my incredible pediatrician wife pointed out that actually knowing who is in "your population" can be downright impossible.  

First, maintaining a list of people with accurate demographics including contact information is still very hard in 2015.  In addition to simple names, addresses and ages--all of which can change over time even with perfect data fidelity, we have to add a status to that list.  Are you a patient of Dr. Schutzbank?  Do you have Masshealth insurance?  Since when? When does or did that change?  

Outside of health care, we do this well and we call it Facebook.  Everyone ensures that their information is updated regularly.  However, Facebook is voluntary and the information is necessarily interesting to the poster.  Sharing pictures of vacation may motivate me to log in, find the photo, upload it, tag it, etc.  Updating my primary care doctor selection is just not that interesting to me.  Furthermore, this information must be kept perfectly private and secure, so crowdsourcing solutions are a challenge.  Lists of names remain hard, but fortunately perfection is not required for progress.  Instead, we can define populations for different players in health care in descending order of ease.

Government & Public Health: Geography-based populations

If your foray into health care is through government and/or public health methods, your population is likely defined geographically.  Cities, states, zip code ranges, whole countries will be in or out of your jurisdiction.  This will cause all sorts of problems when neighboring geographies have radically different services and people start to move.  Short of that, it is easy to at least theoretically know who is in your population.  

Having a criteria that can be measured makes thing easier. Furthermore, geographic constraint (which is true regardless of who you are as all health care is local), makes it a little bit easier to design constrained interventions.  If obesity is a problem and there is no place to walk in your town, you can make places to walk in your town (without worrying about making places to walk in every town). Not easy, but easier.

Payors of health care: Customer-based populations

If you are a health plan, insurance company, union, self-insured employer or some other purchaser of health care services, then you too can define your population.  Someone, somewhere, somehow, is paying for your services.  And that is your list.  You have all of the list problems, and that people die, they lose benefits, paperwork has a lag, etc.  Fundamentally though, with good list hygiene, your population is knowable.  

Since the relationship here is customary rather than geographic, the interventions will look differently.  The tend to focus on remote, scalable solutions using technology.  Once you are not in the same place as your population, you could be anywhere in the world.  Although attractive, there is a growing recognition at the importance of relationships in care and therefore a shift in intervention design. 

Additionally, Payors arguably have the most difficult regulatory challenges.  Public health and government officials have plenty of rules with which to contend, but it is the payors that have to guess if certain behaviors break the rules or not, often post hoc.  Fear of regulatory violations, especially as organizations grow large (which all regulated organizations must do), can chill innovations in the name of fraud and waste prevention.  Once we cross into care providers the game changes quite a bit.  Although mired in regulation, the truth is that a license to practice medicine confers incredibly wide latitude in the treatment of patients, especially outside of facilities.  

Specialist Care Providers: Condition-based populations

When it comes to specialty care, populations may not be fixed, but they can be predicted.  The very advantage of specialization is that by limiting what comes through the door, you can meet the needs of your population.  It is why primary care doctors claim specialists have it so easy.  Additionally, you often have some geographic limitation to your specialty, although "catchment areas" can span several states based on disease prevalence. 

Your population is guided by your conditions, and therefore your interventions are condition specific. If you are an endocrinologist specializing in thyroid disease, you better be setting up your interventions to be convenient and effective for the treatment of thyroid disease.  You have an ultrasound in the office.  You can biopsy right there and have the ability to prepare and view tissue.  However, true innovation is dependent on a deep understanding of the diagnosis, treatment and ongoing management of your conditions.  Specialists ought to be leading the way in keeping patients out of the office, but fee for service keeps getting in the way.

Primary Care Providers: Geographic, customer, condition-based populations

Primary care may very well have the hardest problem in defining population.  The typical method is empanelment--a list of patients who are supposed to under care of a given doctor.  This sounds great, but it is a particularly challenging instance of the list problem.  Patients may "establish care," but do they continue?  Do they have to break up with their primary doctor formally?  If they change insurance, change jobs or move away does the primary care physician ever get notified?  Formal empanelment via HMOs has been tried, but is arguably less effective and often rejected as too controlling.  Attribution methods are used (patient saw Dr. X. for 2 visits and Dr. Y for 1 visit, therefore they are a Dr. X patient, even when the last visit was a "switch" to Dr. Y).   

Most Primary Care practices that successfully solve this problem do it through payment reform of some kind-- HMO attribution, concierge and/or Direct Primary care customer relationship, health plan style enrollment/dis-enrollment, limiting eligibility to membership in certain organizations (employers, Medicare, etc.).  

Even without knowing your population for sure, primary care offices can go a long way to determine prevalence of disease and geographic needs.  Preparing for common conditions and community engagement outside the practice may be the only way practices can manage their population. It may mean that the measurement end is weak, that it is hard to prove interventions work, but healthy patients do not need you to prove that you helped them, only that they are helped.

Do not give up! There is a way to get your arms around your population somehow and doing so will allow you to become far more effective in caring for your patients.

What is Population Health Management anyway?

In thinking about my last entry on recommendations, I've gotten to thinking a little more deeply about the broader term Population Health.  Population Health is a term that has been used increasingly since the passage of the Affordable Care Act.  But what does it mean?

In a recent report from Academy Health-- the lobbying arm of Health Services researchers, they share an interesting conundrum:

"The phrase “population health” is increasingly used by researchers, practitioners, and policymakers in health care, public health, and other fields. Although their understanding of this phrase differs, many see attention to population health as a potent opportunity for health care delivery systems, public health agencies, community-based organizations, and many other entities to work together to improve health outcomes in the communities they serve."

So we don't agree on exactly what it means, but it represents a great opportunity!  As insane as this sounds, I know exactly what they mean.

Regardless of whether you are a payor, provider, public health worker, government official, or simply a thoughtful person, it has probably occurred to you that we can take better care of our population beyond the one at a time model prevalent in medical care.  Hence the idea of focusing on population health.

Past that, the term breaks down a little bit, and there may be a way to put it back together.

First of all, who is in your population?  It depends on who you are-- a payor has members, governments have constituents, public health workers have jurisdictions, primary care providers have panels (sort of).  Let's assume you can figure this out and manage all of the challenges of constantly updating a list.  (An aside--it is amazing how difficult keeping an updated accurate list of names still is in the technologically marvelous era in which we currently live.  Just look at your last formal party invite list and weep at how many people have moved, married, lost your friendship, etc.) So you have your population, how do you manage their health?

Let's start with an example from the medical system. What we have done in health care for the longest time is reactive, serial care, synchronous care.  That is to say, we generally take care of people, one at a time, as they make appointments with us.  The performance of our health care system suggests that this is not a great way to improve the health of individuals or populations.

One common suggestion in the primary care world is the "registry."  Simply put-- what if we had a list of everyone in our population with a given condition, like diabetes (it is ALWAYS diabetes).  We could work on those patients getting their foot exams, eye exams, A1cs, and other things done for their diabetes without waiting for them to come in to us.  We can shift from being reactive to being proactive.  Problem solved, population managed.

Or have we simply changed from one list of patients that we care for one at a time (appointment list) to a different, and possibly better list (diabetes registry).

On the other end of the spectrum is the public health opinion-- big changes that affect everyone at once.  For instance, great roads.  I studied medicine and public health in New Orleans and had the great fortune to learn from Larry Durante.  It turns out in nearby Metairie, we had the 9th most dangerous intersection in America in 2001.  The medical system likely worked overtime to absorb all of the car accident victims with better ambulances, trauma bays, surgeries, rehabs, etc.  But it was "fixing the damn intersection" as Dr. Durante put it, that actually solved the problem.  Here we did one thing and helped lots of people by preventing a problem.

So now we have a few ends of the spectrum here, all of which fall somewhere into population management.  In fact, there is a group out of Duke trying to marry the shockingly different disciplines of health care and public health.

But what if we dive a little deeper into the definition?

Perhaps to resolve some of the confusion, we separate Populate Health Management into its consitutient parts:

1. Population Health Measurement or How is our population doing?
2. Population Health Interventions or What are we doing to make them better?

Separating into these categories may begin to resolve the tension between the measurers (traditionally government and payors) and the doers (health care and public health).  

The measurement piece is crucial, because if you cannot measure you cannot improve.  Getting measurements correct, getting accurate data and in a way that does not impede the actual care of a population is crucial.  Being more in the doer camp, I'd like to come back to measurement in the future.  

When it comes to the doing then, we have a few choices on how to frame our work.  How do we reconcile population health as both a better list of patients and fixing an intersection? For that, why not a two-by-two table?  (I have no art department as of yet, and I use the word patient because, well, I am a doctor).

Population Health Intervention Types:

	One Patient	Many Patients
Present Patient
Absent Patient

In this framework, we can think of doing things that affect one patient at a time, like a doctor's visit vs. things that affect many patients at a time, like fixing an intersection.  However, whether or not the individual(s) are present makes a big deal in terms of the type of intervention.  For example, a doctor's visit is helps a single, present patient.  It goes in the top left.  The intersection fixing helps many patients, all of whom were doing something better with their time when the intersection was fixed--that falls into the bottom right.

What can we extrapolate from this?  Let's go back to our list of diabetics.  We can decide to see them all in clinic soon, top left.  We can decide to form a diabetes group and have a bunch in our office at once, top right. We can text each patient who is overdue for an eye exam, bottom left.  Or we can tweet an informational piece to all of our diabetics, bottom right.  

In this way we can begin to categorize interventions based on their effect size and presence requirements, and start solving problems with solutions from the proper quadrant.  Going back to Metairie, the health system built up capacity to better serve one patient at a time, at potentially huge expense and in no way decreasing the ill effects of the intersection.  We had a lower right problem with an upper left solution.  

Where else in our work can we just "fix the damn intersection?"

A few minutes on Primary Care Innovation from Iora Health (video entry)

For those of you not yet brave enough to watch the full 51 minute keynote (or those of you not related to me... thanks family!), here is a 5 minute interview from the same event, Maine Quality Counts.

Finding Joy & Purpose in Primary Care (video entry)

Today we will go with a video entry.  Check out a talk I had the great opportunity to give at the recent Maine Quality Counts learning session on Primary care practice transformation.  Entitled, Finding Joy and Purpose in Primary Care, it is an overview of the work done In Search of Joy in Practice and at Iora Health. The running time is about 51 minutes, enjoy!

On the making and taking of recommendations

Every day we hear about some new medical recommendation in the popular press.  Usually what we get is an oversimplified report of the workings of a prestigious and thoughtful group, the United States Preventive Services Task Force (USPSTF).  This august group has the incredibly challenging mandate of making preventive medical recommendations to hundreds of millions of strangers.

"Created in 1984, the U.S. Preventive Services Task Force is an independent, volunteer panel of national experts in prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications."  The key to their scope is prevention. Put another way, these are the things that you should do BEFORE something really bad happens to stop that bad thing from happening.  It sounds like an easy task, but it turns out prevention is a tricky thing.

First and foremost, all preventive steps have some element of cost.  Costs look different to different parties but can be broken down into:

• $: financial cost for a service
• Risk of badness: every medical test has an element of risk from anxiety whilst awaiting results through death from complications of a procedure.
• Patient time
• Provider time that could be spent doing something else (we could argue that based on the average paperwork load of a primary care doctor, we value their time close to zero).
• Health system resources to be used elsewhere-- there are only so many colonoscopes and so many colonoscopy suites and so many colonoscopists to go around

But what is the upside of prevention?  It turns out that prevention, in the clinical sense, is only usefully applied to conditions that have the following characteristics:

• High prevalence disease
• A prolonged, asymptomatic phase 
• Effective treatment 
• Treatment is more effective before developing signs and symptoms

In other words, only common conditions that you can have without knowing, that we can treat, and treat early, fall under the category of preventive recommendations.  Similarly preventive tests are only useful when they:

• can detect a high proportion of disease in said asymptomatic phase
• are safe, relatively inexpensive and widely available
• lead to demonstrated improvements in health (as opposed to lead time bias)

It turns out that the USPSTF ends up recommending fairly few things, and they are worth reviewing to understand what the medical world means when they talk about prevention, as opposed to what the general public means (diet, exercise, seat belts, helmets, etc.).  I find in my own practice that different definitions of prevention lead to tremendous stress and disappointment on the part of my patients. 

As stated earlier, the USPSTF must make recommendations to strangers, that is to say, it must advise doctors and patients whose individual circumstances cannot be known.  This burden is a hard one, and it leads to considerable conservatism on the part of the organization.  There are other similar organizations recommending guidelines, standards and evidence review for all sorts of conditions.   

The proliferation of guidelines (and payment attached thereto) has been variously hailed and lamented as the future of medicine.  Coming of age in the era of evidence-based medicine, I have long struggled with the pros and cons of guideline-based medicine.  Rather than try and resolve the answer, I'd like to come at the problem orthogonally considering just how recommendations are used and useful based on the recommender and the recomendee. 

Population level recommendations

These are the province of organizations like the USPSTF.  The recommender is often expert, reviewing reams of evidence of variable quality.  The recommender NEVER knows the individual facts or case of the recommendee, who is effectively the union of patient and provider.  The recommendations ought to be conservative because of their scale and anonymity.  The Ecological Fallacy comes in to play as well-- observations about a group cannot be attributed back to an individual in the group. 

At this level, recommendations are exactly that-- recommendations.  They are incredibly valuable so that we do no harm but will always need to modified by individual providers and patients for individual circumstances.  Without population level guidelines, we would do really, really stupid things to our patients, and/or miss out on really obvious things. 

All of the bristling at population level guidelines come when measurement and its cousin, payment, become attached.  Trying to ensure that their populations get the best possible care, insurers have attempted to tie payment to providers to test completion levels.  While well-intentioned, this can be incredibly dangerous as discussed by Hartzband and Groopman above.  One way to circumvent this issue is to not measure testing rates, but rather measure shared decision rates.  That is, how many patients were offered a real choice in the matter.  Whatever patients ultimately decide, they have to live with the consequences.  While this may be harder to capture than straight mammography rates in an eligible population, if we are committed to excellent care, then it is worth the challenge.  

Panel recommendations

We now pass into the realm from an organization recommending testing to strangers into the realm of relationships.  A panel is a group of patients attributable to an individual provider (or clinical team).  It is a list of individuals who are theoretically known to said clinical care team.  As you can see, we have just moved from the unknown into the known.  Many organizations will begin to recommend treatment pathways for their specific populations that take the best of available evidence and match it with the characteristics of a given population.  For instance, foot ulcers are rare in the general population, but relatively common in people with diabetes.  Therefore, where looking at everyone's feet may not make sense, looking at diabetic individual's feet makes a ton of sense.  

It is at the level of panel recommendations that clinical organizations can combine the best of available evidence with intimate knowledge of their own patients.  Here organizations can be a bit more proscriptive to ensure that proper care happens quickly.  Additionally, through the creation of great protocols/pathways/internal guidelines, a larger care team (beyond physicians and other front line providers) can be brought to bear to ensure excellent care.  

The owning of recommendations to specialized sub populations may be the greatest area for growth in clinical medicine, and the promise of all of this data we seem to be collecting across the country. 

Individual recommendations

Traditionally the stock and trade of physicians and other providers, individual recommendations are the apex of great clinical care.  The basic truth of all of the evidence out there is that your patient just does not meet the specific criteria.  Studies of diabetics may exclude those with other conditions, heart disease may cut off at age 65.  Just what are we to do?  And the common the rallying cry of beleaguered providers-- "My patients are sicker!"

The individual recommendation remains firmly within the Art of medicine.  Here, patient and provider must together combine everything that is known about diseases, treatment, all of the evidence assembled, the individual combination of life and health that make up that patient, and actually make a plan that can work.  In my opinion, this can be the most fun part of medicine because it is where the rubber begins to meet the road.  We can also try things, measure if they work, and try other things.  Where one medicine fails, another may succeed.  Where one sleep apnea mask causes agony, another may bring much needed restful sleep.

Individual knowledge and recommendations are the safeguard against the errors inherent with amassing giant pools of data and distilling specific behaviors.  Nevertheless, to work on individual judgement alone is to forsake great care for our patients.  Similarly, we are professionals, bound by ethics and law to recommend things that are justifiable given clinical circumstances.  We are limited in our ability to make certain recommendations especially when the evidence gets slim and/or the risk to patients becomes low.  

Exercise and diet are great examples of this challenge.  How many times have you had a provider recommend changing your diet and/or exercising.  Beyond that, they may recommend one of a few well-studied diets.   There is a problem here, and it is not your doctor's fault.  

First, diets are hard to study.  Second, the risk of trying to eat differently are very low.  This intersection of hard to study and low risk in individual experimentation fall out of the bottom of what providers can comfortably recommend.  Fundamentally, we don't know, because knowing is hard, and finding out on your own is not particularly risky.  Painful, annoying, time-wasting, but not risky.  And remember, we first do no harm.

Individual Action

This brings us to the ultimate level of recommendation--what each of us decides to do.  Some panel in Washington may recommend screening for HIV in all individuals once aged 18-65.  Our doctor may be urged by their employer and guided by their own beliefs to recommend the same.  However, we each must act and make the choice to do or not do what is recommended.  It is in this responsibility that our cynicism protects us from the errors of the above recommendations.  It is also in this responsibility that our inaction causes us to miss out on what could be life-saving interventions.  

Each of us has the agency, the authority to decide to do or do not with any recommendations we receive.  We also have the power to experiment on our own with exercise, with diets, with life hacks that may make our life better.  In the end, no matter who recommends what, in the immortal words of Steve Winwood, "While you see a chance take it ... Because it's all on you."