Analysis of the first NEJM Catalyst Insights Council survey on the Care Redesign theme. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.
METHODOLOGY AND RESPONDENTS
In January and February 2016, an online survey was sent to the NEJM Catalyst Insights Council, which includes U.S. health care executives, clinician leaders, and clinicians at organizations directly involved in health care delivery. A total of 297 completed surveys are included in the analysis. The margin of error for a base of 297 is +/- 5.7% at the 95% confidence interval.
The majority of respondents were clinicians (44%), with executives (29%) and clinician leaders (27%) nearly evenly split. Most respondents described their organizations as hospitals (37%) or health systems (18%). These hospitals were predominantly midsized (29% had 200–499 beds) or larger (49% had 500 or more beds).
Only 8% of respondents indicated that their major affiliation was with a physician organization. Those physician organizations tended to be big — 64% had 100 or more physicians.
Nearly three-quarters of the organizations (71%) were nonprofit, with the remainder of respondents coming from for-profit organizations. Every region of the country was well represented.
Hippocrates wrote, “The natural healing force within each one of us is the greatest force in getting well.” While the link between physical and emotional health has been recognized from antiquity, the advent of highly effective, curative somatic treatment medicine relegated the link between the mind and the body to the back burner.
Modern medicine’s expertise in lab testing, imaging studies, and pharmacologic and surgical breakthroughs has produced the miracle cures that Americans have come to see as normal. However, the corresponding focus on the physical manifestations of disease has often ignored what is intrinsically obvious to laypeople — that physical and mental health are inextricably intertwined.
But attitudes are changing. In the first NEJM Catalyst Care Redesign survey, clinicians, clinical leaders, and health care executives cite “investing in behavioral health services alongside physical health services” as the clinical practice change most likely to improve the health of communities.
This is not a short-term fix, according to the survey respondents. Over the long term, investing in behavioral health and mental health services is the top avenue that the NEJM Catalyst audience would pursue.
The physical impacts of mental distress have been proven over a wide range of conditions in the literature. The most compelling evidence to me is found in the Adverse Childhood Experience series of publications, showing that there is a strong, graded relationship between traumatic stress in childhood and poor health outcomes (physical, behavioral, and mental) later in life.
Forward-looking health care organizations are starting to change their structures to link the treatment of mental distress and maladaptive behavior to primary care. The Southcentral Foundation in Alaska embedded “behaviorists” in their primary care teams early on their path to developing the Nuka system of care, earning the Baldrige National Quality Award in 2011.
Since then, experiments with models of how to effectively collaborate to treat physical and mental distress concurrently have abounded. Hopefully the end result will be that physicians not only pursue scientifically valid physical treatment, but also cultivate and support the healing force within all patients on their journey to better health.
Our survey data also recognize that in addition to physical and mental health, financial health has a significant impact on patients. The lack of a source of income, access to health insurance, or the foundational elements of Maslow’s hierarchy of needs (food and shelter) have real and substantive effects on health outcomes.
A Passing Grade for Population Health
It was interesting to test what feels like health care redesign dogma — that provider organizations are moving toward wide execution of population health — against the reality faced by clinicians and executives. On a scale from 0 (it’s a fad) to 100 (it’s critical for the future), population health gets a 77. While 77 squeaks into the top quartile, that was a C grade in high school. It is a tepid endorsement for something that so many organizations are betting on heavily. The verbatim comments from survey respondents helped give insight into why.
Overall, health care administrators and executives responding to the NEJM Catalyst Care Redesign survey are more positively disposed to population health than frontline clinicians.
The comments by organizational leaders reflect both anxiety and acceptance about actively managing a transition from fee-for-service to new payment models. Population health seems to be viewed as the path to creating better health, with revenue more tightly linked to outcomes, panel management, and improved community health markers.
The hesitation and comments from frontline clinicians about population health also reflect concern about the future of reimbursement, but they tend to focus more on the individual nature of health care and its relationship aspects. Ensuring outcomes across a population seems a laudable goal, but losing focus on the “N of 1,” on the complexities and benefits of highly personalized, individualized care, is a thread running through the comments of those worried about the implications of population health.
I believe the right path is in the middle. Like virtually any tool, population health can have wonderful uses at the right place at the right time. When doctors and patients understand the evidence-based gaps in routine primary and secondary prevention, the right care is much easier to provide (and receive).
Combined with shared decision making, population health also helps ensure we are enabling person-centered, values congruent care. But for patients with complex co-morbidities or devastating acute conditions — those catastrophic health events where medical miracles occur and where we spend a huge percentage of our GDP — population health may not be a panacea. In our journey towards health care redesign, it can’t be the only tool.
In fact, our survey respondents believe that focusing on executing on evidence-based care through clinical practice guidelines and increasing the communication with patients outside of face-to-face encounters will have more impact.
The good news is that physician practices and provider organizations aren’t waiting for the perfect care design, but are actively making and testing changes to the status quo. Building interdisciplinary teams, increasing cost transparency, and leveraging technology are already well on their way to becoming the norm. Despite the barriers that remain rife throughout the system, care delivery leaders are forging a path to the future.
VERBATIM COMMENTS FROM SURVEY RESPONDENTS
Do you view population health management as a fad, essential, or somewhere in between?
“Population health management is key to enabling people to take control of their health care needs. As the number of hospitals shrinks and the population ages there needs to be a mechanism in place by which providers and patients remain linked.”
“American medical system has created false expectations. All cancers can be cured, surgery is the answer for heart disease, screening for everything detects all serious diseases. Early detection is the answer. Diet, nutrition, healthy life style, non-smoking, and moderation of alcohol consumption are simply not adequately emphasized.”
“There is certainly some faddish behavior around population health but it needs to be a core value of our health care delivery system.”
“Our organization focuses on population health. However, precision medicine is equally important. When a physician encounters a patient, N = 1.”
“So far I have not been impressed with the vision nor the outcomes of current population health research and programs.”
“It is partly fad, and mostly aspirational rather than reality. However, it’s a necessary idea.”
“It is important to understand population health parameters so resources can be dedicated on [a] large scale for intervention with high-risk populations such as smokers, diabetics, and the like. The risk to overemphasizing population health is that some interventions may not have desired outcomes so there needs to be focused efforts on areas that have a proven benefit and avoid focusing on outcomes without demonstrated benefit. It’s not a magic bullet and won’t replace the therapeutic relationship that can [be] between a patient and a trusted physician.”
“It’s important but not sufficient. We can’t abandon high-level care for those who have disease.”
“Population health will succeed as a population movement, not as a health care movement. Until then its definition is necessarily limited though I think we are beyond the tipping point in health care.”
“I only spend less than 1% of patients’ awake-time with them, so having input/structure to the other 99% is critical.”
“We do not have unlimited financial resources so what we have has to be applied in an informed manner. Effective population health management is driven by good data and allows us to better direct resources where impact will be greatest.”
“It seems to be the flavor of the month in responding to government mandates.”
Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.