Population Health: The Ghost Aim

In 2008, Berwick et al. articulated the Triple Aim — improved care experience, improved population health, and reduced costs. Eight years later, the Triple Aim has become the health care sector’s dominant framework and has led to notable improvements: the cost curve is bending and the safety of care is better. Yet, the basic paradigm — which focuses on traditional health care delivery, rather than health itself — has not shifted. It is as if three aims are too many for the sector to tackle at once. While much energy has been invested in improving the care experience and reducing costs, the final aim of improving population health remains elusive — a Ghost Aim.

So it comes as no surprise that the United States still ranks last among 11 industrialized countries on health system quality, efficiency, access to care, equity, and healthy lives. After all, only 10% of health outcomes are affected by medical care, whereas 60% are rooted in social and environmental factors and associated behaviors — which are the essence of population health. To frontline clinicians who grasp the big picture of their patients’ lives, this is hardly news. For example, over half of frequently hospitalized patients lack access to healthy food or are at risk of not having enough food.

A Paradigm Shift to Population Health

In Thomas Kuhn’s theory of scientific revolutions, a paradigm reaches a crisis when the discomfort from the failures of existing science become unbearable, but the paradigm shifts only when there is a viable alternative to the status quo. When it comes to population health, health care stakeholders have been slow to recognize a crisis, in part because of reluctance to accept that better health is their actual goal.

The difficulty of defining the Ghost Aim makes it virtually impossible for health systems to know what their role and responsibility is to population health. Sometimes population health is described as something that occurs outside of health care delivery, such as a community’s rates of obesity, crime, or high school graduation. More often, “population health management” is viewed as clinical interventions aimed at specific patient subsets (e.g., high-need, high-cost patients), with the overall goal of improving care delivery (e.g., reducing readmissions) and reducing costs.

It should be the other way around; improved care delivery and reduced costs should be recognized as means to better population health. Population health should be the foremost aim of the Triple Aim, not the last. And if better health of the population has not been achieved, then the paradigm of care is failing, and something new must be tried.

The time is right for a paradigm shift. We are finally at a moment in the history of health care at which we know what to do to achieve better health, who should do it, and how to get it done.

Five Steps to Operationalize Population Health

To begin, health care leaders and providers should recognize that a viable alternative to the status quo is needed to move the needle on population health. Since social needs are major determinants of health, our health care system must assume responsibility for addressing patients’ unmet social needs — food, electricity, heat, housing — as a standard part of care. In 2008, Berwick et al. envisioned an “integrator” organization responsible for all three Aims, which “link[s] health care organizations (as well as public health and social service organizations) whose missions overlap across the spectrum of delivery.”

Every health care provider ought to care about social needs as a factor in their patients’ health, and even more so in the context of major reform initiatives like accountable care organizations and other alternative payment models. Most recently, the Centers for Medicare & Medicaid Services’ new Accountable Health Communities Model pilot and Comprehensive Primary Care Plus model unify the aims of health, care, and cost through care delivery and payment models that explicitly account for patients’ social needs. In 2017, up to 15 million patients will be screened for these needs through the CMS pilots alone.

How the work of population health should get done is now clear. Health system leaders still often refer to patients’ social needs as a “black box.” Yet collecting data on and responding to social needs can be — and increasingly is — integrated at scale as part of the clinical workflow, with the same disciplined management as any other part of care delivery. Across hundreds of health systems, we have identified five key drivers required to successfully integrate social needs as a standard part of care in diverse clinical settings and geographies:

1. A systematic resource screening protocol
2. Resource referral and navigation
3. A dedicated workforce
4. Data systems and performance improvement
5. Leadership and stakeholder engagement

As health care providers put these pieces in place, they quickly discover that social needs screening reveals key drivers of patient health outcomes and utilization. Patients reporting unmet resource needs have over 50% higher prevalence of depression and diabetes, elevated cholesterol and hemoglobin A1c levels, and more than twice the rates of ED utilization and no-shows.

Kaiser Permanente has documented that 78% of those patients identified as being at highest risk of becoming super-utilizers (i.e., in the top 1% of predicted utilization according to their illness burden) have at least one unmet social need. A recent study across three primary care practices at Massachusetts General Hospital found that patients who received support addressing these needs, including access to affordable medication and food, saw modest but significant improvement in their blood pressure and cholesterol levels. For some patients, the improvement in blood pressure was similar to adding a new blood pressure medication, without any side effects.

Responding to these social needs used to rely on the beneficence of providers, under the often-fickle headers of “mission” or “community benefit.” But if population health is to be more than a Ghost Aim, it has to be part of the definition and system of care, with clear definitions of success. The objective definition of success is when the patient secures the needed resources. Simply handing a patient a list of community resources or other “points for effort” approaches does not count or win anyone partial credit.

Health Leads’ national resource database reveals that just 10% of the community resources are responsible for 90% of the successful resource connections made for patients, illuminating the importance of a new value and supply chain spanning the health and social services sectors. If care providers do not know whether the patient secured the resource, the vital link between process and health outcomes is fractured, and the risk is high of misattribution and scaling an ineffectual intervention.

In short, we think the Ghost Aim is ready to be clearly defined and systematically implemented, through application of the measurement and management accountability approaches that have proved useful with the other two Aims. The health care system is now flooded with a variety of workforces charged, directly or indirectly, with addressing patients’ social needs — promotoras, community health workers, case managers, care managers, patient navigators, and health conductors — which informs a social needs data and measurement infrastructure that enables rigorous monitoring and understanding of their relative efficacy across clinical settings and patient populations.

Health Leads, for example, tracks weekly process and outcomes data (including percent of successful resource connections made) for our frontline resource connection advocates at 17 sites in 7 states to enable rapid adjustments in how we deploy this workforce.

Among other indicators, these data show that a patient is 23% more likely to secure a needed resource if he or she receives follow-up twice within two weeks of flagging this need.

Berwick et al. framed a simple test to know whether the Triple Aim had become real: patients “would recognize that the health care system is mindful of their needs, wants, and opportunities for health even when they themselves forget.” Today, our health care system operates from an understanding of patients’ social needs that is reminiscent of the sector before the Dartmouth Atlas and Framingham Heart Study illuminated flawed assumptions about population health and geographic variation in cost, quality, and utilization. By putting patients’ needs — including their social needs — first; isolating the drivers of impact for those needs; and focusing management discipline and relentless, data-driven improvement to address them, the Ghost Aim will become visible at last.