Care Redesign

Population Health: The Ghost Aim

Article · December 14, 2016

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.

Population Health - Health Leads Weekly Process and Outcomes Measure Data for Patients Screened for Basic Resource Needs

  Click To Enlarge.

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.

Call for submissions:

Now inviting expert articles, longform articles, and case studies for peer review

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Mapping a Technology Strategy for Bundled Payment Care Using a Value-Driven Framework

Harnessing Emerging Information Technology for Bundled Payment Care Using a Value-Driven Framework

A four-part framework developed by physicians at Partners HealthCare provides a stepwise process for assessing and integrating technologies to effectively use data through a continuous patient experience.

UCLA Health CKD Risk Stratification and Management

Proactively Catching the Declining Patient

A coordinated effort by UCLA leaders to identify a high-cost population with chronic kidney disease and to modify care processes and personnel has led to improved health and reduced utilization.

Telehealth and remote monitoring are little used and ineffective for chronic disease care

Survey Snapshot: Treating Chronic Disease Proactively

Though survey respondents don’t indicate strong use of telehealth and remote monitoring, NEJM Catalyst Insights Council members discuss the ways they’re using these tools to monitor chronic disease, with good results.

Platforming Health Care Operations - Consumer-Driven Health Care - Business-Minded Optimizations

Platforming Health Care to Transform Care Delivery

Health care leaders need to focus less on ownership and control of the delivery process, and more on outcomes, cost efficiency, and customer experience.

Shah05_ integrated systems innovation pullquote

Build vs. Buy: What Should Health Systems Do?

The consolidation craze continues, but vertical integration has yet to demonstrate real progress toward the Triple Aim. Health care leaders would do well to consider innovative approaches that are working in other industries, including the tech-enabled full stack model.

Diagram Illustrating the COPD Care Pathway at Allegheny General Hospital

End-to-End Care for COPD Patients that Improves Outcomes and Lowers Costs

Allegheny General Hospital created a comprehensive solution for patients with chronic obstructive pulmonary disease (COPD) that led to improved clinical outcomes, reduced hospital admissions and readmissions, and a resultant decrease in the total cost of care.

David Blumenthal and Bob Galvin head shots

Ripe for Disruption: Why and How Big Players in the Private Sector Are Taking on Health Care

For big tech companies like Amazon, Apple, and Google, the health care sector looks ripe for disruption. Two executives working in different parts of the health care ecosystem discuss what this means for patients and doctors, including the positives and unintended consequences.

Top challenges facing chronic disease management care - insufficient time and care coordination

Care Redesign Survey: To Improve Chronic Disease Care, Change the Payment Model

Many health care organizations are reasonably effective in treating chronic diseases, but they are limited from doing better by fee-for-service payment, which remains the predominant payment model in the United States. This report serves as a snapshot in time, showing the intent of health care providers to be proactive in treating chronic disease, but limitations in their ability to address population health.

Nirav Shah head shot Stanford - AI in medicine and team care

What AI Means for Doctors and Doctoring

Physicians must hone the “four Cs” — critical thinking, communication, collaboration, and creativity — when leveraging AI as a new partner in their care teams.

End of Life EOL Palliative Care in the ED for Patients with Advanced Cancer - Process Map - MD Anderson Cancer Center

Patient-Centered Care at the End of Life in the ED

How MD Anderson Cancer Center is improving end-of-life care in an unlikely place: the emergency department.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Design Thinking

20 Articles

Taxonomy of the Patient Voice

While health care pursues the important trend of putting patients at the center of care,…

How Artificial Intelligence Is Changing Health…

The development of intelligent machines holds great promise for making health care delivery more accurate,…

Proactively Catching the Declining Patient

A coordinated effort by UCLA leaders to identify a high-cost population with chronic kidney disease…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now