Time to dump public health for population health?

The State of Public Health and Primary Care in the US

The United States, despite its advanced medical technology and high healthcare spending, struggles with significant public health and primary care challenges. From rising chronic disease rates to persistent health disparities, the failures of the current public health system, including primary care, are glaring. A shift towards a population health approach is essential to address these shortcomings and improve health outcomes for all Americans. (See table at the end for summary)

The Failings of Public Health and Primary Care in the US

Focus on the Healthy and Wealthy

Public health and primary care’s focus is on getting the most people the most care. This has led to a system that favors the healthy and wealthy, creating a demand for more care and investment in those who can afford it. This approach neglects the reality that most healthcare spending is needed for the sick, those with chronic diseases, and those facing disparities due to race, education, and socioeconomic status. Consequently, while the wealthy receive more care, costs rise, and the sick, who receive less necessary care, end up requiring more expensive, emergency interventions.

Shift Away from Medicaid and Towards Healthier Patients

Private Practices: Many private practices are shifting away from Medicaid patients and towards those who can pay more or have better insurance coverage. This trend exacerbates the issue by leaving the neediest patients with fewer care options and contributing to a cycle of poor health outcomes among the underserved.

HEDIS Incentives: The HEDIS metrics further induce practices to seek out the most compliant and healthiest patients, rather than those who are the neediest and at the greatest risk. This creates a system where healthcare providers are incentivized to focus on metrics rather than the quality and effectiveness of care for high-risk populations.

Inadequate Funding and Resources

Chronic Underfunding: Public health departments and primary care practices have faced decades of underfunding, limiting their ability to effectively address health crises and prevent diseases. This underinvestment has left the public health infrastructure weak and ill-prepared for emergencies.

Resource Scarcity: Limited resources hinder the ability to implement comprehensive public health programs and provide continuous care. Essential services like epidemiological surveillance, health education, and preventive care are often under-resourced, leading to gaps in care and prevention. The unequal distribution of care results in fragmented services for the have-nots, who receive gap-filling, rather than continuous and relationship-based care.

Fragmented and Reactive System

Lack of Coordination: The US public health system and primary care services are fragmented, with responsibilities spread across federal, state, and local levels, leading to inefficiencies and inconsistent care. This lack of coordination can result in duplicated efforts or critical gaps in service.

Reactive Approach: Public health and primary care often take a reactive stance, responding to health crises as they arise rather than preventing them. This crisis-driven approach can overlook the underlying social determinants of health that contribute to long-term health disparities.

Health Disparities and Inequities

Persistent Disparities: Significant health disparities exist based on race, income, geographic location, and other factors. Public health and primary care efforts have not sufficiently addressed these inequities, resulting in unequal access to care and poorer health outcomes for marginalized communities.

Social Determinants of Health: Public health programs and primary care frequently fail to address the broader social determinants of health—such as education, housing, and income—that play a crucial role in shaping health outcomes. Without tackling these root causes, disparities persist.

Ineffective Use of Data

Data Silos: Public health and primary care data are often siloed, making it difficult to get a comprehensive view of health trends and effectively allocate resources. Inconsistent data collection methods and lack of data sharing further complicate efforts to address health issues holistically. Data within primary care is often used to meet process metrics and checkboxes rather than for population health management and identifying high-risk populations.

Lack of Predictive Analytics: While data analytics hold promise for improving public health and primary care, many departments and practices lack the capacity to utilize predictive analytics to anticipate and mitigate health risks proactively. The same is true for primary care practices that know little about their patients beyond the immediate clinical interactions.

Influence of Fee-for-Service (FFS)

FFS Model Impact: The predominance of the Fee-for-Service (FFS) payment model has significantly influenced public health and primary care, leading to a system that prioritizes the volume of services provided rather than their quality or effectiveness. This model encourages a reactive approach, where healthcare providers are reimbursed for individual services, often resulting in fragmented care that lacks coordination and continuity.

Failure of Public Health and Primary Care: The focus on quantity over quality in the FFS model undermines the ability to provide comprehensive and preventive care, which are essential components of effective public health and primary care. This has contributed to the failure of initiatives to address long-term health outcomes and disparities adequately.

Population Health

Population health as a concept of health can be defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”

Need for Outcomes-Based Care: Population health, on the other hand, emphasizes the need for value driven models that reward quality, outcomes, and preventive measures. These models incentivize providers to focus on comprehensive and coordinated care tailored to the needs of specific populations, particularly those at higher risk.

Enhancing Population Health: By shifting to value-based care, population health aims to improve health outcomes, reduce disparities, and promote equity. This approach supports proactive and preventive care, ensuring that resources are allocated effectively to address the unique needs of different population groups.

The Case for Moving to Population Health

Proactive and Preventive Care

Focus on Prevention: Population health emphasizes preventive care and early intervention, addressing health issues before they become severe. This proactive approach can reduce the burden of chronic diseases and improve long-term health outcomes.

Holistic Approach: Population health considers a wide range of determinants, including social, economic, and environmental factors, leading to more comprehensive and effective interventions.

Equity and Targeted Interventions

Addressing Health Disparities: Population health aims to identify and address the needs of specific groups, particularly those most at risk. By targeting interventions to high-need populations, we can reduce health disparities and promote health equity.

Resource Allocation: Population health focuses on allocating resources where they are most needed, ensuring that vulnerable populations receive the support necessary to improve their health outcomes.

Integrated and Coordinated Care

Care Coordination: Population health encourages integrated care systems that coordinate across different providers and services. This reduces fragmentation and ensures that patients receive seamless and continuous care.

Collaboration Across Sectors: Population health fosters collaboration between healthcare providers, public health agencies, and community organizations. This multidisciplinary approach is crucial for addressing the complex factors that influence health.

Data-Driven Decision Making

Advanced Analytics: Utilizing data analytics and predictive modeling, population health can identify at-risk populations, predict health trends, and tailor interventions effectively. This data-driven approach enhances the precision and impact of health initiatives.

Comprehensive Data Utilization: Population health promotes the integration and sharing of data across systems, providing a holistic view of community health and enabling more informed decision-making.

Conclusion: The Imperative Shift to Population Health

The failures of the US public health and primary care systems highlight the urgent need for a paradigm shift towards population health. By focusing on preventive care, addressing health disparities, promoting integrated care, and leveraging data, population health offers a more effective and equitable approach to improving health outcomes. It is time to reimagine our healthcare system, prioritizing the health of all Americans, particularly those most at risk, and ensuring a healthier future for our nation.

In summary, the Fee-for-Service payment model has significantly influenced the shortcomings of public health and primary care by promoting a fragmented and reactive approach to care. In contrast, population health advocates for value-based care models that align incentives with the goals of improving health outcomes and reducing disparities for specific populations.

Summary Table of Public vs Population Health

Note:?As a reminder this newsletter is written from my experience and perspective.?The newsletter does not imply or relay the opinions of others.??The intent is to offer an avenue for dialogue and discussion around important topics in healthcare and healthcare innovation from one doctor’s perspective.??I am a physician and so can only write from my perspective.?If you are clinician, provider, nurse or whatever my goal is to enable you to agree or disagree and have not intention to suggest or imply that only the physician perspectives matter.??They do matter but as part of a larger dialogue that can foster better health outcomes.