The Relevance of Population Health to Academic Medicine

Figure: Daniel M. Fox, PhDWhy has the cluster of concepts called population health become attractive to an increasing number of people? What are some of the barriers to applying the theories and methods of population health in clinical practice, professional education, and policy to affect the determinants of health? How are some of these barriers being overcome? These are important questions, and in this column I attempt to address them. INCREASING POPULARITY Population health is an increasingly fashionable phrase that has a variety of meanings. Some purchasers of health care say they use population-based research to guide them in what they call value-based purchasing. Managers of health plans use population-based methods to measure outcomes and manage variation. Researchers investigate the effects of clinical interventions in populations and the consequences of disparities in income and education with respect to the health status of specific populations. Some public health officials want to redefine their field as population health in order to describe more accurately activities that include surveillance, prevention, education, delivering health services, and concern about socioeconomic factors in health status. Curriculum reformers in academic medicine want students and housestaff to learn more about using evidence-based medicine to manage the care of defined populations of patients. And finally, the word population itself has been important for many years in family planning organizations, which have used it as a euphemism for birth control (for example, the Population Council). Such increased attention to the concept of population in relation to activities in the health sector is the result of the convergence of the rising prestige and practical use of research on populations with powerful external (and some internal) criticisms of the priorities of the health sector. The research that contributed to this convergence has been conducted in many countries during the past half century. Research findings, for example, ▪ revealed the associations of the declining incidences of many infectious diseases since the 19th century with economic growth that stimulated changes in diet and living conditions, with pubic health interventions, and with advances in diagnosis and treatment; ▪ demonstrated that people are at risk of particular chronic diseases as a result of what they smoke, eat, or drink and how much they exercise; ▪ linked differences in the health status of members of populations with gradations in their incomes and social status; ▪ measured the quality of life (or the quantity of disability) in the health status of populations over time; and ▪ documented variations among populations in both the incidence and the outcomes of particular medical interventions. This research coincided with events that created turmoil in the health sector. Most important, collective purchasers of health care in business and government took effective steps to contain the rising costs of health care, beginning in the 1980s. Purchasers sometimes used the rhetoric and findings of population-based research to press physicians and hospitals to take seriously the methods of achieving cost-effective care. These findings included documentation that care is often unnecessary, ineffective, and highly variable among geographic areas, and new insight into the effects of behavior in causing, preventing, or postponing the onset of leading chronic diseases. FOUR BARRIERS TO APPLICATION Four problems impede the application of the findings of population research to clinical practice, professional education, and policy for health care financing and public health. The first problem is the diffusion of responsibility for health. Decision makers in the public and private sectors are not accountable for the overall health status of any population. Most of them are responsible for a fragment of policy that affects the health of a population—for coverage or reimbursement or treatment or prevention, for example. Moreover, legislators and elected executives, the only persons who are, in theory, accountable for such determinants of health status as education, income, and the environment, struggle to balance the priorities urged by interest groups and voters. The second problem is the lack of evidence to guide policy making about the determinants of health. Not enough is yet known to make new policy based on the precise contributions to health status of non-medical determinants and the mechanisms by which these contributions occur. Attempts to devise and publicize summary measures of population health status, most recently by the World Health Organization, have attracted more criticism than praise. The third problem is that advocates and persons who have fatal chronic diseases (and their families) constitute the largest groups of people who accord health the highest priority. Elected officials and CEOs of corporations perceive, and polls confirm, that most people who are in reasonably good health accord higher priority to income, job security, public safety, and education than they do to improved health status. Most people, moreover, care more about having choices among providers and access to the broadest array of treatment than they do about the relative cost—effectiveness of particular interventions. Many purchasers talk about using research to guide them in buying for value. But recent studies show that value purchasing, as a set of techniques guided by evidence, is used routinely by only a few corporations, purchasing coalitions, and public agencies. Similarly, only a few projects to reallocate resources across policy sectors, in the United States and other industrial countries, report any success. The most successful projects spend health services funds in an adjacent sector (for example, social services in the United Kingdom), or coordinate resources within a tightly organized chain of command (for instance, preventing suicide in the U.S. Air Force). Moreover, projects to improve population health can end quickly when the party in power loses an election (an example is the cancellation of a promising program to integrate health, social, and education policy in the Canadian province of Prince Edward Island), or may not be sustainable when an incumbent political leader (such as the current governor of Oregon) is subject to term limits. The fourth problem that impedes the practical use of the theory and research findings of population health is resistance to the new focus on population health in public health and medicine. Many leaders in public health fear that an emphasis on the health of populations could result in having some of their responsibilities and resources transferred to physician groups and health plans, corporations, and the education sector, and continue the erosion of the public health infrastructure. Similarly, some hospital leaders worry that the successful application of population-based research findings could reduce utilization. Some physicians, in both the academy and the community, suspect that because population health advocates want to transfer funds from medical care to foster the improvement of other determinants of health, they are not sensitive to their pleas for the restoration of lost autonomy, territory, and income. SUCCESS STORIES Each of these impediments to improving the health of populations is, however, being addressed successfully in a few, scattered places. Here are two examples of modest success in addressing each impediment: ▪ Diffusion of responsibility. (1) The Tricare program of the U.S. Department of Defense is achieving the military goal of force-readiness by coordinated attention to the health status of uniformed personnel, their civilian dependents, and retirees. (2) Officials of the Centers for Disease Control and Prevention are collaborating with public and private sector leaders in the New York metropolitan region to develop land-use policies that achieve public health goals that are compatible with both economic development and planning the urban and suburban infrastructure. ▪ Lack of evidence. (1) Sales of the Cochrane Library's regularly updated systematic reviews of clinical trials have increased 250% since 1998. (2) Executives of a few large corporations are working to persuade colleagues in other firms to use the value-purchasing method. ▪ Health is not the highest priority. (1) Early in 2000 the U.S. National Security Council for the first time defined a disease (HIV/AIDS) as a problem of national security. (2) A joint project of the Council of Foreign Relations and the Milbank Memorial Fund is working with leaders of the foreign policy community to increase the priority accorded to population health in foreign affairs. ▪ Resistance in public health and medicine. (1) The first textbook of public health that has population health in its title and emphasizes multiple determinants of health has just been published. (2) The Collaborative Center for Child Well-being has substantial funding to synthesize and apply to policy knowledge about the broad determinants of child well-being and its significance across the life span. WHAT'S AHEAD? These examples suggest that the concept of population health is more than a platitude but much less than a powerful influence on policy, practice, and education. Population health is not a powerful influence because we lack a feasible politics that reduces the present fragmented responsibility for health. Without such a politics, increasing knowledge about improving the health of populations will not inform medical education and practice, corporate and government purchasing of health care, and the allocation of resources by each level of government. Achieving a feasible politics of responsibility will take considerable time, brilliant strategies of persuasion, and considerable luck. Some advocates of the concept of population health are optimistic that resistance to it can be overcome. Persons in academic medicine, public health, and clinical practice who bet against them could be losers in the politics of allocation to and within the health sector in the next generation.

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