‘Population-Based,’ Meet ‘Patient-Centered’ | Managed Care Magazine Online |MANAGED CARE | May 2012 – by Timothy Kelley
It’s hard to believe we’ve made so little progress on reconciling these two ideas since 2012.
With the coming increase in the elderly population who often have multiple interacting health problems, population medicine might end up being of little use.
Health care doesn’t lack for big ideas, even if their definitional boundaries do sometimes get fuzzy.
Take “population-based medicine” and “patient-centered health care,” for example. Both are phrases we hear and read every day, and maybe even believe in. But do they coincide or collide?
When you apply today’s population-based medicine at the granular level, it sometimes results in inappropriate care from a patient-centered point of view.
The fact is, one’s view of the compatibility of these concepts depends on what one is used to seeing when one gets down to cases
Defining the terms
Population-based medicine is one of managed care’s fundamental notions.
The American Medical Association recently defined it as an approach that:
“allows one to assess the health status and health needs of a target population, implement and evaluate interventions that are designed to improve the health of that population, and efficiently and effectively provide care for members of that population in a way that is consistent with the community’s cultural, policy, and health resource values.”
Provide medical care in a “way that is consistent with the community’s cultural values?
Even when they are wrong? Like Christian Scientists refusing necessary blood transfusion? Like certain communities believing vaccination harms their children?
This is part of our problem with opioids: culturally, they are rejected as “heroin pills”, yet for pain patients, they are indispensable.
Most people in health care have long since cast off the fear that this approach implies a cookie-cutter insensitivity to patients’ individual needs.
As for patient-centered care, definitions differ — and that’s part of the trouble.
But it has been described by recent Centers for Medicare & Medicaid Services (CMS) Administrator Donald Berwick as including:
“transparency, individualization, recognition, respect, dignity, and choice” in the patient’s health care experience.
It is also widely understood to draw on the concept of the patient-centered medical home (PCMH), in which a practice is organized to provide truly coordinated, proactive and therefore cost-effective care.
“The physician is the leader of a team of professionals,” says Stephen Rosenthal, vice president for network management at Montefiore Medical Center in the Bronx, N.Y., and president of the affiliated Care Management Co., describing how the PCMH model works
“They manage the complexity of the medical issues for a population of patients so the physician doesn’t need to have face-to-face contact with each patient on each occasion to satisfy their health needs.”
“They are two sides to the same coin,” says Boland of our two ideals
So what’s Stefanacci’s gripe?
Problems ‘in the weeds’
For one thing, he is a geriatrician, and older patients tend to be medically complicated.
“If you’re doing population-based medicine through a large health plan,” he complains, “your guidelines might tell you, for example, that all nonvalvular fibrillation patients need anticoagulants, and you might ‘ding’ all those practices that don’t have 80 percent of such patients on anticoagulants.
But for very frail elderly patients, an anticoagulant may in fact be contraindicated — they could fall and develop a subdural hematoma that would actually cost the patient and the system much more.”
Stefanacci offers another example.
From a population-based perspective, a diabetic population should have glycated hemoglobin A1c levels below seven, he says, and doctors may be penalized if a sufficient percentage of their patients aren’t kept to that level. “But when you get down into the weeds and start looking at 85-year-olds in a nursing home, that number may be inappropriate.”
Population statistics don’t apply to any specific subset of a group: 50% of humans have prostate glands, but when you’re only dealing with professional football players, it’s 100%.
Going by the averages of current healthcare recommendations could be deadly for seniors.
The majority of health studies are not done on older people, so we have no way of knowing what “normal” is for them/us.
what has been called the art of medicine, he says, “is really taking all the multiple variables in a patient and making adjustments.
Population-based medicine should have enough nuance to apply patient-centered care, but the models that are out there don’t allow that level of variability.”
“There’s an element of truth to that,” Rosenthal concedes. “As an industry, health care isn’t quite there yet. We’ve done a better job with certain segments of the population — diseases such as cancer, for example — than with others.”
Rosenthal doesn’t share Stefanacci’s worry about HbA1c targets that may be inappropriate for the elderly because, as he says, “it’s ultimately at the discretion of the physician.” But he moves closer to the Stefanacci stance when he talks about predictive modeling.
For Kasuba of Tufts Health Plan, it’s partly a problem of perceptions.
Interventions suggested for someone by population-based data, he notes, “may or may not be perceived by that individual to be appropriate for themselves.”
In circumstances of shared decision-making, he says, patient-centered care requires consideration of the patients’ own values.
How it works when it works
Patient-centered medical home models operate on the assumption that population-based medicine and patient-centered care need to be done simultaneously, and that is “eminently possible,” says Susan Stuard, of the Taconic Health Information Network and Community.
“In our patient-centered medical home project, we’ve been working with six health plans to create a multipayer claims database to look at costs, utilization, and outcomes,” Stuard says.
Those data are put to work. To hear Stuard tell it — and she’s no abstract theorist — it is precisely population-based data that make the PCMH possible.
“Patient-centered care is about having time in the exam room to discuss with patients their choices for health care,” she argues.
“How is she going to lose those 25 pounds she needs to lose? Will a man with prostate cancer choose watchful waiting or aggressive treatment when both are reasonable options? And does a woman have questions about her mammogram?” But checking whether she’s had the mammogram shouldn’t occupy the doctor’s time, says Stuard, because in the PCMH model such basics “were already flagged on the way in” — and they are on the checklist, thanks to population-based medicine.
As is so often the case, the truth about what’s best for any individual is never truly generic.
Some aspects of a doctor’s duties could be done by technology (administrative stuff) or assistants (taking vitals, routine check-ups, and follow-ups), to free up their valuable and expensive time to truly listen, diagnose, and treat their patients who have non-routine problems.
Population data can make the initial “default” decisions (pain and swelling in an ankle after a misstep = patient most likely has a sprain, is urged to rest joint, prescribed anti-inflammatories) but doctors must focus on the individual as soon as it becomes apparent that their patient deviates from the default (several other joints become periodically painful, skin areas intermittently show lace-like pattern of redness, headaches become common = patient has EDS, a connective tissue disorder, requires multi-faceted treatment, possibly requires prescribed opioids for lifelong increasing pain)
“Health plans’ problem is that in many cases they are disconnected from the delivery of services,” says Rosenthal. “They have a relationship with the member and the employer, but only limited relationships with the doctor and the community.”
A tale of two circles
Lucy Johns, an independent consultant doing business as Health Care Planning and Policy. Years ago she developed a course for medical directors called “Population Medicine in Managed Care” that counseled physicians to “merge a population perspective with clinical medicine to create a practice that keeps people out of the health care system when they don’t need to be there.”
She explains with a symbolic visual image: a small circle inside a larger one.
- The large circle, “population health,” represents the population that CMS and others now would like providers to be accountable for.
- The smaller circle includes people who are receiving care or who have ongoing health problems.
“The border between the two circles is the prevention of problems and the promotion of health, which evidence proves will keep that population out of your office,” says Johns.
“Prevention and promotion take resources, but far fewer than hands-on services. If you’re on a fixed budget of any kind, you’ve got to address population health.”
And the need to make the two ideals converge isn’t going away.
“It’s going to have to be figured out,” she says.
“We are never going to have perfect measurements.
But we are always going to have limited resources.”
A double ‘stewardship’
That exception, of course, is Kaiser Permanente. “They have done a remarkable job, investing heavily in analytics in the past 10 years,” says Boland. “They basically have the whole data sheet right there when the doctor reaches for it — the patient’s latest symptoms, what he or she was in for last time, and the various things that Kaiser as an organization can do for that person.
You can’t do patient-centered care if you don’t have access to evidence about population health, says Sharon Levine, MD, of the Permanente Medical Group of Northern California.
“Our ability today to measure and monitor the effect of illnesses and interventions gives us information about people who are like the patient,” says Levine. “From that we begin to understand the needs, preferences, and clinical concerns of the patient in front of us. That’s not the end of the story — it’s the beginning of the story.
The key here is getting much more useful and applicable data by using only “information about people who are like the patient,” not whatever population was used in the latest scientific research studies.
Coming: a monkey wrench
“The devil is in the details,” insists Vogenberg.
And in down-to-cases reality, he says, population-based medicine and patient-centered care are indeed not in perfect sync — and may never be.
He warns, for example, of one big devilish detail that is on the rise: the category of “personalized” specialty drugs and biologics, such as the prostate cancer drug Provenge, which require individual formulations because they work differently based on different individuals’ genetic makeup.
These drugs are outrageously expensive – it costs hundred of thousands of dollars to treat a person with them.
Today most of these drugs are costly injectables, but they will increasingly appear in oral formulations — as some multiple sclerosis drugs already do — and will pose tough ethical and logistical questions about allocation of resources.
The availability of these biologics, says Vogenberg, threatens to throw a monkey wrench into the whole health insurance business and health reform efforts.
“What we have today is very much population-based,” he says.
“What you do for one, you do for the other. And whether it’s a copayment or a deductible, case management or disease management, everybody’s exposed to the same benefit design, the same management approach and strategy from 20th-century insurance risk underwriting.
But in the next 5 or 10 years we will need a whole different strategy, because the variation in care and the cost of the components of care will be that much greater.” He doesn’t say just what such a new strategy might be, but is helping to lead an employer-driven biologics initiative that intends to develop one.
Whatever surprises the future holds, knowing everything we can learn about populations would appear to be an always indispensable guide — and the delivery of care an always perfectible process.
Author: Timothy Kelley was editor of MANAGED CARE from 1995 to 1997 and is now a senior editor at Wainscot Media in Montvale, N.J.