The Dark Matter of Population Health
Last week, CMS proposed new rules for compensating physicians through value-based payment. Now open 60-days for comment, the final rules aren’t expected until fall of 2016. The proposed rules have received mild applause from physician organizations – notably the AMA – for relieving practices from some of the draconian data management needed to earn a bonus. The flaw remains, though, in the presumption that insights to lower health care costs and improved outcomes are lurking in the data. In fact, the needed data are largely missing, and our system and health care workers are still configured to mitigate disease rather than to improve population health.
The mystery of high health care costs is like Dark Matter. Astrophysicists know that Dark Matter constitutes 85-90% of the universe, but they don’t know what it is because their instruments can’t see it. The Dark Matter of population health is health ecology – the social, behavioral and environmental factors that drive 85% of health outcomes. These domains are like Dark Matter, because the claims and EHR databases don’t contain social, behavioral and environmental data. Missing data can’t be analyzed, so health ecology is disease-care’s very large blind spot.
Patients with diabetes rarely have an A1c above 9% due to bad doctoring. It is due to poor health ecology – lack of money, distressed home life, low literacy, unreliable transportation, adverse childhood experiences leading to adverse adult behaviors, and lack of protective factors (such as a support system, participation in a community of faith, safe streets, healthy foods, ability to exercise, etc.). These issues are why diabetes, hypertension, body weight and many other chronic conditions are not in control.
The grand experiment of value-based payment may not be a panacea to better outcomes at lower cost. That’s because physicians and hospitals are being assigned accountability, but have little influence over health ecology. The ability to address these issues isn’t even in the skill set of most physicians. Yet, as if doctors are the root cause of inequity in health ecology, CMS is fixing to reward or punish physicians anyway. Medical homes seem better situated to address social, behavioral and environmental issues, but are woefully under-financed to solve health disparities. These big problems belong to entire communities. Assigning accountability to health care workers isn’t likely to work, when the most influential forces affecting health are families, employers, community-based organizations as well as local, state and national policies.
Perhaps the most colossal gamble is that meaningful use kinds of checklists can “certify” quality, as if healthy behaviors come from linear logic derived from data.
Patient portal – ☑︎
Document-sharing – ☑︎,
Cultural appropriateness – ☑︎,
Screening and immunizations – ☑︎,
Patient engagement – ☐.
Patient engagement may well be the most difficult factor to address, and should not be reduced to a checkbox. The hallmarks of people who maintain their own health lie outside of the medical system, and such individuals rarely act primarily to lower medical costs. Rather, they engage in healthy behaviors seeking quality-of-life and to satisfy emotional well-being directly derived from those behaviors. Almost never do patients engage because of knowledge and data awareness, and those who do so (e.g., cardiac rehabilitation patients) don’t sustain healthy behavior change without direct emotional and spiritual rewards.
Still, one factor impeding engagement is the relationship between patients and primary care practices. Health insurers will pay primary care practices handsomely for providing wellness and chronic care management, but many PCPs vehemently protest that patients aren’t willing to spend time on a wellness visit or pony-up the co-pay on chronic care. Moreover, PCPs think they already do prevention and chronic care. The truth, however, is that medicine’s take on prevention is mainly vaccines and early detection.
American medicine is weak at primary and secondary prevention of chronic disease. Do Americans really spend over $20 Billion a year in wellness, yet not want to talk with their doctor about it, nor pay $10 a month to help stay on track? What patients are saying is not that they don’t care about wellness, but that the wellness advice doctors provide is not worth $10. And maybe it’s not. After all, $10 can buy gym membership for a month, but only buys a sound bite from a doctor.
It doesn’t help doctors that their sound bites don’t help patients protect their well-being. This often frustrates patients, because most people prioritize quality-of-life over length-of-life, but doctors are focused on longevity. The discussion patients need is how he or she risks losing quality-of-life by doing nothing, and what he or she stands to gain by engaging – investing – in healthy behavior. People do not want to be dependent on family and health care workers, but health care workers typically avoid such conversations until the end-of-life is near – decades too late.
Who Is Accountable for Health Ecology?
Value-based payment for health care is being heavily leveraged on the shoulders of primary care physicians, who are a minority of doctors in the USA and paid the least – often multi-fold less than procedure-based specialists. Burdening primary care practices with the key role in reducing health costs thus seems misaligned with current spending. Health informatics is likely to be disappointing until health ecology is an adjustment factor in health insurance payments. That is essential if physicians are to understand how social, behavioral and environmental issues drive poor outcomes.
Once physicians do understand health ecology, will it be fair to award bonuses and extract penalties based on the health ecology demographics? Who will serve populations laden with health disparities, which are likely to lead to penalties? Those who take on patients with disparity may rightfully protest a payment system that cannot take health ecology into account.
Population health is a community-wide problem and will not be solved until PCPs connect with employers and community-based resources that are better situated for helping patients invest in health behavior change. So is payment reform doing the right thing, or are we plunging into the abyss before we can clearly see the Dark Matter of population health?
Geoffrey E. Moore, MD FACSM
Peter G. Sepsis, MS, MPH