By Paul Nicolaus

February 20, 2017 | It’s the perpetual puzzle. Why is it that the U.S. healthcare system carries such a hefty price tag while consistently lagging behind in the key indicators of national health? Per capita, America doles out over twice the average of other developed countries and at nearly 18% of the nation’s GDP, devotes far more of its economy to this sector than its peers.

Most of the roughly $3 trillion in annual U.S. healthcare spending is geared toward direct medical services while a smaller amount is devoted to screening and meaningful interventions to alter the social determinants of health (SDOH) such as housing, food, finances, transportation, personal safety, and environmental hazards, Joel Reich, M.D., chief medical officer of Eastern Connecticut Health Network pointed out.

“Many look at the U.S. and say, ‘You’re spending way more of your GDP than anybody else in Western developed countries,’ and it’s true,” he said. “But if you look a little further at what we spend on social services, which become the things that address the determinants of health, we spend a lot less than most of the developed countries,” he said.

Yale School of Public Health professor Elizabeth Bradley has studied this dynamic over the years and co-wrote a book with Lauren Taylor entitled “The American Health Care Paradox: Why Spending More is Getting Us Less.” In it, the authors rely on extensive research, including a comparative study of healthcare data from 30 countries, to begin to unravel this conundrum.

What they found is that we’ve somehow managed to leave out of our calculations some of the most impactful spending that countries can make to improve the health of their populations. If expenditures on healthcare are combined with investments in social services, the U.S. health rankings shift in the direction of an average spender with average outcomes.

The finding seems to align with the notion that health is dictated by much more than genes and medicine alone and gives added support to the idea that an effective system must address social, environmental, and behavioral factors in addition to delivering care to the sick. Ultimately, this ratio of spending between the social and medical care is, in Reich's mind, an essential part of the larger discussion surrounding population health.

As the U.S. healthcare system transforms from fee-for-service to a value-based care and payment system, there is a growing awareness of the importance of better managing these SDOH. And as value-based care dollars become even more at risk for providers, translating into greater upside gains or downside losses, Reich predicts that these factors will increasingly come into play.

Leveraging SDOH

Intriguing examples of addressing SDOH can already be found. Some hospitals are beginning to work more closely with their local housing department or Department of Social Services to help the homeless settle into apartments.

The time, effort, and financial investment of managing this relatively small group of people who often cycle back through the system with little or no source of payment can wind up leading to fewer emergency room visits and reduced healthcare costs.

Other hospitals, like Boston Medical Center (BMC), have used food to help manage medical conditions. Its Preventive Food Pantry addresses nutrition-related illnesses by providing the types of healthy sustenance frequently missing in a family’s diet due to factors like accessibility and cost.

Patients with nutritional needs are referred by BMC providers who write “prescriptions” for foods that are both medically and culturally appropriate. Together with the Greater Boston Food Bank, families are offered fresh fruits, vegetables, and meats.

“As these dots start to get connected, particularly around housing and food, they matter much more to the healthcare providers as the cost of healthcare shifts over from the insurance side to the provider side,” Reich noted.

The efforts extend beyond just housing and food, however. Transportation is yet another factor that can play into health outcomes as a lack of adequate transit can lead to missed appointments, delayed care, and missed medication, all of which can result in poorer management of chronic conditions, worse outcomes, and lost revenue for providers.

To address this, some healthcare entities across the country have begun to partner with companies like Uber or Lyft to make it easier for patients to attend their appointments.

Ultimately, Reich envisions a much closer alignment between social issues and medical care will emerge over time, but it will likely evolve differently in different places depending on the population.

Some endeavors may be able to assist with this process. For example, the County Health Rankings & Roadmaps, a collaborative effort between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, compares the health of nearly all counties throughout the U.S.

The rankings provide a view of the ways in which health is impacted by where individuals live, learn, work, and play and offer up a starting point for communities looking to actively bring about change and improvement by building a culture of health.

Replacement of Population Health

“I think it’s easy to talk about population health like it’s something new,” Reich added, but it’s far from a recent development. In the past, it was just viewed more as a government public health program whereas the use of the term in recent years has broadened to encompass a geography, or a group covered by an insurance plan, or all the people within the service area of a healthcare system, for example.

John Mattison agrees that in order to look ahead it is helpful to consider the history of population health. Picture the country doctors from a century ago. Because these doctors lived in the communities they served and visited people in their home environments, they were aware of huge determinants outside of biology that influenced health, he explained to Clinical Informatics News. Even though it has become fashionable to declare that we’ve recently discovered the social determinants of health, compassionate practitioners have long understood the context of disease.

“It’s coming of age in that people are creating new terms and popularizing the notions, but in fact, great physicians did this many generations ago,” Mattison said, “and it’s been lost in the blizzard of technology."

When he considers the future of population health, Mattison believes the convergence of personalized medicine and community-based health will replace traditional models of population care. And as the assistant medical director and chief medical information officer at Kaiser Permanente, Southern California, Mattison has plenty of experience to back up that perspective.

Mattison was intimately involved in the design of Kaiser’s original population care systems, which predated the organization’s electronic health record by well over a decade. While that work was underway, data was funneled from a variety of sources into a single repository, and from there care gaps could be identified.

If a member was due for an immunization or mammogram or prostate exam, those issues could be addressed. Those at risk for certain diseases who weren’t being optimally managed could be identified as well.

The use of a care management summary sheet included all identified care gaps in one location for every individual. Mattison recalled one of the most compelling examples of the setup’s success, pointing to a woman who came in to have her eyes checked for a new pair of lenses.

When her summary sheet indicated she was due for a mammogram, she was scheduled to have it taken care of that same day. Because there was a lesion, a biopsy was scheduled for the following day, and lo and behold there was a small, early cancer.

Within a matter of days, surgery was performed to remove that cancer. “And she is cured, alive, and well because we had that care gap put in front of the very next visit she had anywhere in the system, which just happened to be to an optometrist,” he said. 

Kaiser also began sending voice and text messages to its members. In other words, the organization performed both in-reach and outreach to address all identified gaps in care. When a population of members with an issue was identified, those who were the most advanced in the course of their illness were assigned case and care managers.

That was one of the original forms of population health and population care, Mattison said, so in the pre-electronic health record world, this was already driving Kaiser’s quality outcomes significantly higher.

Toward Personalized Care

Once a universal electronic health record came into play, the notion of population care began to undergo a transformation. As opposed to highlighting groups of members who were due for a screening test or immunization, tools began to be applied at the individual level. But Mattison had sensed a shift of this nature much earlier on.

“I gave a presentation inside of Kaiser Permanente about how population care was becoming obsolete about 20 years ago,” he said. What he explained at that time was that once enough information about each individual became available, people with the same disease wouldn’t necessarily be treated in the same manner.

His prediction at that time was that population care would be completely replaced by personal action plans for individuals that are updated every time new information about that patient or their disease became available.

By looking at the datasets—one about the individual member and the larger set about the disorder—and then looking at the best recommendations at the individual level, care has shifted from the population to the personal.

“So we’ve gone from what are cohorts of individuals that we prioritize as a way to direct our focus on improving health, wellness, resilience, quality of care, and outcomes to one that is much more personalized,” he said.

Along the way, a new era of personalized medicine has begun to take place. It allows the organization to go after the best possible opportunities for health, wellness, resilience, disease management and prevention for its members on an individual level while retaining the ability to view data across individuals to prioritize work across an entire population.

Population care is evolving into a way to prioritize work within the panel of an individual physician, care manager, case manager, or specialist, he added. It has also become a way to prioritize work within the conventional population of people who are overdue for preventative care, immunizations, or management of a disease condition.

Motivating Patients

Because the human experience is so vast, variable, and dependent upon the interaction of highly complex biologic systems—the microbiome, immunome, genome, connectome, exposome, and socialome—Mattison believes that being precise about all that before we understand these interactions is a little overambitious.

For example, children who receive excessive antibiotics in the first five years of life experience changes to the bacteria in their gut, and that influences their immune system because it is trained by the microbiome to a large extent.

That interaction between the microbiome, the immune system, and the brain results in abnormalities that are evident 10 years later when an MRI scan is performed. It is clear that these systems are interconnected—the empirical evidence is overwhelming—but knowing exactly how it works within each person is far from precise, he explained.

“We need to continue applying the best evidence we have from the world of big data knowledge of populations and apply it to individuals in a personal way,” Mattison argued. In the meantime, Kaiser continues to make strides toward greater levels of precision.

After investing heavily in reviewing the literature and coming up with clinical practice guidelines over two decades ago, Kaiser implemented evidence-based practices. And using the large amount of data available about its individual members, Kaiser is increasingly making use of the inverse–practice-based evidence.

If a teenager with an autoimmune disorder is experiencing problems with clotting and issues with her kidney, for example, the existing literature may say nothing about that constellation of findings. If Kaiser turns to its own data, however, it may be possible to find others who look similar to this individual to see how they were treated and what happened.

Mattison is also working on projects to integrate health information across multiple institutions to create a larger reservoir of information that would help address the needs of those who come in with uncommon complications.

Better understanding motivation at the individual level is another realm of personalized medicine that has fascinated Mattison. It is known that compliance with medical recommendations is often very low, he said, but the very term non-compliance is biased. 

What that says, in a sense, is that the doctor failed to convince the patient to do something, so that person is blamed for not following the recommendation. But the medical community hasn’t done its job of understanding that patient’s home or work environment in a way that leads to the development of effective regimens.

The end game is wellness and resilience and ultimately happiness, he explained, but we can’t do that without paying attention to the social context of an individual—what their capacity is for change, what kind of support they need to change what they do, and what kind of motivational tools they actually respond to.

Getting closer to personalized medicine will involve looking at an individual and their values and determining—given that person’s choices, appetite, and motivational style—how to motivate with what they need to know, when they need to know it, using a modality that resonates with their motivational profile.

“So when I think of personalized medicine, it’s not just knowing the individual and knowing the literature and doing the intersection between the two,” he said. It’s helping people understand their values, priorities, and objectives through empathy and compassion and then delivering options that allow for greater levels of participation in their own health.

Paul Nicolaus is a freelance writer specializing in health and medicine. Learn more at www.nicolauswriting.com.