Engaging in Nontraditional Partnerships to Improve Population Health

Population health, which encompasses the health outcomes of a specific group of individuals, has become an important concept in modern health care systems. Many public policy initiatives in recent years have included population health measures as a key component of optimizing the performance of the US health care system. While such traditional, incentive-based government programs have increased awareness of the importance of population health, truly meaningful change to the US health care system will require reorganization of the structures of care across populations. Broad, lasting improvements across the medical, social, and economic determinants of health will require innovative thinking and the formation of nontraditional partnerships. We provide examples of novel and effective partnerships that have recently been established between health care providers, patients, commercial insurance companies, government entities, academic researchers, pharmaceutical manufacturers, local community organizations, and other stakeholders.

The discipline of population health has seen a meteoric rise in popularity and attention in the last 15 years since Kindig and Stoddart sought to clarify the term
in 2003¹:

We propose that population health as a concept of health be defined as “the health outcomes of
a group of individuals, including the distribution of such outcomes within the group.” These groups are often geographic populations such as nations
or communities, but can also be other groups such as employees, ethnic groups, disabled persons,
or prisoners.

In 2008, improving population health was identified by the Institute for Healthcare Improvement as part of the Triple Aim for improving the US health care system, along with improving the experience of care and reducing per capita costs of health care.² Similarly, in 2011, the improvement of population health was included as a key goal of the National Quality Strategy, which was established as a result of the enactment of the Patient Protection and Affordable Care Act (ACA).³ As the United States grapples with trying to improve our health care system, the solution is founded on reorganizing systems of care for populations.  

Population health goes beyond medical care, extending into the nonmedical determinants of health, their impact on health outcomes, and potential interventions to impact them. The key determinants of health are genetics, social circumstances, environmental conditions, behavioral choices, and medical care.⁴ Because medical care only contributes an estimated 10% to outcomes,⁴ organizations have begun to think beyond health care delivery to identify ways to improve population health. Additionally, since people spend the majority of their time outside of contact with health care systems, it is imperative to identify opportunities to engage patients between medical care encounters.

Diverse Stakeholder Efforts

Numerous policies and experimental value-based care performance programs have been put into place to align incentives, stimulate new behaviors, and create systems to achieve these goals.  For providers, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) brought forward 2 tracks of participation through the Merit-Based Incentive Payments System (MIPS) and alternative payment models (APMs).⁵ The Medicare Star Ratings program introduced rewards for payers that can provide high-quality care for their populations.⁶ Both private and public accountable care organization constructs are designed to engage and align health systems around value-based contracts.

Additionally, hospital organizations with 501(c)(3) federal tax exemption status are required to complete a Community Health Needs Assessment (CHNA) as part of the ACA. Aimed at addressing population health challenges, this provision requires such hospitals to assess the social and economic condition of the community and to determine how the community perceives its health status and health care needs.⁷ This outreach and engagement can enable the identification of the major risk factors and causes of health problems, which can then be used to develop a strategy and an implementation plan to address the identified needs. Finally, CHNAs are publicly reported along with the progress made toward addressing those needs, which provides transparency and accountability.

With each of these programs, systems and incentives have been put in place to align health care stakeholders around value-based care. Providers, health systems, and payers each assume key responsibilities to reorganize care. Robust and monumental change to a complex system requires coordinated effort across broad and diverse stakeholder groups. The Centers for Disease Control and Prevention (CDC) states the following about population health, which goes beyond alignment and further specifies partnerships⁸:

[P]opulation health [is] an interdisciplinary, customizable approach that allows health departments to connect practice to policy for change to happen locally.  This approach utilizes non-traditional partnerships among different sectors of the community—public health, industry, academia, healthcare, local government entities, etc.—to achieve positive health outcomes.

Whether health departments or other constituents take the lead, lasting change across health and the social and economic determinants of health represented in broad-based population health will require not only joint effort but also innovation and nontraditional partnerships. It is these interdisciplinary, interconnected partnerships that are the pathway to population health; when all parties can align and contribute, collective organizations are strengthened for improved health care.

Creating Opportunities for Partnership

The CDC statement above is a broadly inclusive list, notably including the pharmaceutical industry, which has always had a key role to play in health care. The pharma industry transforms scientific discovery into innovative medicines that are key components of health care for both acute and chronic diseases. Across the industry, there is support for systemic and dramatic change in health care—medicines perform better in the context of improved health care systems that facilitate value-based care. However, manufacturer participation is not often enabled by prevailing policy programs.

Quality organizations have developed frameworks related to population health that are more inclusive and can offer opportunities for broader partnership. Recently, the National Academy of Medicine (formerly the Institute of Medicine) convened the Committee on Core Metrics for Better Health at Lower Cost, which developed the Vital Signs: Core Metrics for Health and Health Care Progress report.⁹ This report was published in 2015 and proposes a basic framework to monitor progress toward improving population health. In 2016 the National Quality Forum (NQF) developed an action guide entitled, Improving Population Health by Working with Communities: Action Guide 3.0,¹⁰ which is intended to align with the National Quality Strategy and help improve population health. Recently, the National Committee for Quality Assurance (NCQA) included Population Health Management as a new standards category for Health Plan Accreditation. This action is part of a shift in focus from treating a single disease state toward evaluation of the whole person.¹¹ This recent event is likely to accelerate movement toward population health improvement by establishing accountability for health plans, encouraging them to further support clinicians and health systems.

These broad frameworks from nongovernmental coalitions have brought industry and providers, health systems, and payers together from across the health care continuum and community in the pursuit of increased cross-functional engagement and improved population health. In the section below, we provide more specific examples of interactions between trade associations and private payers to show how the breadth of coordination and engagement for all parties can continually bring further advancement toward better population health.

Nontraditional Partnerships in Action 

In 2016, the American Medical Group Association (AMGA) established the Together 2 Goal campaign as a population health initiative, with the goal of significantly improving care for 1 million people with type 2 diabetes by 2019.¹² This multistakeholder program brings together AMGA member physician groups, professional organizations, and pharmaceutical/device companies to achieve this ambitious population health initiative. Together 2 Goal provides resources and a venue for sharing best practices to advance the quality of care in type 2 diabetes.  Resources are brought forward by participating members as well as pharmaceutical companies, with the common goal of improving the delivery of evidence-based care to individuals living with type 2 diabetes.

Humana’s Bold Goal strategy is an example of a commercial health insurance company undertaking a population health initiative. The goal of this program is to make communities across the country 20% healthier by 2020 by improving key social determinants of health and chronic conditions through pilot programs and community/physician partnerships. This initiative began in 2015 in 7 communities across the United States to engage key community stakeholders to develop evidence-based, scalable solutions to improve population health. The Bold Goal website has an open invitation to join them in the journey to improving health.¹³ Those organizations that have joined Humana include professional organizations, faith-based organizations, social service providers, health systems, clinical groups, and pharmaceutical companies, all united with the common goal of improving population health. Based on the success of the initiative, this program has now expanded to include additional communities across the United States. 

Most of these frameworks call for multistakeholder collaboration to improve population health. Industry participants can bring deep expertise in the disease areas of interest, most obviously through the pharmaceutical products and rich datasets surrounding these products. Perhaps less well-recognized, manufacturers also can contribute nontraditional resources and tools to engage with patients and support the systems within which these pharmaceutical products are used. One example to complement the new NCQA Population Health Standards, is a practical resource guide for population health managers.¹⁴ This NCQA resource provides tools and in-the-field examples of how health plans could implement the standards in practice. 

Another example of resources offered by industry participants is the development of programs to support medication adherence. Medication adherence continues to be suboptimal in patients with chronic conditions such as asthma, diabetes, hyperlipidemia, hypertension, and depression, with reported adherence rates ranging from ~50% to 70%.^15,16 Higher levels of adherence to evidence-based therapy for these types of chronic conditions have been associated with decreased disease-related health care costs, including lower rates of hospitalization.¹⁷ Many potential interventions have been explored to improve medication adherence. In an analysis of data from patients using the Care4Today mobile phone application, developed to help patients track and manage medications,¹⁸ self-reported medication adherence rates were higher with this tool (~85%) compared to historical adherence reports.¹⁹ 

Shared decision-making has been offered as a way to increase medication adherence by improving alignment between patient goals and preferences with chosen treatment options. A recent study by Romanelli et al observed that involvement in treatment decision-making increased the likelihood that patients would be adherent to medications to treat cardiometabolic diseases.²⁰ In that context, the American Diabetes Association recommends that treatment decisions be made in collaboration with patients based on individual preferences.²¹ To facilitate shared decision-making in the choice of antihyperglycemic agents in type 2 diabetes, an evidence-based decision aid was recently created by an independent panel of experts.²² In a pragmatic controlled study comparing use of the decision aid with usual care, use of the decision aid positively impacted factors that may impact medication adherence, including knowledge, decisional self-efficacy, and decisional conflict.²³

Another example of how pharmaceutical manufacturers can play a role in improving population health management is in the development of resources to assist those responsible for population health management. These resources assess population risk to identify groups of patients for targeted outreach. The Anticoagulation Quality Improvement Analyzer (AQuIA) is a software tool to analyze health plan data to identify patients with atrial fibrillation who are potential candidates for anticoagulation.²⁴ The tool uses evidence-based algorithms to stratify patients by stroke risk and bleeding risk to identify patients who may benefit from consideration of anticoagulation. Similarly, a predictive risk model using health care claims to identify patients with type 2 diabetes was recently developed to assess risk for major adverse cardiac events.²⁵ This model was developed to answer population health managers’ requests for assistance in cardiovascular risk stratification. 

Many pharmaceutical manufacturers have sought to engage with the movement to improve the health of our health care system in the United States. Many in the industry have been willingly engaged and have sought creative and collaborative ways to participate in the process. The examples above demonstrate how various tools can fit together into programs that may be further motivated by the NCQA standards released earlier this year.²⁶ The NCQA has presented the phrase “systems, not silos” as a guiding principle. Through experimentation, as the CDC states, “non-traditional partnerships among different sectors of the community” are gradually emerging as a path for a broad coalition of stakeholders, which may be necessary to make an impactful change to complex health systems.⁸ In this spirit, there is room for additional frameworks and nontraditional partnership programs for pharmaceutical companies to fully engage with the other providers of care in the pursuit of a pathway for improved population health.

Finally, as innovation advances and targeted therapies become more common, the promise of personalized medicine comes closer to reality. It will become especially imperative that all stakeholders (traditional and nontraditional) in the health care system truly work as a system in support of the patient at the center. By functioning in this way, health care can become further grounded in the goal of achieving the Triple Aim and ensure appropriate treatments are used in the appropriate populations with the necessary supports to ensure safe and effective treatment. By using each stakeholder’s perspective and expertise, all constituents can create a pathway to realize the full potential of targeted treatments while delivering care in the most cost-efficient manner and, critically, improving the patient experience.

References

1 Kindig D, Stoddart G. What is population health? Am J Public Health. 2003;93(3):380-383.

2. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769.

3. National Quality Strategy. National Quality Strategy Overview. https://www.ahrq.gov/sites/default/files/wysiwyg/NQS_BriefingSlides_1-27-17.pptx. Published January 2017. Accessed October 15, 2018.

4. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood). 2002;21(2):78-93.

5. Centers for Medicare & Medicaid Services (CMS). MACRA. cms.gov website. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Updated September 21, 2018. Accessed October 15, 2018.

6. Centers for Medicare & Medicaid Services (CMS). Medicare Part C & D Star Ratings: Update for 2019. cms.gov website. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Downloads/2019-Star-Ratings-User-Call-slides.pdf. Published August 8, 2018. Accessed October 15, 2018.

7. Association of State and Territorial Health Officials (ASTHO). Clinical to community connections: community health needs assessments. astho.org website. https://www.astho.org/Programs/Access/Community-Health-Needs-Assessments/. Accessed October 15, 2018.

8. Centers for Disease Control and Prevention (CDC). Population Health Training in Place Program (PH-TIPP): What is population health? cdc.gov website. https://www.cdc.gov/pophealthtraining/whatis.html. Updated January 31, 2018. Accessed October 15, 2018.

9. Institute of Medicine, Committee on Core Metrics for Better Health at Lower Cost. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: The National Academies Press; 2015.

10. National Quality Forum. Improving population health by working with communities: Action Guide 3.0. qualityforum.org wesbite. https://www.qualityforum.org/Publications/2016/08/Improving_Population_Health_by_Working_with_Communities__Action_Guide_3_0.aspx. Published August 2016. Accessed October 15, 2018.

11. National Committee for Quality Assurance (NCQA). NCQA release new standards category – population health management. ncqa.gov website. https://www.ncqa.org/
news/ncqa-release-new-standards-category-population-health-management/. Published August 3, 2017. Accessed October 15, 2018.

12. American Medical Group Association (AMGA). AMGA foundation launches its next national campaign – Diabetes: Together 2 Goal^®: New campaign aims to improve the lives of 1 million people with type 2 diabetes. Atogether2goal.org website. https://www.together2goal.org/About/PR/2016/20160312a.html. Published March 12, 2016. Accessed October 15, 2018.

13. Humana. Be at the center of something bold. populationhealth.humana.com website. https://populationhealth.humana.com/. Accessed October 15, 2018.

14. National Committee for Quality Assurance (NCQA), Janssen. Population Health Management Resource Guide. https://www.ncqa.org/wp-content/uploads/2018/08/20180827_PHM_PHM_Resource_Guide.pdf. Published 2018. Accessed October 15, 2018.

15. Thier SL, Yu-Isenberg KS, Leas BF, et al. In chronic disease, nationwide data show poor adherence by patients to medication and by physicians to guidelines. Manag Care. 2008;17(2):48-52, 55-47.

16. Briesacher BA, Andrade SE, Fouayzi H, Chan KA. Comparison of drug adherence rates among patients with seven different medical conditions. Pharmacotherapy. 2008;28(4):437-443.

17. Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005;43(6):521-530.

18. Johnson & Johnson Health and Wellness Solutions, Inc. Care4Today. https://www.care4today.com/. Accessed October 15, 2018.

19. LaMori J, McAllister D, Devlin F, Doshi D. Use of a mobile health management application to manage multiple chronic disease medications. Value in Health. 2016;19(3):A205.

20. Romanelli RJ, Huang Q, LaMori J, Doshi D, Chung S. Patients’ medication-related experience of care is associated with adherence to cardiometabolic disease therapy in real-world clinical practice. Popul Health Manag. 2018;21(5):409-414.

21. American Diabetes Association. Standards of medical care in diabetes - 2018. Diabetes Care. 2018;41(suppl 1):S1-S159.

22. Shillington AC, Col N, Bailey RA, Jewell MA. Development of a patient decision aid for type 2 diabetes mellitus for patients not achieving glycemic control on metformin alone. Patient Prefer Adherence. 2015;9:609-617.

23. Bailey RA, Pfeifer M, Shillington AC, et al. Effect of a patient decision aid (PDA) for type 2 diabetes on knowledge, decisional self-efficacy, and decisional conflict. BMC Health Serv Res. 2016;16:10.

24. Lang K, Bozkaya D, Patel AA, et al. Anticoagulant use for the prevention of stroke in patients with atrial fibrillation: findings from a multi-payer analysis. BMC Health Serv Res. 2014;14:329.

25. Young JB, Gauthier-Loiselle M, Bailey RA, et al. Development of predictive risk models for major adverse cardiovascular events among patients with type 2 diabetes mellitus using health insurance claims data. Cardiovasc Diabetol. 2018;17(1):118.

26. National Committee for Quality Assurance (NCQA). Health Plan Accreditation (HPA). ncqa.org website. https://www.ncqa.org/programs/health-plans/health-plan-accreditation-hpa. Accessed October 24, 2018.