Home' The Source : Fourth Quarter 2013 Contents prosthesis is stocked and we order what we want when we want
it—all with little to no evidence about what we’re doing. The other
route represents value-oriented care, with careful observations
of why we’re making certain healthcare choices.
The hapless administrator has three choices: He can sink in his
canoe and call it a day. He can choose the route toward “more is
better” because it seems easier, not knowing that 200 feet in that di-
rection he plunges into an abyss. Or he can choose the harder route,
making his way through some rough waters
of reform before finally setting off into the
population-health, value-based sunset.
Q. What should be the industry’s
A. In all this conversation about reform,
we’ve forgotten that medical error is the
fourth-leading cause of death in our coun-
try. It’s a huge problem. We have to lick
medical error before we can begin working
on the value equation—reducing avoidable
hospital admissions, coordinating care,
practicing based on the evidence, reducing
variation, getting doctors to hold the line
on physician preference items, etc.
Q. How would you define popula-
A. David Kindig, M.D., Ph.D., emeritus
professor of Population Health Sciences
and emeritus vice-chancellor for Health
Sciences at the University of Wisconsin-
Madison School of Medicine, coined
the term “population health” about 35
years ago. He was writing about the fact
that population health has three core
1. Health outcomes, such as morbidity,
mortality and quality of life
2. Social determinants of health, such as
socioeconomics, education level and crime
3. Public policies and interventions that
link these two
The main message is that the social de-
terminants and behavioral components are
critical. Healthcare inside a medical facility is only 15 percent of
the story; 85 percent of healthcare is what happens outside the
hospital. I’ll use the example of Philadelphia, where I live, which
is the sixth-largest city in the nation in terms of population. Of the
nation’s top 10 cities in terms of population, Philadelphia is the
poorest, with the lowest per capita income. About 60 percent of
our public school students are obese; 25 percent of our population
smokes (5 percent above the national average). Despite five medical
schools in the area, we have a huge population health challenge.
We have to reach outside the four walls of our hospitals to coor-
dinate with community pharmacies, nursing homes, extended care
facilities and the like, and link all of these care providers—from the
hospital’s board of trustees to the folks delivering home infusion
medication. It’s a big operational challenge, but we’re going to
have to become a well-oiled, organized, value-generating team.
Q. You’ve used the phrase, “moving from sick care to
health care.” What are some of your ideas for doing that?
A. We’ll need registries of patients, greater physician education
and new relationships with our managed
care providers. We’re going to have to find
new ways of looking at how we’re delivering
care at the bedside and in the community.
Maybe we need better measures of popu-
lation well-being based on what reduces
readmissions and overall admissions, such
as smoking cessation and/or programs that
reduce obesity and stress.
We’re going to have to think about the
behavioral contributors to some of our ma-
jor population health issues. A 2006 issue
of the Annals of Internal Medicine asked
What percentage of adult Americans do
all of the following things?
1. Don’t smoke cigarettes or cigars.
2. Eat fruits and vegetables.
3. Exercise three times a week for 20
4. Wear a seat belt.
5. Maintain an appropriate body mass
You may or may not be surprised to hear
that only 3 percent of Americans do all of
those things. We take our Lipitor on the
way to buy a Big Mac. If I made rounds in
a hospital anywhere in this country today,
I would predict that 40-plus percent of all
admissions are still due to smoking, un-
healthy diet, lack of physical activity and
alcohol abuse. Those are the kinds of chal-
lenges we’re facing.
From the public policy perspective,
population health is still not on the radar
screen of the National Institutes of Health
and other federal agencies. Care coordination for chronic illness
is where the money is being spent. But from a policy perspective,
the biggest bang for the buck comes from behavioral change. For
example, in 1972 President Richard Nixon declared a war on
cancer. While billions of dollars has been spent, the No. 1 factor
contributing to decreases in cancer deaths has been smoking
cessation—a behavioral change.
We can begin practicing population-based medicine, but it’s
going to take a concerted effort. To make the kinds of behavioral
changes that are necessary, we’re going to have to align economic
I thInk we’re at
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Continued on page 30
28 The Source | Fourth Quarter 2013
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