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How do we improve what health experts call “population health”—put simply, the opportunity to live a healthy life—in a way that is meaningful to patients?

Allow me to start with the story of one of my patients—I’ll call him “Raj.” Raj is a Pakistani immigrant living in Queens. When I first examined him about a year ago, I saw he had scars from a kidney transplant; I found out his kidneys had failed because of high blood pressure.

At some point, likely related to his transplant surgery, he developed hepatitis C. A quick glance at his chart revealed that he’d endured multiple ER visits and admissions over the past year, for everything from blood in the urine to nausea to needing medication refills. He had a nephrologist in a different system and a hepatologist at my hospital, but he came that day to establish primary care with me. 

Raj is slender, always impeccably dressed, and usually has a smile on his face. I learned that he, his wife, and their three kids were living in a friend’s house and that he worked at a bodega. I struggled to convince him of the need to reduce the salt in his diet and to take all his meds. At our last visit, he came in lugging a bag of about 20 pill bottles, clearly overwhelmed and exasperated. We spent the visit selecting the 12 medicines he actually needed to take, but even then, it was a tough sell. “I feel fine,” he told me.

How did Raj end up with such fragmented, complex care? A better-coordinated system, addressing the broader determinants of health, might have helped Raj before his hypertension grew severe enough to damage his kidneys, or perhaps before he developed hypertension at all. Indeed, about 13 million U.S. adults are not aware of their hypertension. What if reducing this number were a population health priority?

This raises the question of who’s accountable for population health. Which population does Raj belong to?  My practice?  His nephrologist’s health system? His health plan?  Queens? A multiple of these? It gets complicated to organize common goals across sectors. This dissonance is a major reason that health care reform hasn't resulted in as much productive collaboration as had been hoped, and health care systems are still primarily reactive to patients who seek care. Even innovative, value-based payment system experiments tend to focus on beneficiaries who are getting care, rather than the most marginalized patients.

Addressing these issues means getting better at allocating resources, measuring what matters, and renewing our focus on the highest-need patients.

We have resource allocation that favors health care over health. Of the U.S.’s $3 trillion in health spending, less than 3% is allocated to public health activities. Meanwhile, inexorable health care spending growth tends to cannibalize spending on education, the environment, and public health in an era of low economic growth and fixed local and state budgets. Solutions must address the market failure of underinvestment in community-based prevention. For example, Massachusetts has a $60 million Prevention and Wellness Trust Fund which supported nine community-based partnerships focusing on pediatric asthma, hypertension, tobacco, and falls among older adults. 

We also need to do a better job of measuring what matters. Our ultimate goal is to help people live longer, healthier lives, but an accurate measure to get at this has proven elusive. We must start evaluating performance not through hundreds of metrics across the alphabet soup of programs—ACO, DSRIP, PCMH—but instead simpler measures that resonate with our patients and capture their subjective quality of life.

Finally, we need a renewed focus on the highest-need patients—people like Raj.  However, there is growing evidence that populations of high-need patients change when applying different lenses—they are different by payer, by system, by predominant health need—and even over time. Meanwhile, the literature shows few interventions that work well for such patients. Taken together, these two conclusions challenge the ready application of existing approaches to care for high-need patients—instead we must understand the particular circumstances of different groups of high-need patients and craft interventions around that understanding.

At its core, population health is about empowering individual people to live a fulfilling life. There are challenges to making this vision a reality, but we are at a unique moment of convergence in the wake of health reform. There are reasons to believe in progress, even if we only take small steps, like helping one husband and father manage his medications—and helping him hold onto his winning smile.  

Adapted from remarks delivered by Dr. Chokshi at the Hermann Biggs Society in February, 2016.  Patient details have been changed.