Population Health, the Triple Aim, and the Health Effects of Social Services
This article was written by Jon Christianson, PhD, Medica Research Institute senior fellow, and James A. Hamilton chair in health policy and management at the School of Public Health at the University of Minnesota.
A few months ago, I was driving through a small community in southern Minnesota that, according to its residents, was the first town west of the Mississippi founded by Norwegian immigrants. (To you, this may sound like the answer to a very difficult trivia question, but it has more significance to some of us in this part of the world!) The town was in the midst of celebrating Norwegian Constitution Day. In Norway, the celebration consists mostly of children’s parades and other events that highlight and reaffirm that country’s shared cultural values. Coincidentally, it also was the last day for potential grantees to submit proposals to participate in CMS’ Accountable Health Communities (AHC) initiative. If you are familiar with the AHC model, you probably guessed the connection.
The AHC initiative provides an interesting example of how health services research can influence US health policy development over time, and perhaps even change the way health policy is viewed in a broader sense. Somewhat arbitrarily, one could argue that this particular journey began with the emergence of “population health” as both a term and a framework for assessing the performance of our health care system. Three of the leading players in the story are David Kindig, MD, PhD; Don Berwick, MD, MPP, FRCP; and Elizabeth Bradley, PhD, MBA; all are well-known health services researchers but also expert translators of their work to policy makers. Berwick took the further step of “crossing over” to direct the actual implementation of health policy as acting head of CMS.
The Concept of Population Health: Laying the Foundation
The concept of “population health” has been discussed for decades, but it was elevated to a much higher level of consciousness through an article published in 2003 by Kindig and Canadian colleague Greg Stoddart, PhD.1 In their article, “What Is Population Health?,” they offered a very brief, but also very broad, definition: “…the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” (p. 380) They followed with the suggestion that population health could be thought of as a field of study: “…the field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two.” (p. 380) The authors offered specifics in each of these areas, but anticipated that some readers might find their definition too broad to be useful. (p. 382) They were right.
Since then there have been a number of attempts to revise the definition and, in some cases, provide more specifics through the addition of modifiers (eg, population health management, population health medicine).2 Other efforts have sought to distinguish the use of “population health” to describe residents of a geographic area (“total” population health) from its application to specific subgroups of the population defined by disease state, sociodemographic characteristics, or organizational affiliation.2
In this ongoing discussion of how best to think about and measure “population health,” it’s easy to overlook other observations made by the authors. Of particular importance for our purposes, they noted that the determinants of “population health” (in addition to good quality medical practice) were likely to include such factors as “the social environment (income, education, employment, social support, culture) and the physical environment (eg, air and water quality)”1 (page 381). The implication was that improving population health—as measured by such things as mortality and quality-adjusted life years—requires not only better, more cost-effective medical care and social services, but also improved coordination of services across these domains and possibly a different balance between the 2.