Are accountable care organizations truly improving population health? According to two public health and policy researchers in the March 20 issue of the Journal of the American Medical Association, that depends on whose definition of “population health” you use.
The well-known goals for ACOs are to control healthcare costs, improve quality in healthcare and improve population health, Dr. Lawrence Casalino and Dr. Douglas Noble from the Department of Public Health at Weill Cornell Medical College write in the article.
In the context of the Patient Protection & Affordable Care Act and the Centers for Medicare & Medicaid Services’ rule for ACOs, population health refers to a healthcare organization’s pool of Medicare beneficiaries. And ACOs seem to have interpreted their population health responsibilities that way, too, as preventive care to all patient and care management for patients with chronic diseases.
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This is a major step forward from the model of the past, said Noble, a visiting researcher from the UK under the Commonwealth Fund’s Harkness Fellowship program. “ACOs are doing a very radical thing which is moving away from doctors only considering what they can do for patients when they’re in front of them,” he told me in a phone interview. “That’s an enormous thing for Americans, and I’m really impressed with it.”
But the authors propose that the term population health is oftentimes used in a context more closely related to public health, and that’s a context in which ACOs aren’t as well poised to succeed.
“Population health is thinking about any number of people living in a geographic area – it could be a county or a state – and all of the services available to them, and part of that would be high quality healthcare without a doubt,” Noble said. But it also implies factors outside of the medical realm, like social services, the public health system and socioeconomic factors. Those are areas where most ACOs lack the incentives and capabilities to act effectively.
The authors argue that talking about ACOs in that context leads to a “lack of clarity about what ACOs are doing are about population health and may divert attention away from social and public health services and from socioeconomic factors critical to health,” they wrote. “It’s not merely a semantic issue of little importance if ACOs are described, or self-described, as working to improve population health when what they are really doing is improving medical care for their own patients.”
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A model that integrated that broader definition of population health would be more of an accountable care health community, where ACOs would cooperate with other organizations to improve the overall health of a certain geographic population.
Whether that’s something ACOs could or should eventually be able to do is a whole other issue. But the only way we’re going to be able to have that discussion, the authors say, is if we make a clear distinction between population health in and out of the context of ACOs when formulating healthcare and social service policy.
On that note, perhaps the authors would be fans of the U.S. Agency for Healthcare Research and Quality’s concept of “practice-based population health.”
