Dec 4, 2015


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Dr. Hess: This is Rachel Hess, and I am here today with Dr. Pamela Peele, the Chief Analytics Officer for UPMC Health Plan. Today we're going to talk a little bit about population health, and I know you said population health isn't what people think it is. Why do you think that?

Dr. Peele: So you know, and I'm sure all our listeners know that we mandate that people go to school and get an education in this country. We pay for that education through federal, state, and local dollars, and we've been doing this for well over 100 years. The beauty and the benefit of that is that we have a population that's educated and literate. They can take that education and literacy into the formal work market. It supports a very strong and robust economy. That strong, robust economy pretty much benefits everybody.

So we seem very comfortable in this country with the idea that we're going to use state, federal, and local tax dollars and demand that people go to school and become literate. But we don't talk then about how we protect that investment when we want them to take it into the formal labor market. So if you're not well enough to take your investment fully into the formal labor market, then we didn't protect our investment in your education.

So I think that is the way that we should think about and form our basis of why we as a nation should care about population health management. We care about educating our population. We care about having a robust, literate population that can support a robust economy. But we can't do that if they don't have sufficient health capital.

Dr. Hess: I think you make a great argument about why we care as a society. But in our country today we still have health insurance markets primarily driven by employers.

As an employer I may say, "You know, those people who we didn't protect our investment in, they're actually not in my pie. They're being dealt with in Medicare, Medicaid, other social welfare programs, and those programs, they should be worrying about population health. But the product that I provide to my employees, it's not really necessary. I've got the ones that made it." Why in an employer-driven payment model do we still care?

Dr. Peele: What's actually driving the employer model behind this isn't the employers, per se, because you make an excellent point. Why would any individual employer who wasn't suffering for a lack of labor, so if you're suffering for a lack of educated and literate individuals than you might care. But if you already have your employees, you might not actually care about that. You're right.

But CMS cares. The Government cares. Medicare cares, and as Medicare pushes, that change the way dollars flow behind taking care of individuals and populations, so does the rest of the country move. Medicare leads the way in the way we finance health care in this country and who we are allocating those dollars to. Commercial markets simply fall out. But you're right. Any individual would ask the question, "Why should I care?"

Dr. Hess: We've talked about this idea of population health, and from an academic medical center standpoint we are thinking payment models are changing. We are getting to a point where we're assuming risk for the population that we care for. But it sounds like you're saying that we back up the idea of population health. That population health doesn't start when I cross the threshold into the health system.

Population health starts before that. As academic medical centers, how far back do we go? Where do we start thinking about managing our populations before they get to us?

Dr. Peele: We should start thinking about managing our populations when they're in the womb. So the very basic piece if you think about population health management, it's not about acute trauma. It's not about acute medical events. It's about chronic illness and chronic disease, the burden of chronic illness and disease on society. So when we start talking about how are we going to manage chronic illness in this society, I think we have to go all the way back to birth to start managing that.

There's a secondary piece of this that I think would be worth academic medical centers, policymakers, CMS, and the country in general thinking about. If what we really want to do is get in front of chronic illness through using population health management techniques, in order to get in front of it, we're actually talking about children in adolescence. What have we already invested in? Schools.

We've already invested in the brick and mortar of schools. We already legislate and mandate that people send their children to school. We should be putting population health management prevention efforts and education into schools. We already want the children to show up there. So that to me is where academic medical centers, employers, the government, we should be focusing our attention.

The downside, as you know, Dr. Hess, is that the payoff isn't going to be in two or three months. It has a long tail on that payoff. It's actually a generational transfer going on here of having to invest in children. When they come to school, which is where we mandate they be, that payoff is going to be a generation away.

Dr. Hess: We were talking a little bit about moving some preventive health and health education, and health literacy into our school systems. What role do you think academic medical centers can play in that transition?

Dr. Peele: Academic medical centers are poised to be the leaders in doing this because they are training tomorrow's providers, the nurses, the pharmacists, the physicians. They're the ones who are providing the training. If we're going to get ahead of population health management and by doing it through prevention in children and adolescents in schools, academic medical centers have to come to the plate and start including in their training programs and rotations, schools.

Dr. Hess: You've made a compelling argument for the ethical and societal motivations behind population health management, and I think it's hard to not agree. But what are the economic benefits of it?

Dr. Peele: Well, if we had a single-payer system, we would immediately see the economic benefits within the generational transfer, meaning a single-payer medical system. But we don't have a single-payer system. This is one of the reasons we've had so much trouble in my opinion getting preventative medicine into importance and getting it into play, if you invest in prevention and you invest in public health now, the payoff might be 10 or 20, or 30 years down the line. You as an employer, are probably not going to have that individual in your employment at that time.

We're asking you to invest, but you're not going to get the payoff. But you would get the payoff from somebody else's employee if they invested. So it has to be all in. Everybody has to play. You can't let some employers play and some other employers . . . You can't mandate that some employers invest in covering preventive medicine and not mandate that other employers invest.

That is part of what the Accountable Care Act has actually done. It has mandated that certain types of benefits shall be covered under the Accountable Care Act, and those include well visits and preventive medicine visits. The payoff to that is going to come to employers all over the country in decades, and it doesn't matter who was employing the individual at the time the investment was made.

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