Aug 16, 2017


Interviewer: What is population health? How can it potentially keep people healthy and also lower health care costs? We're going to examine that today on The Scope.

Announcer: These are the conversations happening inside health care that are going to transform health care. The Health Care Insider is on The Scope.

Interviewer: Angie Fagerlin is the chair of the Department of Population Health Sciences at University of Utah Health and today we're talking about population health. It's kind of a health care concept that you might not have heard of but you could be hearing more about.

First of all, what is the definition of population health? I mean, the one that we're using right now, because there's lots of them, aren't there?

Dr. Fagerlin: Right. You can ask 10 different people and you'll get 10 different definitions of population health. How we're defining it right now at the University of Utah is really thinking through how can we improve the health of a population? So it's not that complicated in some senses.

We can make it much more complicated, but really trying to think about how to deliver the best health care possible in the way that people want it to be delivered. It's a collaboration between the health system and the patient.

Interviewer: All right. Now, to somebody that is not in health care, they might be listening to this thinking, "All right, we're interested in keeping a population healthy. Isn't that what health care systems do? Why is this a new concept?" But it's not traditionally the model of the health care system.

Dr. Fagerlin: Right. A lot of people talk about health care system both in terms of health, but mostly in terms of disease. How do we fix a problem that is already there and how do we fix the problem of one person? What we're trying to do in population health is more focused on prevention so that people don't even have to come into the health system. And so we're thinking, "How do we prevent high blood pressure or broken bones due to falls or some of those kind of things?" So it's more prevention based than fixing a problem that's already there.

Interviewer: Because that's how hospitals work right now, right? You get sick, you go see your doctor, you don't really ever see your doctor when you're healthy.

Dr. Fagerlin: Right. So much will have to change if we're really going to commit to this because right now a lot of places are more fee for service. How health systems often make money is by having people come in and being sick. So for this to work, we need to flip it to think that preventing disease is as valuable as treating disease, which is a difficult concept because it's hard to prevent disease. We have to do a lot of different things and a lot of those are behavioral. We have to make the decision to drink less, smoke less, or not smoke at all, to be honest, eat better, exercise more.

And those are things that often have to come outside the health care system or that are really tricky to do on the health system level. Very differently than giving somebody a surgery or a pill where you know exactly what will happen when you do those things.

Interviewer: Yeah, and they come to us, so they're looking for that help at that point where population health is preventing those things from happening, so we kind of have to go out in the community. What does that look like even?

Dr. Fagerlin: Well, I think one really neat example is the diabetes prevention program, right? So we know when people are getting at risk for diabetes. If you take people's blood sugar, it is a certain level, we can call people as having pre-diabetes, right? And so if we go to those people before they get diabetes, before they need to go on medication, before they need maybe insulin, and put them in the CDC's diabetes prevention program which we run here at University of Utah, we can help them decrease their weight, increase their exercise, change their diet, that might prevent diabetes.

But that's us calling them up and saying, "Look, we see that you have pre-diabetes, that you're getting close to maybe getting diabetes and we want to prevent that from happening and we have the tools that can do it, and let's partner together so that we can prevent that diabetes."

Interviewer: But that's even a challenge because now you're trying to get somebody to change their lifestyle habits, which, I mean, how many times have you had your doctor say, "Well, you need to drink a little less," or, "You need to eat a little less," and you're like, "Don't tell me what to do."

Dr. Fagerlin: Oh, never, never. I've never been told a healthier diet and eat more fruits and vegetables.

Interviewer: How would that look, like, in another situation? I've heard, for example, one of the biggest dangers to elderly are falls, right? So there, again, it's not that an elderly person's coming in for our care. We're trying to prevent a fall from happening, which would mean going into their environment. Is that another way population health might play out?

Dr. Fagerlin: Exactly. And we've actually started discussions with some groups in the community. There are programs in Salt Lake that goes in and helps weatherize elderly people's homes to help decrease costs, right? And so we've talked with them and they're at the very beginning of these conversations, but the idea is to, while they're going in, to have somebody maybe from physical therapy or occupational therapy to go in and look at, especially students, as a way to really help them understand better these conditions and go and look and see what kind of things could we do that would be relatively easy and cheap to fix to help prevent falls in the elderly.

Interviewer: And of course with both diabetes and falls, it comes down to that those are occurrences that then lead to worse health occurrences in both instances. What are some of the other major issues when it comes to population health? Obviously the fact that this is a new radical idea and some people might reject it. Are there other obstacles?

Dr. Fagerlin: Well, you know, and I want to go back to, actually, that last question a little bit because one of the ways that you can make this less radical or to be more accepted is by talking to people before you do things. A lot of times we think, "Oh, we know the answer. So I'm the chair of population heath so I know how we should do this and we're just going do this and tell people how it's going to go." But really the kind of one of the core concepts of population health is to engage the stakeholders, engage the community, engage the clinicians, engage the payers, engage the health system to think about all . . . and to get all of their perspectives and to think about how can we roll this out in a way that's going to benefit everybody?

Interviewer: Yeah, sure.

Dr. Fagerlin: And that makes it less radical, right? Because everybody agrees, everybody has the same goal in mind, which is a healthy patient, healthy population.

Interviewer: Got you. That makes a lot of sense. I mean, on a business level, that's what businesses do too. They try to get buy-in before they make major changes, so why not do that in population health? But that's even a new way of thinking for health care systems.

Dr. Fagerlin: Right. I mean, that's one of the interesting things that have occurred since the Affordable Care Act. One component of the Affordable Care Act was this kind of shared decision making and involving the patient in the process. They started this Patient-Centered Outcomes Research Institute, and one of the key components of that institute was that patients had to be involved in the research from day one, not just as participants, because patients are experts in health care, but it just added a different perspective. And so by engaging patients as the experts that they are, we can better figure out how to deliver population health.

Interviewer: But it just makes total sense, doesn't it? What's the saying that's been around forever? An ounce of prevention is worth a pound of cure. Isn't this how things should work? So I guess we just all have to kind of agree that maybe this is the direction we need to go and hammer out some of those details as we go?

Dr. Fagerlin: Yeah. I agree. And it's funny because it's so much harder to prevent than to treat, right? Because, really, a lot of that is patient based. You know, I have to make the decision to eat a healthier lunch, you know. I have to make the decision to get up every morning before my kids wake up to go for my long run. And those are hard things to do. It's much harder to do those things than to pop a pill, assuming that you can afford the pill in the first place, right?

But, you know, and so it requires a collaboration between patients and providers rather than it being more provider-centric where they provide you a treatment.

Interviewer: What needs to happen next? Is there a next step to further this idea of population health to reality?

Dr. Fagerlin: I think some of it is really trying to figure out how do you pay for this?

Interviewer: Yeah, it really comes back down to paying, doesn't it?

Dr. Fagerlin: It does. And then the other thing it really comes down to is how do we do prevention? When people have so many other things to do and focus on in their lives -- their kids, their jobs, their parents -- doing prevention might not be great. So how do we make it right? How do we make people understand that it's better to prevent diabetes than to get diabetes and then have to treat it?

Interviewer: And then the problem is, though, they might be preventing something that might not have ever happened to them in the first place, right?

Dr. Fagerlin: Right. And they don't know. So they'll figure . . . or maybe it won't happen to me, right? You know, not that I've ever said that.

Interviewer: Do you think population health is the answer?

Dr. Fagerlin: I think it's one of the answers. I mean, to improve the health of a population, there's a lot of answers. Some of it is precision medicine, right? But there's also, I mean, there's a lot of things that we need to improve the health, including better treatments, you know, figuring out over-treatment, under-treatment. So there's a lot of components that we really need to understand in terms of how to improve the population health. It's not just population health.

Interviewer: And is population health the answer to the healthier population and reduced health care costs?

Dr. Fagerlin: It's one of the answers, definitely.

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