When “Quality” reaches inside our homes…

Many potholes await us as we drive America’s healthcare system down the road towards a (still slightly amorphous) vision of “population health.”  Can lots of providers manage risk as well or better than the small minority of those doing so today?  Will the payment system transition fast enough to drive change but not so fast that safety-net providers fall off a cliff during the transition?  Can we generate enough real connectivity among the dark corners of our health IT infrastructure to actually manage population outcomes on a massive (read: national) scale?

These are significant (though largely solvable) challenges.  However, of all the potential pitfalls on our population health journey the biggest in my mind that has yet to be answered is… Will America’s patients really accept it?

Until recently, hospitals and physicians have been graded on quality metrics (if they were graded at all) that were largely under their direct control .  The classic example is CLABSI (central line bloodstream infections).  CLABSIs happen inside the walls of a hospital and are nearly 100% preventable when doctors and nurses perfectly follow their insertion and maintenance bundles.

To drive success on other metrics, like surgical site infections and unplanned readmissions, providers by necessity have learned how to extend their reach beyond their walls through care management and better connectivity among inpatient physicians and ambulatory practices.

The great ACO experiment goes a step further.  Meeting a metric like “attributed beneficiaries with controlled hypertension” requires not just seeing the patient, diagnosing hypertension, prescribing the most medically appropriate therapy, and following up at the appropriate intervals.  Instead, it means making sure patients fill their prescriptions, take the actual medication, don’t do other things that could make the medication either not work at all or work too well, and document that their blood pressure improves and stays improved (meaning continual assessment, reassessment, and tweaking of the management plan over time).

With accountability for actually achieving this level of control over chronic conditions, ACOs have become increasingly creative in accessing and influencing patients where the opportunity to do is greatest – in their homes.  Mission Health’s Caramedic program is one example, bringing care coordination literally and physically into a patient’s house via a community paramedic to directly impact the social determinants of health that really drive “population health” outcomes.

And here’s the rubon the whole, how far will a nation of generally independent, freedom-loving people allow their healthcare system into the parts of their lives that until now have remained generally private?

While Americans have granted Facebook, Google, Apple and Amazon nearly universal access to everything we do everywhere we do it, how will America react when Alexa is telling them to take their beta blocker and auto-reorders a week of healthy meals instead of suggesting they buy more laundry detergent?

When you really get down to what it takes to manage chronic conditions you reach both incredibly complex social issues (like medication affordability, transportation, and housing) along with the seemingly simple decisions we make each day about whether or not to eat potato chips, walk the dog, or smoke a cigarette.  Taking the accountability of a population health framework to its logical conclusion means unleashing the creative power of disruptive innovators working with providers to actually make America healthier, and that means accessing and influencing day-to-day decisions like these.

Like all things, better population-level outcomes will come a price – making and keeping America healthier will require a level of daily interaction with accountable parts of the healthcare system in a way unimaginable even twenty years ago.  It will mean balancing incentives and penalties that go far beyond whether we pay a higher health insurance premium for choosing to smoke, and trading access to our homes and ourselves for the chance to live longer, healthier lives.

Do you think America is ready? 




  1. Great question….I worry a great deal that our American individualism that has srved our society well on many regards may be getting in the way of good health….and yet I remain hopeful that people really want to enjoy good health. Care providers walk a fine line between teaching/ advising…and trying to mandate healthy practices. The March 7th JAMA article re “Attributing Death to Diet” is a great place to start.

  2. Whenever a transformative concept or technology comes along, I worry less about the early adopters and more about those at the tail of adoption. In population health, we need to know more about why late adopting patients are reluctant to take actions that benefit their health. Can we providers convince them that sharing control actually means their taking control?

  3. […] and investment.  It also presumes Americans are universally ready and able to accept it (see previous post for a longer discussion on this point).  While bundled service payments can simultaneously drive this innovation and fund […]

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