Connecting Population Health and Care Inequities

What must physician leaders grasp about population health to address inequity in patient care across diverse populations?

The Challenge

The U.S. healthcare system is a multidimensional and highly complex landscape that requires constant and holistic improvement to enhance the quality of patient care. That being said, true improvement within a system of this nature requires more than linear progress, as the tactics necessary to foster desired outcomes are not always black and white. The challenges surrounding population health serve as a prime example of this truth; when improvement is achieved among one population, those benefits may not extend to other groups congruently.

Population health refers to healthcare that seeks to improve health outcomes within entire populations by targeting the social determinants of health and harmonizing healthcare services across the care continuum. Abstracting what is involved in achieving this harmony requires one to understand how patient diversity impacts resource allocation, how the U.S. healthcare system’s structure impedes population health outcomes, and how the three components of the Triple Aim intersect, just to name a few.

One question that emerges from this discussion is: What can physician leaders glean from the topic of population health to understand how care inequity between populations can be addressed? One word to consider is the term “collaboration.”

Key Takeaways

When we think about health within the context of a single individual, we can perceive how biological factors facilitating one’s health work together like an ecosystem. Within an ecosystem, if a single animal species is unable to fulfill its role, it can result in immeasurable damage to the ecosystem itself. Congruently, if one organ or bodily system is functioning poorly in a patient, that one component can distress their other bodily systems and ultimately threaten their life.

This simplistic yet poignant imagery conveys that systems are sustained through the interrelationship of their constituent parts. Now, let’s apply this notion to population health and inequity in the U.S. medical system.

Population health is deeply intertwined with the various social determinants of health, including economic, environmental, and social factors. The Triple Aim framework, a central principle of population health, is a widely adopted approach to improving population health outcomes with an awareness of these determinants. The Triple Aim encompasses three key objectives:

1. Improving the patient experience of care.

2. Improving the health of populations.

3. Reducing the per-capita cost of healthcare.

Furthermore, the Triple Aim acknowledges that improving health outcomes requires more than the delivery of quality healthcare services. It also requires an approach that addresses the social determinants of health and the need for health equity across populations. As one example, consider how low-income populations may receive inequitable care due to the prevalence of financial hardship.

• Despite healthcare access and outcomes being improved for select populations, vast disparities still exist among low-income and minority populations.

• Factors such as lack of access to quality food options, limited transportation, poverty, and insufficient housing all play a role in the quality of care these vulnerable populations may receive and readily access.

• Stress factors correlated with financial hardships increase the susceptibility of low-income populations to numerous ailments in comparison to other populations. This, in turn, increases the need to allocate resources toward preventative care, primary care, and manpower, a need that often goes unmet due to the current structure of the U.S. healthcare system.

What is the solution to this healthcare inequity? The answer may be far too extensive, complex, and enigmatic to offer within the confines of this article. However, we can definitively say that it requires collaboration across sectors and disciplines, including healthcare, public health, social services, and community organizations, to improve health outcomes for all members of the numerous populations.

The Bottom Line

The bottom line is, successfully addressing healthcare inequity will require profound collaboration between the various systems, services, and organizations that facilitate the functioning of our healthcare system in the U.S. It will require leadership within those systems and organizations to acquire interdisciplinary knowledge and skills, so they can collaboratively promote the changes our healthcare system needs to address inequity of care and the social determinants of health.

If you would like to learn more about population health and the myriad of ways that it impacts today’s healthcare initiatives, see our newly developed course by Dr. Mitchell Kaminski, “A Journey Through Population Health.” This course will help you to better understand the basic precepts of population health, how features of the current U.S. healthcare system impede population health outcomes, and how to apply population health management principles to your respective practice or health system.