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Public health leader: Sacrifice efficiency to improve measurements of population health

In order to not only truly achieve population health but also accurately measure its success, it may mean sacrificing some efficiency. At least, that’s what Sandro Galea, M.D., dean of the Boston University School of Public Health, thinks.

In a Harvard Business Review article, Galea writes that one of the great challenges that population health initiatives face — the Institute for Healthcare Improvement’s “Triple Aims” and the Affordable Care Act (ACA), for example — is how to measure success.

The issue here is that when it comes to measuring outcomes, the focus is on the group of individuals as a whole. Therefore, researchers and clinicians do not always take into consideration the various circumstances individuals may be facing, Galea said.

“That’s unfortunate because, as every business person knows, what gets measured is what gets managed,” Galea said.

Often what happens is population health initiatives target what Galea calls “low-hanging fruit” — in other words, the groups of people that are more easily accessible and more open to changing their behavior.

This dilemma inevitably widens health gaps, improving the health of some while marginalizing other communities and leaving them behind.

Take behavioral intervention apps that help people quit smoking, for example. “People who can neither afford a smartphone nor lead lives organized enough to be driven by apps are left out, widening the health gap between app users and non-users,” Galea said. “Closing those gaps should be at the heart of efforts to measure and improve population health, even if it means sacrificing some efficiency.”

And, in Galea’s opinion, here’s why we should be willing to accept these sacrifices even though the cost of healthcare is a top concern right now:

  • Health equity could bridge social divides and yield larger dividends than simple cost savings.
  • Narrowing health gaps drives much of healthcare.
  • Poor health in some groups ultimately threatens the health in all groups. Take the recent Ebola epidemic in West Africa, for example: “While concern about the health of West Africans may feel like a distant problem for some of us, their health in an age of ready travel is inextricably linked to the health of Americans — an inescapable fact that should impel even the most cost-conscious among us to call for investment in better health for all,” Galea said.

Galea believes there are several ways the measurement of health indicators can be changed so that metrics can better account for inter-group differences:

  • Make closing the health gaps between groups a prime objective — for example, closing the gap between those who have access to mobile apps and those who don’t.
  • Include relative indicators of health along with absolute indicators in metrics. Therefore health systems would be required to measure factors that may differ, like race, ethnicity and income, for example, and would also be required to tabulate, report and hold themselves accountable to relative achievement across these groups.
  • Establish incentives that promote both efficiency in improving numbers and equity in closing gaps.

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