The Conditions That Lead to Poor Health and Why Concerted Investment in Population Health Is Needed Across Sectors

[Music] Hi, this is Jim Nickman. And this is Brian Elbowl, and you are listening to Conversations about Healthcare Delivery in the United States. A podcast series featuring our conversations with prominent experts, innovators, and leaders in the health sector. Sherry Johnson is currently Director of the University of Wisconsin Population Health Institute, principal investigator of County Health Rankings and Road Maps, and professor of Population Health Sciences. She's dedicated her career to hardening with children, families, community organizations, and systems to advance health and lobby. [Music] Sherry, thank you so much for joining us. Thank you for inviting me. So, I thought we might start with a big picture question about Population Health and really what the term "me" is, right? There are lots of different terms that get used. What is Population Health? What does it mean relation to the public health, to community health, the clinical care? Maybe you could just start with a little bit of a description there. Sure. So, we definitely appreciate Dave Kinding's leadership in this field, and his definition in the Mill Bank piece many years ago that population health is the health outcomes and the distribution of those outcomes in a population. That population could be defined geographically, it could be defined by other shared characteristics like racial or ethnic identity, and the health outcomes then are produced by patterns of health determinants over the life course, and those health determinants are created by policy and practice. So, that's how we think about population health. I like the Institute of Medicine's definition of public health, what we do collectively to assure the conditions for everyone to be healthy. So, there's an action orientation, I think, in the IOM definition that is helpful, but I think that there's a lot of overlap between the definitions and that can create some confusion. Yeah, particularly as the term is used a lot more frequently these days, the term population health, and I think sometimes it's used in the more formal way you're describing, and sometimes it's used in a population health management sort of way, like how people care of their panel of patients, right? And I'm wondering what you think about that, right? This sort of mixing of terms or it's just kind of paying attention to population health in a bigger scale way, just a good thing overall, and we're going to sort this out as we go. Yeah, the biggest concern I have about the population health management terminology being overlapped and maybe confused with the broader version of population health is that it shifts again the conversation and probably the resources toward healthcare. And healthcare is one part of the equation, but healthcare is not going to produce population health in and of itself. We know this sort of quite clearly that the United States spends more of their GDP on healthcare than any of its peer countries, but we get less value from it in terms of how long we live. We spend more on the healthcare system and similarly get less in terms of how long we live or how well we live. And so that's my biggest concern that shifting or using the term as part of healthcare will potentially sort of suck the life out of the ways that we need to be investing in population health across other sectors, including the notoriously underfunded governmental public health system. I think what makes it even a little bit more complicated is that a lot of healthcare providers or insurance companies are starting to pontificate about the importance of population health. And yet as you started in the beginning thing of this is something in the public health field does, but we could end up having competition about who's doing what, which I'm not sure would end in a happy way. Yes, yes, the other conversation that I know is brewing in lots of places is about screening and in the population health management world, the ways that screening for what I think is best termed health related social needs has been inflated as population health. And the broader sense and the work is is really important. Of course, we need to make sure that people have transportation to our clinical care appointments or electricity at their house so they can store their diabetes medication properly. Those are individual health related social needs. They don't change the conditions for a population. They change the we meet that we attempt to meet the needs of each individual patient and we attempt in those efforts to measure how many people in a particular population might have that similar similar need. I understand it we're not actually using that data in a way that would actually shift the conditions for the whole population. And that I think is what I hear most in the health care sector as how they are addressing population health. There are some exceptions, you know, the health anchor network, I think is my favorite exception to that rule in terms of addressing upstream conditions. Yeah, I think that's a really important distinction right between you know addressing something individual versus dressing a broader social determined in that kind of a community or societal way. And I wonder if you could talk a little bit more about that because that was a key part of your definition as well right the kind of addressing these health determinants, these social health determinants. How does population health do that right? You know, what are the ways in which it really thinks about social determinants in a broader way. So one example is we used to lead the culture of health prize, which is the Robert with Johnson Foundation's national program that recognizes local communities across the country for their work to address the multiple determinants of health. And one example we highlighted this year in our national findings report for county health rankings and road maps is what's happening in greenville South Carolina. So using this transportation example, anybody who's ever worked in a clinic who knows that their patients need to get there in order to be seen knows how important it is to address transportation. And often do that by assuring that people have you know a medical transport voucher or bus tickets, I treat children are used to treat children so. But in greenville what they did was they used local grassroots neighborhood residents who had the lived experience of having a transportation system that didn't meet their needs for a couple of reasons historically the public transport system there hadn't. And so being built to provide fair access to neighborhoods that were predominantly black. And so those neighborhoods didn't have the type of access to the transportation system that would have afforded them fair opportunity to get to wherever they need to go. Greenville folks got together they started surveying people on the bus there was called green shirts they collected data from other bus riders long story short they were able to get about $11 million in new investment to expand routes and to switch from a cash only system to a like bus card system because people previously couldn't get changed. So you didn't have the right amount of the exact dollar you were going to lose a couple of sensor so getting your change back so that's the kind of shifting of conditions now you've shifted the way that the transportation transportation system is structured so that it provides more fair access especially to those who have historically been left out. So you actually need the public transportation system to get to the doctor or wherever else they want to go. Yeah so the other key component of your definition what a population health was paying attention to these differences or distinctions and outcomes by various conditions including things like race and ethnicity and I'm wondering if we can talk a little bit more about that. So you know even in that example you just gave how this population health do that or how central is that to how population all thinks about these things these kind of distributional differences. I think it's becoming increasingly central. One of the things that I've been doing lately as I talk to folks is also lifting up that this is not new to understand that the social construction of race and the way that the hierarchy of human value has been constructed in the United States along lines of the socially constructed races has been named as a factor in health and differences in health for century. So W.E.B. Du Bois's Seminole study, the Philadelphia Ennegros that was written in 1899 named many of these concepts and theories that we are now seeing in the current scholarly literature in population health. And so the idea that racism, which assigns people to advantages or disadvantages that produce health or not, as a fundamental driver of differences in how long and how well people live is I think well-established and I think people are starting to pay attention to the fact that just naming the differences and outcomes by people who are assigned to different racial groups is insufficient and probably harmful because it essentializes the incorrect idea that there are value-based differences in who matters who doesn't. Yeah and that's an important distinction right? So it's sort of what you're saying population health has to be aware of how some of these assignments and some of these descriptions of distributions can be helpful or harmful is that sort of the point there? Yeah I think the idea that we need to keep measuring the differences by quote race and ethnicity because if we don't understand whether they're getting better or worse we won't know you know how much more work we have to do simultaneously though I think as practitioners and scholars we have to constantly name that it is not the mere fact of me being a black woman that I have more likelihood of experiencing certain health outcomes it is the set of systems and structures embedded in racism that are creating those health outcomes. You know the other side to this that even has a little bit more complexity is that I would probably argue that poverty is one of the more important population health challenges and that you know extreme poverty leads to bad outcomes and so that gets tied in here also of you know how do we address that issue which is again as fundamentally difficult as other population health elements. Right and poverty is also produced by a set of policies that have created childhood poverty in our country that is far and above what it should be and we know that people of color black folks indigenous people some Asian American groups Native American people have experienced a set of policies and practices that create higher levels of poverty for them things like land seizure for the Native American people chattel slavery for African American people and you can name those policies and practices throughout the history of this country as drivers of the concentration of poverty amongst those groups of people. Yeah I think that's another really important part of the definition you gave and the focus of population health is those policies and practices that kind of speak to some of those historical differences and prescribed by those policies and practices and I wonder we can talk a little bit more about that right so you know how does population health engage those things is it about kind of noting and describing is it about changing what's the kind of goal or focus there. I think it's both first we have to identify what those policies and practices have been and I think demonstrate the ways that they have resulted in conditions or determinants of health that are driving the differences in health outcomes so you know again you can start with for African Americans chattel slavery then go to on convict leasing or contract leasing where people who were emancipated then were many forced back into forced labor through a set of policies that were enacted in the South you can go up to redlining you can then look at policies related to mass incarceration you can look at policies related to school funding adequacy so there are in the scholarly literature I think now many many many examples of the ways that policies have created the conditions for poor health and so if we can make those policies we can also make different policies that would undo some of those. Yeah yeah and you know you you noted how there is somewhat renewed focus or emphasis on on race and how that does have a obviously historical precedence here although I also wonder if the focus on racism is a little a little newer at least in in in some of the kind of current parlance right you know I think people are much more directly and explicitly calling that out and exactly ways you're describing and I'm wondering what you think of that evolution and how you've seen it kind of change your influence population health and and and language and descriptions and focus within the field. Yeah I do think there is movement toward understanding that racism is at play but again I think this it's not new double the boys needed in 1899 so it's I think we have to think together about why it continues to light is taking so long for people to then take action at the level of racism. If these are facts and constructs and theories that have been in the scholarly world for a hundred years. Yeah so you also mentioned that the danger of potential too much integration with the clinical care system is that's where you know the life is going to come and that's where some of the funding is going to get kind of pushed to and I'm wondering what the alternatives to that right what what are some alternatives to kind of thinking about infrastructure upon which population health can live or funding upon which population health can live how do we what are some alternatives there to that clinical care system. Well I think fairly funding the governmental public health system would be the first step and the governmental public health system is I think historically has been rooted in work that aligns with the population health framework in terms of addressing environmental conditions for example there's a you know a history of governmental public health involvement in quote urban renewal it's not necessarily the best history but I think there is a a first step in funding that system so that it can address the conditions of communities that could improve health and then I think there's also the role for whether that governmental public health system can really become the public health 3.0 version of itself where those folks are the chief health strategists and they are the locus of coordination across sectors That is really necessary to address all the things that are impacting our health And that that I don't think ever really been fully funded in that way and I don't have a clue how much money it would take to add and quickly do that Is that happening anywhere? Well like DT you know you look a lot at and your role Kind of what's happening across the country and I'm wondering how many good examples of that or another country's even I Think there is you know, there's movement. I think some of the states like Washington state and I can't give you a very specific example have Have moved in that direction, but I can't think of a standout example of a state or a local governmental public health system that is fully adequately funded and Coordinating across all the sectors that that need to be involved. Yeah, but probably says something that we're not a media like coming to our Think are you fingertips? It's interesting. I think there are there are also You know who who's doing what leaks all over the place? So I I'm not sure about this Brian, but I think that Like in New York there was a big movement to lower the speed limits in in neighborhoods, which is a population health act But I think that was you know pushed by the transportation department Instead of or in addition to the public health department so these things get You know the boundaries the same thing with bicycle And of course safety on bicycle passes Yeah, I like that phrase leak all over Because then it's hard to figure out right how cool supposed to be in charge of The people's health it is you know governmental public health that is their charge, but how do you actually? Operation the lies that Broad tent with no leaks You know, I guess the more positive state is that you need collaboration among different Agencies in a city government or a state government So I'm wondering if we could talk a little bit about careers in population health and and it's a it's a big feel that can mean lots of different things As we've talked about and I'm wondering if you could I'll talk a little bit about that like how do people who want to engage in this field do so? And what are the options or paths for for making that happen? I think there's options across the spectrum so you know community health workers are people with first-hand knowledge of community conditions and are in communities doing both the work to connect community members to clinical care often but also doing the advocacy work with other community members to name the conditions that need to be addressed at the population level and engaging in advocacy work and education to those that are in formal positions of elected leadership so you can start as a community health worker You can work in governmental public health and I think the pandemic has obviously created much more awareness about the types of things that governmental public health staff and leaders do for us So working in disease surveillance and a in a local or public or state public health department you can work in in an academics center and conduct research about the determinants of health you can work in transportation department and think about you know vision zero that would reduce pedestrian fatalities especially in communities where traffic calming measures haven't been fairly implemented so I think the great thing about both population health and public health is that there are so many doors to walk in um and you don't necessarily always call yourself in a public health person or population health person but that's actually what you're doing Yeah, yeah and I'm wondering if that um um If you could talk a little bit more about how those careers sort of interconnect exactly as you say right You know if you think of yourself or you're you know you're going and you're getting a clinical degree and are what are going to work in in the world clinically but want to do it in a way that's very population health minded or if you're in public health and you want to do it in a way that's very population health minded how do those kind of careers intersect if you well? Yeah, so I'm a clinical child psychologist by training so I don't have an MPH and my experience in public health has always been through practice so federally qualified health centers which are um community health centers that are funded through the health resource service administration whose charge has always been to meet the needs of underserved communities defined by health provider shortage areas or medically underserved areas using a population health approach not only clinical care but addressing the other uh determinants of health um the the thing that um I think is also very unique about federally qualified health centers is that they require that the board leadership be 51 percent people who receive care there so the voice of the people in the community is embedded in how they determine what they do and how they do it so so for clinical people who are interested in marrying their clinical skills with a um broader community level approach to meeting um meeting people's needs and shifting conditions you can't get any better training than working in a federally qualified health center um I think from the other direction if you are thinking already about a career in public health and you think you want to do that in a clinical care setting there is a lot of opportunity to um work with data there's a lot of data collection mean data collection happening through especially electronic health records there's all kinds of quality improvement work that you can get involved in for defined populations there's this you know health anchor network where I think health systems are learning more about how to use their vast resources and power to actually shift the conditions the social and economic conditions in their um service areas so lots of very interesting ways to combine is it so one of the things we have seen um hawkov and sometimes actual practice of change in other health related fields is technology and I'm wondering if there is any role uh what what the role of technology in changing how we do or what population health is or how we engage with it is that something we see happening or or not right is this sort of you know a lot of description and now I'll change it up here I don't have much experience probably because I'm not uh I am a psychologist and I'm um I tend to be very relational and so while I know technology is can support um relational uh work it's not my um go to approach so I'm really um I'm not sure I have anything to offer there yep I I was gonna ask um it's a little bit related to that and other issues but and you know there there are some examples of competition approaches to health care in our country you know whether it's placed like Kaiser Permanente or whether it's met you know like Medicaid managed care plans have some often their weakened sentives but they have some incentives to think about uh the whole picture and do you see that at a part it is is your experience anything of what role are they beginning to play where there's a payoff if you can peak keep people healthier uh and is that going to grow over time do you think well I think there are definite pros to that approach especially as you start to see payers thinking about using their resources to assure for example safe secure affordable housing and the ways that that is demonstrating positive impacts on things like mental health or even diabetes management. And so that's encouraging. I think the challenge will be is that again scalable to the level that we're actually shifting conditions or are these efforts going to be really only focused on the population that that ensure our health system is responsible for. So it starts to feel a little bit like whack-a-mole if you leave that you know that HMO and for you leave that health system does your housing leave with it. And so that I think also leads to the question about sort of the ways that we have made health care, a commodity and a capitalist system versus a right in a human rights frame. And what would it look like if we actually shifted that level of approach to how we provide health care. Actually your answer makes you want to ask one other question which is what's happening in other countries compared to what's happening in our country about population health and keeping people healthy. I think that is where I started with this comparison to other OECD countries and those countries that have more robust social safety nets both around housing and income and health care access for all have longer life expectancy and one of you all's colleagues in New York, Dr. David. -Auxie. -Choxie? Yeah, made a really impactful quote at a National Academy's Roundtable on Population Health Improvement that life expectancy is declining on our watch. And I it's a really profound statement that with all the investments in all the technology and all the discovery that our health care and biomedical science enterprise has in the United States, life expectancy is declining on our watch. -Especially among poor people. I'm wondering if we can use that as a way to kind of transition to some concluding thoughts that are a little forward looking with kind of that in mind. Where do you see this the field of population health going? Where should it go? How can it better focus on and address some of those issues you just mentioned including some of the broader population health decline? -So one of the directions I think is back to some of the earlier roots of public health that recognized that health is political that the ways that we collectively assure the health of the people is through the decisions that we make around shared resource allocation and our shared resources are not necessarily currently distributed across everyone in a fair way. So getting to this understanding that we can't separate politics from health and how does public health and population health engage in the political process that drives everything from how we distribute resources to how we make decisions, what is our role there and how do we shift political processes in a way that would result in more fair outcomes? -Yeah, yeah an important focus for the future. So Sherry thank you so much for joining us and it's been a great conversation with lots of challenges ahead. -Thank you for inviting me. -Thank you. -Now a message from Springer Publishing. Variety, flexibility, accessibility and the freedom to choose what works for your busy life. That's the Springer Publishing way. Visit SpringerPub.com/PublicHealth or content and tools to move forward in your career. Use code podcast for 25% off your next purchase. -So Jim, I thought a good conversation with Sherry on population health. What was your sense of the discussion? -It's interesting. I was involved in population health stuff at Robert Joseph Foundation. It's a very beginning I feel and it's interesting to see how complex and diverse the number of ways are emerging that you can address it and I think that makes it good but complicated. -Yes and as she said it's something that addresses lots of different areas and gets confused with lots of other kinds of focuses and approaches. Although I think Sherry gave a compelling definition kind of going back to some of the core descriptions of what it is, I also appreciate that she sort of made central the focus of race and racism and kind of brought us back to the boys and and really how that looks and how some of these key kind of questions and discussions we've been having for a long time and need to recognize that and understand and appreciate that as well. -Yes, and it shows how this chapter of our book ends up intersecting a lot with the equity and inequality chapter, which is these things go hand in hand. -For sure. Lots of ways for individuals who are focused on a wide variety of careers to engage in. It's almost really a framework for how one can think about this from lots of different perspectives, which I thought was a good approach as well. -Yes, I agree and it's interesting. It's not just public health where you can get interesting careers but also perhaps in insurance companies at some point or a capitated type of systems or even places that are really trying to rethink how our cities keep people safe and healthy. So there are lots of opportunities I think out there. And of course, healthcare providers in this country are never going to not try and being involved in everything. So there will be jobs at that level also. -Yes, so I'll inaugurate discussion. This concludes another great episode of Conversations about healthcare delivery in the United States. -Thanks for listening and stay tuned for more episodes and additional resources related to the textbook. Conversations about healthcare delivery in the United States have been brought to you Restbringer Publishing Company LLC. All rates reserved. 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