Population Health and the Assessment of Value

True managed care is based on the notion of an integrated delivery system, an industrialized system of care designed to enhance population, as well as individual health status. The Affordable Care Act (ACA) and the philosophy embodied in the Triple Aim (ie, the triangle of care, population health, and costs) 1 are leading the evolution toward the integrated delivery system and away from the component-based episode of care strategy or the fee-for-service method, where goods and services are applied and reimbursed individually, usually during an episode of sick care. The pace of change is, at times, frustratingly slow for the providers and industries that are entrenched in the fee-for-service method of healthcare delivery. However, the evolution toward what Fineberg calls a “health system” as opposed to a “healthcare system” is under construction. 2 Fineberg makes the distinction between a system that is focused on health (ie, population and individual health system) and systems focused “only on the formal system of care designed primarily to treat illness.” 2 He concludes that the current system, which focuses largely on sick care, is neither financially sustainable nor yielding the levels of population health that investments in the US healthcare system would suggest. 2 Increasingly, systems are bundled into care packages in which care is continuous across providers and settings to achieve and maintain optimal health status for the populations. George C. Halvorson, Chief Executive Officer of Kaiser Permanente, stated, “We sell care by the package, not by the piece.” 3 A widespread interest in outcomes research has flourished anew, stimulated by the push of integrated health systems. The passage of the ACA in 2010 is certainly part of the emerging change. New funds were appropriated and were authorized to support research on outcomes, effectiveness, and patient-centered outcomes research. Much of this work has been coordinated through the US Agency for Healthcare Research and Quality. Thus, outcomes research will play a prominent role in the restructuring of the US healthcare system. Applied health economics and outcomes research (AHEOR) is a discipline that considers the evaluative clinical sciences and the roles they play in the quest for better value in the integrated health system, as outlined in the Table. The tools of AHEOR and integrated delivery systems are care pathways and heuristics grounded in the convergence of evaluative clinical sciences, such as epidemiology, risk assessment, wellness, e-Health and informatics, evidence-based medicine, healthcare quality and safety, comparative effectiveness research, patient-centered research, health services research, and cost-effectiveness analyses. Practitioners of AHEOR apply the evaluative sciences to actual practice settings by converting structure, process, and outcome systems’ variables into strategies for more effective, patient-centered, and efficient care. Once an institution commits to restructuring for population health, many of the historical foundations of healthcare are challenged and are changed. For example, Kaiser maintains patient registries for dozens of conditions, such as spine surgery, cancers, and heart attacks, where patients are monitored over time for the total health impact, not limited to the condition that occasioned entry into the registry. 4