Population Health: Cockroaches, Health Behaviors, and Social Determinants

By Nalini K Pande, JD

I was at a conference a year ago on dual eligibles when I heard that a health plan was going to focus on pest control to help its patients. What? A health plan was going to hire exterminators for its patients? Then, I realized just how brilliant this idea was.  Cockroaches present numerous health issues, including triggering asthma attacks.  If you want to stop expensive Emergency Room (ER) asthma visits, then attacking the root cause of the problem would be a good start.  In essence, treating the asthma attack in the ER would be only one piece of the puzzle.  Focusing on how to make sure you don’t send your patient home to a cockroach infested housing complex would make much more sense.   Had the health plan stumbled upon something innovative, cutting edge and timely? Yes!  In fact, it did so by adopting a population health focus.  

What is Population Health?

Population health can be defined as  “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”  Population health shifts our concept of health away from individual, clinical health, and instead complements public health by emphasizing a more community health focus.  David Kindig’s County Health Rankings Model (below) provides a nice overview of key factors to consider beyond clinical care.  In fact, we see that health behaviors, social and economic factors and physical environment are even more critical to health outcomes.  Thus, if you want to improve the health of vulnerable, sick and poor populations, perhaps moving outside the clinical walls of the doctor’s office might be the best place to start.

County Health Rankings Model

Aligning Forces For Quality and Population Health

Aligning Forces for Quality (AF4Q) is the Robert Wood Johnson Foundation’s “signature effort to lift the overall quality of health care in targeted communities, reduce racial and ethnic disparities and provide models for national reform.”   These targeted communities, known as Alliances, have played a unique role in improving the population health of their communities. Alliances, as neutral conveners, have, among other things, created strong partnerships to improve Health Behaviors and address Social Determinants. 

Health Behaviors: Providers and health plans need to focus on activities that help identify and assist patients in managing their own care and modifying their health behaviors.  Their ability to proactively reach out to patients who need preventive and chronic care and help them access care management will require them to transform their systems for communicating with patients.  AF4Q Alliances have stepped up to help:

• • Puget Sound  Health Alliance conducted an outreach campaign to engage consumers in their health care.  Own Your Health is a campaign to empower consumers to become active participants in their own health and health care. 
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• • P2 Collaborative of Western New York worked with New York eHealth Collaborative (NYeC) to gather consumer input for the design of a patient portal to help New York state residents better manage their health and health care.
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• • Let’s CHANGE (Commit to Healthy Activity and Nutrition Goals Every day) is a partnership with the Healthy Memphis Common Table and the Shelby County Health Department to fight childhood and family obesity.  It includes 37 organizations spanning a broad spectrum of businesses, community-based organizations, and government.

Social Determinants: “Bridging the gap” between health care and population health stakeholders, includes a recognition of the importance of social determinants of health ranging from poverty, to education, to housing.     P2 Collaborative of Western New York is working with the Mayor’s Task Group for Creating a Healthier Niagara Falls on an empowerment approach for Niagara Falls. 

Can hospitals, health plans and other providers “go it alone” to address every category of Kindig’s model?  Perhaps the more important question to ask is: “Why would they?”  By partnering with community groups such as RWJ’s AF4Q Alliances, as well as public health entities, health systems can finally treat the whole individual and truly impact health outcomes. 


Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, population health, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.
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Dual Eligibles and HIT: Managing Not Just Measuring

By Nalini K Pande, JD

Why is HIT Important to Duals?

There’s an old saying in the health care quality world: “We cannot improve what we don’t measure.”   And, of course, the follow-up to that is: “how can we measure without good data?” Health Information Technology (HIT) is at the heart of one the most exciting aspects of health reform.  HIT systems are designed to collect and display data related to the delivery and care of patients.  

Dual eligibles are covered under both the Medicare and Medicaid programs and are generally the sickest and most costly beneficiaries of the Medicare and Medicaid programs.  Given this, it is essential that HIT systems, including Electronic Health Records (EHRs),  are designed to supply actionable data for the measurement of dual eligibles and ultimately, to improve the care of this unique population and reduce costs.

Where Are We Now?

The future of the nation’s health measurement and  HIT agenda is at a cross-roads.  We are still in the process of changing old systems to move us into the health electronic age.  We are also in the process of developing and endorsing measures specific to the duals population.  As we do so, there are several key issues that we must focus on to improve the care of the dual eligibles population.  One issue that stands out above the rest is how to better manage this unique population, not just measure them.  It is not enough to just collect the data.   Rather, it is what we do with this data and the measurement findings that will ultimately lead to improvements in health outcomes and care delivery for dual eligibles. HIT can capture data that is critical in improving care coordination, care transitions and disease management for dual eligibles.  We must use this information to analyze clinical trends and better engage dual eligibles as well as help providers in clinical decision support.

It’s no surprise that in the world of health apps and iphones, we turn to HIT to revolutionize our health care systems and improve outcomes.  However, HIT alone is not the Holy Grail we seek.   Rather, HIT is only a tool to get us the data we need to measure and improve our patient outcomes, our clinical care, and our delivery systems.  The story cannot end with more measures and data.  Otherwise, we will simply collect a lot of good information without much action.  We must re-tool our delivery systems and health care culture so we can act on the data we capture such as changing patient care plans and engaging patients differently.  Essentially, we must focus on moving from health measurement to health management and outcome improvement.   This will take a stronger focus on analyzing the data, and measurement findings, using predictive modeling, and taking a more proactive rather than reactive approach.  Many Accountable Care Organizations and other health entities have embraced this new approach but it is far from the norm.  Can we afford to shift from measurement to management?  Many fear the cost of HIT alone is too great.   However, with duals costing Medicare and Medicaid $250 billion, can we really afford not to?



Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, and emerging payment models including health information technology, accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.

Follow @nalinipande

Dual Eligibles and ACOs: A Blueprint for Success

By: Nalini K Pande, JD

Background:  Why Duals Need Stronger Focus and Attention

You may notice that when we talk about health reform, most health policy experts tend to bring the conversation back to the dual eligibles.  These beneficiaries are covered under both the Medicare and Medicaid programs and are generally sicker and costlier than Medicare and Medicaid beneficiaries as a whole.  Thus, it is no surprise that duals have been the focus of those trying to bend the cost curve.


ACOs May Be Uniquely Situated to Address Key Duals Issues

How do we improve the care of these beneficiaries while also working to reduce costs?  Accountable Care Organizations (ACOs) that take on dual eligibles, are uniquely positioned to provide effective solutions. An ACO is a group of coordinated providers in which provider reimbursements are linked to quality metrics and reductions in the total cost of care for an assigned population of patients. Given their emphasis on patient-centered, integrated care and coordinated Medicare and Medicaid benefits and funding streams, ACOs could facilitate greater quality improvements and reduce cost-shifting between programs as well as overall costs. Yet, the fundamental question still remains:  What is the blueprint for success?

Two core frameworks will need to be developed as part of a blueprint for success:
   • ROI Framework
   • Measurement Plan

Certainly additional key components will be necessary.  However, two critical components of the blueprint for ACO success are ROI (return-on-investment) and Measurement frameworks. First and foremost, a successful ROI framework is needed to ensure financial viability of the ACO structure: (e.g, hospitalization costs must be significantly reduced to pay for increased expenses in care coordination, care transitions, and care management). 

Second, a measurement framework will be needed to test improvements in quality.  Key measures should include patient-reported outcome measures, beneficiary experience, care coordination measures, utilization and cost measures, etc.

As part of this blueprint, the ACO must consider the barriers and challenges to changing the current system. How can the ACO overcome these barriers?  This will depend on whether the ACO can achieve a true culture change at three levels:

• • at the governing level with a stronger focus on clear and attainable management goals and benchmarks with diverse stakeholder input
• • at the clinical level with team-oriented care in order to improve care coordination and
• • at the community level with a focus on population health and collaboration with community organizations.

Can ACOs that take on duals bend the cost curve and improve quality? This has yet to be seen.  Setting ACOs up with a blueprint for success may be just what the doctor ordered.

Nalini Pande, Managing Director, Sappho Health Strategies has nearly 20 years of experience in healthcare policy and reform.  She has considerable experience in Medicare and Medicaid, and emerging payment models including accountable care organizations and patient-centered medical homes. Ms. Pande also has strong expertise in dual eligibles and the specific issues facing this unique population.  Ms. Pande is a graduate of Harvard Law School and Princeton's Woodrow Wilson School of Public and International Affairs.

Follow @nalinipande