Population Health Management and Rationing towards Reducing Healthcare Costs

Some believe Population Health Management and Value-based care are about making Careful choices, But Physicians are not in the business of Rationing

This article was originally published by Illumination Curated on Medium

The concept of value-based reimbursement or merit-based payment towards a medical service or procedure has become healthcare policymakers’ focus for the past decade. It is supposedly meant to maintain high-quality medical assistance to patients while reducing wasteful spending. But so far, half-decade into its implementation, the concept of merit-based valuation has been an utter failure. That has not only failed to reduce the cost of the quality of service but also has placed an overwhelmingly high burden on physicians. Amidst all; the same policymakers blame doctors for not being rational when it comes to cost control. What the latter attitude means is the subject of different conversations. However, the argument conflicting, is that those who use the phrase value-based reimbursement in conjunction with the population health model also fail to realize that the latter two phenomena can hardly be eclectic unless the value is fictitious. Because value-based reimbursement is the trait of personalized healthcare as opposed to the population health model. The question is why a physician is accountable for the rationale created through bureaucratic processes such as administrative values and standards.

The Cost-Saving Rationale behind the Population Health

The idea of population health and Population health management (PHM) is a two-century-old concept that has gained a modern attitude. Population health in recent decades has become more embraced by legislature and policymakers. The new version advocates multisectoral collaboration, coordination with community services, and nonclinical mediations. The policymakers use that to gather, preserve money, and save lives. Such a theory stands valid, given low public personal expectation and subjective perception. And It would be more successful if the quality of medical service was dictated to everyone as a one-size-fits-all solution. But that is not the case!

Itis is understandable that the need to focus on preventing diseases before they occur. But beyond that, PHM merely focuses on “social determinants of health,” encouraging healthier lifestyles and chronic disease management. Furthermore, PHM’s notion is to promote a “population” healthier, reduce health care utilization, and save money. And that is irrespective of individual factors. That does not mean that personalized healthcare would cost higher.

Personalization of healthcare requires transparency, promotion of the open market, and accountability. The said is something that is utterly lacking within the current system. Personalization may seem costly in a closed and controlled market scenario. However, in the long run, it would shift the decision-making from organizational bureaucracy to the individual clinical encounters, hence eliminating middlemen, favoritism, and price-fixing practices.

The Value-Based Healthcare ambition and its Contradiction with the Population Health Initiative

Some scholars believe that Value-based Care combined with Population Health Management translates into the perfect match. They advocate; population health delivers correct value-based care, and that medical professionals lack insight into the physiognomies of both individuals and larger groups of patients. I concede that physicians must gain access to individual and population health needs and status; however, I also believe most middle persons already consider various individual and social factors in their clinical judgment. Then again, what is contradictory, as I pointed out earlier, is that policymakers place much less emphasis, if at all, on personal factors. The same scholars also controversially believe Population health management substitutes “one size fits all” care with tailor-made, cost-effective interventions based on patients’ risk levels. And the latter approach is well aligned with the goals of value-based care. Since population health utterly takes into account the collective determinants within a group of people, for the same reason, it cannot incorporate genuine value. For instance, the quality and value of care may be fit for 80% of the population. Still, it may be not acceptable or useful for the other 20% because cost reflects the quality of medical service rendered to a patient by a physician during a particular encounter. Hence the real value cannot be based on population-based medical care. Instead requires a personalized healthcare system.

The Careful choice, Medical Practice, and Physician Clinical Judgment; it is all about Semantics

Those who paint the practice of medicine using phrases such as careful physician choices, sound clinical judgment, and improving physician rationing when ordering tests and rendering care are only playing with the semantics. So, one should ask, what does it mean to make sound choices, or what determines a clinical judgment as rational?!

Since the administrative rationale focuses on cost control, then irrespective of what a physician bases his or her clinical decision while trying to deliver a value-based service, thus physician will always lose the battle of the semantics defined by the insurance industry as well as the governments. In other words, Insurance industries will dictate what a quality, value, and hence what good clinical judgment entails.

Rationing about Healthcare Cost Reduction; Hypocrisy or Bureaucracy?

The fact that population health and utility social determinants of health and disease as the major player in the healthcare delivery model’s cost-effectiveness is valid. Yet, it is utterly hypocritical to rationalize its effectiveness in delivering care as a quality-based service model.

The determination of quality and value always necessitates a point of reference for comparison. The quality, supply, and demand or availability of a needed service also contribute to specific quality service costs. Since medicine is a science of indefinite variabilities and no two services are identical, qualities must vary. The point of reference for the quality of medical care established by administrations and 3rd party entities (including the world health organization) is one. It is applied to every scenario for all patients. For instance, quality of care may simply imply maintaining a certain laboratory level of blood glucose or blood pressure measure, irrespective of how the patient feels or comprehends.

Population Health is about Cost control, but Value-based Reimbursement is Personal

Indeed, the relationship and the interest between value-based medical care and population healthcare is conflicted, just like the latter stays a tool based on the collective outcome, whereas the former is purely personal.

That is true; population health primarily focuses on limiting resources and curbing costs, whereas the value-based model is meant to balance the quality and value. However, it would only work if it was applied to individual patient cases in clinical settings. Once again, personalized healthcare is not necessarily synonymous with high-cost care. It would reduce costs if implemented wisely, and perhaps if done correctly, will take the patients and doctors off the administration’s target list as contributors to high Healthcare Costs, protects physicians from being accused of acting irrational wasters of healthcare resources. In other words, correct personalization will cut the hands of the middlemen and bureaucrats of healthcare. It will place the healthcare system in the hands of patients and doctors who are the healthcare system’s core players.