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The Fatal Flaw in Population Health

January 07, 2020

Population health was once an esoteric focus for thought leaders, and today there are multiple national associations promoting public policy and research in its name. Population Health Alliance (PHA) is a multi-stakeholder professional and trade association focused on population health, while the Interdisciplinary Association for Population Health Science (IAPHS) pursues a mission matching its name.

The simple idea of population health is to focus on the health of all people in a specific place, and to understand the many causes of health outcomes for that population. This brings to bear many clinical specialties along with a concern for health disparities between the rich and poor. While behavioral health should be an essential focus, it is too often missing or underestimated in importance.

If population health is about improving the health outcomes of the population one serves, then this goal cannot be achieved without a strong emphasis on the domain of consolidated behavioral health. Why then would an organization like PHA not have members or leaders from the behavioral health industry? The answer is likely a lack of interest by physical health leaders, as well as by our industry.

Our industry too often waits for an invitation to the table. When that invitation finally comes, don’t be surprised by your assigned seat. We not only fail to meet the needs of healthcare consumers with this approach, but we damage the reputation and the assets of our field. The fatal flaw in population health, its minimizing of the role of behavioral health, reflects a flaw in the focus of our industry’s leadership.

Our narrow understanding of population health

A quick scan of perspectives by leaders in behavioral health offers a strangely limited view of population health. For example, a few years ago BHE included this view from an executive:

Population health is viewed by many as a strategy for primary care providers, but behavioral healthcare plays an intricate part. Often chronic health conditions co-occur or can lead to substance abuse or mental health issues, and working with primary care is important to create a complete picture of patients. (Marbury, July 12, 2016, “How to leverage population health strategies”)

The importance of behavioral health comorbidities cannot be denied, but the implicit acceptance of behavioral health not having a more fundamental role in population health is disturbing.

The question is why this blind spot exists. The surgeon general’s report long ago settled that mental health is essential to health. Yet there are many more articles every year reinforcing the connections between physical and behavioral health. This unwittingly denigrates the independent significance of behavioral health. I would argue that both messages are profoundly important.

This will not be resolved with more studies. The problem is more political than scientific. We seem reluctant to promote our industry. We have long deferred to pharma as the largest representative of behavioral healthcare solutions. They have the deepest pockets, but that does not explain everything. Nothing prevents our executives and researchers from joining, even leading, the pursuit of population health.

Why our industry should own population health

If you are struggling to assert yourself within a hierarchy, you need to establish your value outside the framework that dismisses you as subordinate. The hierarchy in which we are cast as secondary is healthcare, and the opportunity for a fresh value proposition is population health. Our value related to comorbidities is significant, but our impact on health is great for both clinical and non-clinical problems.

Which non-clinical problems are critical for health? Health-promoting behaviors, ranging from exercise to nutritional eating to nicotine use, are major determinants of health. Differences in availability exist here based on socioeconomic factors. When mental health and substance use issues are added, we see a strong value proposition emerge for how CBH is a leading driver of population health.

Healthcare industry leaders and academics promoting population health today would presumably welcome CBH as a critical domain. The importance of its three components – mental health, substance use, and health behaviors – are self-evident to them, and no other healthcare discipline owns the vital domain of health-promoting behaviors. Behavior is pivotal for a comprehensive model.

The uniqueness of behavioral health is that it has a role in virtually every medical specialty, whether managing a disease process through health-promoting behaviors or comorbidities from mental health or substance use problems. The pervasiveness of behavioral health is not confined to specific disorders. A person’s daily mental status – e.g., mood, attention – impacts treatment adherence.

Behavioral health is the domain that should lead all discussions of population health due to: 1) the inclusion of conditions that are most disabling, like depression; 2) complications from comorbidities, thereby driving 20% of total healthcare costs, and 3) the overwhelming impact that health-promoting behaviors have on physical health conditions.

Importance is relative

One way to demonstrate value or importance is through comparison with a peer group. For example, surgeons can assert their superiority based on having higher incomes. Musculoskeletal conditions can impress by costing roughly 50% more than other conditions. Behavioral healthcare could accept the challenge and find a winning set of statistics, but this is not wise path to follow.

It is preferable to locate one’s position or role within a totality. The reference point is more stable than shifting peer comparisons. How does behavioral health fit into the total health of a population? How significant is its role in the well-being of individuals and groups? How critical is behavioral health status to the level of productivity found in a workplace? Behavioral health is quite important in all cases.

Is this line of reasoning too calculating or self-serving? There is a marketing consideration to be sure, but having a stable anchor is useful when assessing relative importance. Furthermore, we are better off evaluating how our specialty fits into what matters most to people, like their health and well-being. We can share statistics on morbidity, burden and disability as well, but better funded specialties have long controlled that narrative.

The shift in focus that puts behavioral health in its best light is both positive and holistic. When blood pressure or glucose test as being normal, there is no clear improvement in quality of life. When a person demonstrates positive mental health, no abuse of substances, and robust health-promoting behaviors, this is a formula for enhanced functioning and well-being.

Spread these contagious qualities throughout a group, and the health of that population rises. The contagion factor deserves an article of its own. Behavioral health is a powerful force driving the health of populations, and we are strongly affected by the health behaviors of those in our family and social group. We are just beginning to understand this as a force for change.

Conclusion

A simple call to action follows from these arguments. Thought leaders in behavioral healthcare should have their organizations join policy and research groups like PHA and IAPHS. They should seek leadership positions and promote the vital role our industry can play in population health. These organizations currently neglect our field. Get them oriented with the CBH concept.

The goal is much broader than this. We must simultaneously promote CBH as a critical focus within the primary care setting, and we should be moving clinicians into those settings and into telehealth delivery systems to direct care with a biopsychosocial focus. We are ready for the next parity movement, directing our resources this time to achieving parity of focus and funding with physical health.

While we may be starting from second-tier status, this is based on historical stigma and misunderstanding, as well as the failure of our field to speak with one voice. We have silos separating our leaders in public and private systems, mental health and SUD specialties. We have allowed health-promoting behaviors to exist in limbo, despite fitting our core competency better than other disciplines.

This is the last in a series of five articles focused on advancing a new clinical model called, consolidated behavioral health or CBH. The ramifications of this model have been explored in the primary care setting and within the burgeoning realm of population health. The need for a new parity movement has been articulated. As with any new proposal, improvements are both necessary and welcome.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

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