In 2003, David Kindig and Greg Stoddart popularized the term ‘population health’ in their American Journal of Public Health article, What is Population Health?  While the term had long been used at least in Canada, there struggled to be a common definition. Kindig and Stoddart defined population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” More recently, the Centers for Disease Control (CDC) references Kindig and Stoddart’s earlier work on their website, but also provides a nationally-relevant update. The CDC views population health as “an interdisciplinary, customizable approach that allows health departments to connect practice to policy for change to happen locally. This approach utilizes non-traditional partnerships among different sectors of the community – public health, industry, academia, health care, local government entities, etc. – to achieve positive health outcomes.”
Providers and health systems are becoming much more interested in population health, as their financial reimbursement is tied to health outcomes – many of which are influenced by what happens beyond a clinic visit, inpatient stay, or procedure. Don Berwick stimulated a focus on population health when his Triple Aim was a foundational concept built into the Patient Protection and Affordable Care Act, more commonly known today as Obamacare.
Population health and health outcomes rank poorly compared with other developed nations. The World Health Organization’s 2018 World Health Statistics shows that the US ranks 44th overall for infant mortality and 34th overall in life expectancy at birth. This same report notes that, based on 2015 data, the US is the spends more on health care per capita than any other developed country (16.8% of GDP, which recent estimates exceed 18%). Much has been written about how to solve for this, and clearly there is a role for many in broad efforts to improve the overall health of the population. This reality influences the sense of urgency to address population health, but nothing influences it more than having a financial incentive to do something about it. Where value-based reimbursement models for health care are being emphasized more, there is a direct relationship with interest in health care providers and health systems to do more to improve the health of the population they serve. In this specific way, we have an alignment of interests: improved reimbursement for health systems if they achieve improved health outcomes.
Value-based programs are enduring, mostly because there is a shared interest in reducing health care spending and believe that these programs are effective in achieving reduced spending. New laws, such as the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA), more aggressively move toward value-based reimbursement models such as Alternative Payment Models (APMs) and Merit-Based Incentive Payment System (MIPS); both of which will be implemented by 2019.
The focus on population health is essential to achieving reduced health spending for payers (government and commercial), as well as providers. Patients, or consumers and their employers, are also interested in reducing what they spend on healthcare, especially as more costs have shifted to consumers.
From the demand (consumer) perspective, the predominant health concerns have to do with chronic and systemic disease; most of which are the result of lifestyle choices, most of which include multiple organ systems, and therefore DRG and CPT codes. Our system isn’t designed to take care of patients in a whole systems biology perspective. We have yet to embrace the need for a more systemic approach to disease diagnosis and treatment. This is where Functional Medicine offers an approach that is effective at providing not just a more comprehensive assessment, but also the kind of supports and services that help achieve lifestyle changes so that the root causes are addressed.
My own experience with Functional Medicine began in 2013 when I was working with Toby Cosgrove of the Cleveland Clinic and the Institute of Functional Medicine to envision what it would take to establish a program and create the evidence base to support the improved outcomes and cost effectiveness of this model. Within the year, we had a Center for Functional Medicine on the main campus opening up to serve patients. Every part of the operating model, research initiatives, teaching program were created for this specific purpose. We have all learned even more since opening day and made improvements upon the Center for Functional Medicine. The Center for Functional Medicine’s existence and continued demand (~3,000 patients are on a waiting list to be seen now, so more avenues for access are being explored) are evidence enough that there is a need for a model like this. More importantly, the Functional Medicine approach and model are integral to improving population health.
Chronic disease affects more than 50% of all Americans; 75% of those over 65 years old have more than one chronic disease, which comprises 93% of Medicare expenditures. Prevalence and incidence rates are increasing for factors that drive chronic disease, and multiple chronic conditions.
Assuming the above trends continue, clinical care programs that address chronic disease are paramount to decreasing demand, while also improving population health.
Functional Medicine is a systems-oriented approach that fosters patient engagement, while addressing the root cause of the patient’s issue – often permanently, assuming that associated required changes in lifestyle are maintained. The image is an overview of the Functional Medicine model that has evolved at the Cleveland Clinic, with the initial model provided by the Institute for Functional Medicine.
The science behind the concept continues to grow, in part due to the commitment from the Cleveland Clinic. In 2010, David Jones and others published the Textbook for Functional Medicine, available here.
There are two innovative approaches that Functional Medicine provides:
1. Systems approach to diagnosis and patient engagement: Functional Medicine’s diagnostic approach focuses on the root causes of chronic conditions. As the image shows, lifestyle factors are understood, as well as stress, trauma, environment, etc.
2. Supports (resources, tools, and processes) for sustainable lifestyle changes: the Center for Functional Medicine has developed a Functioning For Life (FFL) program that includes health coaches, nutritionists, and other personalized supports designed to help the patient achieve health in a sustainable way.
There are challenges with any model. One noteworthy challenge with Functional Medicine is that most insurers do not cover the costs of some of the diagnostic testing, especially some of the more extensive blood work and nutrient profiling, as well as gut microbiome genetic testing.
Nonetheless, a Functional Medicine strategy incorporates many of the most influential factors driving chronic disease and, therefore, population health.
A two-pronged strategy to optimize the effectiveness of a Functional Medicine model is worth considering. My recommendation is to have concurrent efforts at the individual level and the community level. Most health systems start population health strategies by focusing on their most expensive populations. While everyone can appreciate the logic, the path to long-term and sustainable results is more likely the two-pronged approach outlined below: