Guest Post: Implementation matters. Particularly if it relates to what matters to the purchaser

Paul Terry formal photoBy Paul E. Terry, Ph.D., Chief Science Officer, StayWell Health Management

I picked up an undercurrent during this year’s Care Continuum Alliance – CCA Forum 2013 that I tested often in break-time conversations. “Do you think there is a connection between the return on investment (ROI) and value on investment (VOI) discussions?” I asked. While the answers I got ranged from technical to philosophical, the general tenor from consultants and purchasers alike was a genuine appetite for broadening the criteria we use to judge success in population health management.

I think three things explain a great vibe at the conference that spoke to a readiness to take population health from what has been an inordinate focus on ROI to a preference for advancing VOI. Many view VOI as richer, if not more meaningful to purchasers, first, because of opportunities that accountable care organization (ACO) and regional exchanges could present; second, because of extant limitations in ROI methodology; and, probably most important, because VOI represents the next level of maturation and opportunity for the field.

Regional exchanges and the VOI of wellness

Most presenters who ventured into whether and how the exchanges could influence population health management acknowledged it’s too early to tell. I found Medical Director for Employers Health Coalition Bruce Sherman’s rendition especially edifying given his postulate that small employers may finally have enough critical mass to reconcile the VOI of prevention. Sherman, a medical director for Ohio’s Employer’s Health Coalition, is able to see more clearly than most how the lack of investment by one employer ultimately disadvantages the collective competitiveness of a region.

A scenario I posed to Sherman that he agreed was viable was one where exchanges and population health management providers become more focused. Businesses generally are adjusting to an era of hyper-specialization, and winning or losing in population health will relate to a VOI that is different from one employer to the next.

What I found telling about the VOI propositions offered by those who discussed exchanges or ACOs was the continued preoccupation with the employer as purchaser. It’s more than ironic that “patient centered” homes and value-based purchasing are watchwords, but that the consumer’s values and needs still get short shrift. When a conference has panels of patients replace experts, I’ll be convinced we are fully embracing patient-centered concepts.

At long last: positive proof that wellness works for everyone all of the time

Would the CCA Forum, or any science-oriented group, organize sessions to support this headline? Of course not, but it’s attention-getting isn’t it? That’s undoubtedly a goal behind the hyperbolic harbingers of the notion that wellness doesn’t work.  Nevertheless, the CCA Forum made room for a “great debate” on ROI so presenters could posit that piece meal programs tested using quasi-experimental methods will yield unimpressive or inconclusive results. Not much grist for disagreement but, ever the optimist, I’m predicting those bent on scaring up controversy will inadvertently help to advance VOI metrics.

Short of more randomized controlled trials for comprehensive, long-term population health programs that balance individual interventions with culture change, today’s ROI methods are about as good as they’re going to get. My Dad taught me that you don’t dignify some criticisms with an answer. If CCA is looking for debate questions, here are some that I’d find interesting: Do wellness programs over-measure and under-intervene? The ratio of incentives to educational program spending is nearing 4:1; could this do more harm than good? The Affordable Care Act (ACA) rules could lead to annual health screening for many who would otherwise not be due for screenings according to clinical consensus guidelines; how should this be reconciled? Qualified debaters would be credible scientists who don’t have a financial interest in proving or disproving the questions.

Taking PHM to the next level

Conferences are at their best when they offer healthy doses of both education and inspiration. That the behavioral economics principles advanced in the book “Nudge” are being successfully applied in a clever product like “StickK” is a grand testament to how research can drive innovation. Seeing how an icon to consumer-based health education such as Weight Watchers is mobilizing its formidable peer-support infrastructure as a population health strategy is also remarkable. Learning how the Joslin Diabetes Center is translating its exemplary results in diabetes management into the diabetes prevention sphere was another example of how champions for change build on their own success.

This year’s CCA Forum was, as usual, masterful at enabling networking. It was during an informal lunch debate I had with three of population health’s most prolific researchers — Ron Goetzel, Ph.D., vice president, Truven Health Analytics, Seth Serxner, Ph.D., MPH, chief health officer, OptumHealth and Dee Edington, Ph.D., Edington Associates — that I was reminded of a fourth tenet for why implementation matters. Thought leaders don’t bemoan the failings of others because looking for bad apples is precious time away from creating ever more effective systems that support implementation excellence. Leaders are problem solvers, not problem describers. What’s more, they have an abiding message advancing what they are for, not merely polemics about what they’re against. On this count, this year’s CCA Forum convinced me that when it comes to implementation matters, the value of population health management is in very capable, and constructive, hands.


Guest Blog Post Disclaimer CCA invites guest bloggers to post on Voice on Population Health Blog as a benefit for our members and the industry and to allow for exchange of ideas and information regarding population health. The views, opinions and positions expressed within these guest posts are those of the author alone and/or of the company the author represents and do not represent those of the Care Continuum Alliance (CCA), its members, or the industry as a whole. CCA is not responsible for the accuracy, completeness and validity of any statements made within this guest post article. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author(s) and any liability with regards to infringement of intellectual property rights remains with them.

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