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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.


Originally published by Illumination Curated on Medium


Photo by Mārtiņš Zemlickis on Unsplash

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. It failed to reduce the cost of the quality of service and has placed a 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. That is why physicians are 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!

It 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, it would shift the decision-making from organizational bureaucracy to individual clinical encounters, in the long run, hence eliminating intermediaries, 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 countenances 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 not be acceptable or valuable 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 actual 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 it means to make sound choices or what determines a clinical judgment as rational?!

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

Rationing about Healthcare Cost Reduction; Hypocrisy or Bureaucracy?

Population health and utility social determinants of health and disease as the major player in the healthcare delivery model's cost-effectiveness are valid. Yet, it isn't sincere to rationalize its effectiveness in delivering care as a quality-based service model.

#populationhealth #publichealth #healthcare #bureacracy

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