What Goals Matter? Population Health Management & Chiropractic

One of the terms being heard a lot these days is population health management (PHM). What are some of the implications for chiropractors? Should we be paying attention?

PHM is a concept for strategies that attempt to address needs in the health of a population. It is an updating of the idea of disease management (DM), which became popular in the early 2000s. Given that a large driver of  escalating American health care costs is the expense of treating lifestyle-related chronic diseases, the concept of disease ‘management’ sold well to insurance company programs and commercial products for employers. By and large though it did not work, at least in terms of a return on investment. Heavily medical in nature, chiropractic generally wasn’t and hasn’t been part of these programs and strategies. Yet we know we have a contribution to make, and even more so when you consider overall population health goals. What does it take to get us there?The way public health outcomes are commonly defined, problems need to be eliminated, leading to good outcomes. This approach makes sense when you’re talking about polluted water and air. It seems to make sense when talking about diseases, too. Communicable diseases are possible to control through interventions, even if the interventions are politically polarizing subjects. For example, setting aside whether the delivery media, timing or universality of vaccines are appropriate, the scientific fact is that these and other interventions can control disease–at least up to a point. ‘Improvement’ as an outcomes goal equates to ‘lessening’ a problem.

But it turns out things are quite different when we talk about chronic, lifestyle-based disease, because outside of genetic factors these diseases are the culmination of a series of environmental insults, poor choices in diet and exercise, and a host of other controllable factors. So the thinking has been that interventions can control these problems in much the same way polio and other communicable diseases have been controlled. Interventions = control. But in practice it is more complicated than that.

DM: R.I.P.
Disease management programs focus on identifying risk factors, targeting people who exhibit them, and aggressively reaching out to people with these factors to try and ‘manage’ their emergent and pre-emergent diseases. With the high price tags that come with treating diseases related to smoking, obesity, and their ghoulish stepchildren heart disease, diabetes and the like, this strategy seems to make sense. But it turns out it’s very difficult to manage diseases, because you have to manage the people who have them. For most of the American public, being ‘managed’ is anathema given the fact that we’ve been acculturated to view health insurance coverage as something akin to a basic human right, and if I choose to eat at McDonalds eight days a week, that’s my business. Well, of course it is–but if I do, the costs of treating my illnesses when all that grease, sugar and salt make me sick are underwritten by a much bigger group. Because those costs are distributed across a larger pool, each person’s individual choices have an impact on the pool–a fascinating and prickly social reality.

It turns out that identification of people in DM programs whose lives get reduced to a list of ‘risks’ based on unhealthy behaviors is not often popular, and programs that seek to exact ‘compliance’ from people tagged with risks often find that these efforts aren’t always appreciated. As a consequence, DM programs have been dropped by many who tried them. Enter population health management.

At its heart, PHM doesn’t really manage health, but tries to get at more complex sets of factors that may improve health. It focuses more on prevention (early problem identification) and ‘wellness,’ at least in medical terms. But that’s still a very medical, control-based model, and what PHM doesn’t do is focus on identifying, supporting and protecting the intrinsic abilities we all have for being and staying healthy–at least the way we understand that as chiropractors. Where DM programs focus on compliance as a program adherence measure, some PHM program metrics for success and outcomes are starting to wisely substitute ‘engagement’ for ‘compliance.’ This is a very different goal in behavior modification: intrinsic (self interest) motivation produces far longer-lasting change than extrinsic (incentives, rewards, etc.) motivation does. (For more on this, see information on motivation here and Dan Pink’s book Drive about this important distinction). From the chiropractic perspective, we already understand that engagement with their own ongoing maintenance is critical for patients’ long-lasting health and stability; someone who passively receives an adjustment and goes and does the same thing that produced the dysfunction is not going to enjoy optimal health. And in the new economic reality of health care, ‘engagement’ is often motivated simply by the skyrocketing costs of health insurance and care.

A New Paradigm
To answer the question posed above, we should be paying attention to all this, because with the Affordable Care Act, PHM has been framed in some important ways that hold implications for chiropractors. Where risk identification could be used to deny health care coverage, companies can no longer do so. With the broader pooling of Americans (28% of the 8 million newly enrolled people are in the 18-34 year old ‘young invincibles’ demographic with normally very low health care costs), there’s a larger fiscal buffer in coverage for lifestyle-based chronic disease. Consumers are coming to understand that they must be more engaged in managing their own health care, and these intrinsic motivators (self-interest) are driving some important achievements in lowering risks. [As an aside, the new framework for this is ‘patient activation,’ a concept that is fostering the development of tools such as the Patient Activation Measure, which depends on a competency of health literacy. ‘Activated’ patients are more responsible and effective in managing their own health care needs: those with demonstrable competencies in managing their own health care were shown by an AARP study to be less likely to be readmitted to a hospital within 30 days, experience a medical error or suffer a health consequence from poor communication among providers.]

On the surface, chiropractic’s contribution to this area may seem unaligned with orthodox PHM goals. But if humans may be viewed from a neovitalistic perspective as possessing self-developing, self-maintaining and self-correcting capacities, those capacities need to be impaired for chronic disease to take hold. Chiropractic can make a material contribution to population health by helping to ensure peoples’ bodies function as optimally as possible. PHM goals should be expanded to include–even depend–on this reality.

It’s critically important for our profession (and for population health) that we focus on articulating what our contribution is because of how delivery models for health care are changing under the PPACA and its aftermath. Patient-centered health (medical) homes (PCHHs) and their big brothers and sisters Accountable Care Organizations (ACOs) are going to dominate the service delivery landscape. As of now, chiropractors are largely excluded from these–excluded because our contributions are not understood and we’ve been politically marginalized. But because of our appreciation and understanding of the centrality of optimal neurologic function as a requirement for health and wellness–that our bodies constantly seek to establish and maintain–we should be at the core of every service delivery model. The way we do this, however, will affect our profession’s viability and health. I submit that we can’t be included as a therapy, because that permits us to be marginalized and falsely compared with other therapies. We must be included as a distinctly different–but collaborative and integrative–paradigm of care. If we fail at this, we may find that problems associated with becoming part of a provider network are a walk in the park compared to penetrating membership in a PCHH or ACO.

It is important that we as a profession ‘own’ the fact that we work from a philosophic paradigm shared by many, but a clinical paradigm that we use alone. No other profession looks to the nervous system as the foundation of health, and no other profession looks to remove sources of interference that impair neurologic function in the same way as we do. We may share some interventions with other professions, but the chiropractic adjustment is singular and unique. It’s also important for population health.

Our challenge as a profession is in how we describe the evidence we see of problems in people who are not getting regular chiropractic adjustments. Many will argue ‘where’s the problem?’ Our answers need to be able to point at least to evidence of at least an associative relationship between sub-optimal or impaired function and health problems. More than enough evidence exists that chiropractic care is cost-effective for treating a number of conditions in contrast to medicine. But we need to also look at how we can define our impact on overall health and quality of life in those who are under chiropractic care. And then we must insist on a role of distinction based on that identity, not a therapeutic role based on a single intervention (the adjustment) that others may emulate or copy–however poorly.

The Chiropractic Paradigm
The paradigm of chiropractic is distinctive and unique in its application. As highlighted in an earlier post, the ACC Paradigm on Chiropractic frames the basis for our role in serving humankind and defines the basis for our contribution to population health.

Doctors of Chiropractic, as primary contact health care providers, employ the education, knowledge, diagnostic skill, and clinical judgment necessary to determine appropriate chiropractic care and management.

Doctors of Chiropractic have access to diagnostic procedures and /or referral resources as required.

Doctors of Chiropractic establish a doctor/patient relationship and utilize adjustive and other clinical procedures unique to the chiropractic discipline. Doctors of Chiropractic may also use other conservative patient care procedures, and, when appropriate, collaborate with and/or refer to other health care providers.

Doctors of Chiropractic advise and educate patients and communities in structural and spinal hygiene and healthful living practices.

What does this definition establish as the potential role and set of responsibilities for doctors of chiropractic in population health management? I think there are three basic truths.

Three Truths
Framed as simply as I can, I see three basic assertions about chiropractic and population health that we should all be in agreement on–and seeking to promote.

1. Health and well-being are dependent on the ability of the nervous system to dynamically and effectively respond to environmental challenges (suboptimal nutrition, unhealthy thinking, inadequate movement). This dynamic response capacity is neurologically mediated.

2. Even subtle impairments to nervous system function can and do have long lasting and wide ranging effects on our bodies’ ability to achieve and maintain health (homeostasis as a steady-state achievement, homeokinesis as the dynamic response capability required to achieve homeostasis). Decreased vitality, increased susceptibility to disease, and overall weakening of our ability to achieve and maintain health are the consequence of suboptimal neurologic functioning viagra sin receta medica.

3. Evaluation of and clinical care to address potential impairments to optimal nervous system function are important components of basic population health.

Given the context for chiropractic care, its potential role, responsibilities and contributions to population health, what might this produce? In terms of establishing goals, there are some powerful and appealing opportunities to consider.

Ideal Goals & Optimal Outcomes
In another earlier post, I penned one person’s vision of a set of PHM and public health goals that should be agreed upon by all involved:

A number of stakeholder professions have established the following overall goals for the population of the United States. It is our collective belief and goal that each individual can and should enjoy, within genetic or other uncontrollable limitations:

  • A lifestyle characterized by an unpolluted environment, food free of chemical and genetic contaminants, relationships free of violence, appropriate levels of physical activity, society-sponsored education customized to individuals’ learning needs and the guidance needed to develop a mature expression of emotional and social intelligence, incorporation of citizenship responsibilities and individual health practices.
  • Pre- and post-natal development characterized by optimal nutrition, safety, joy, wonder, a functional family and economic security.
  • A body able to express innate capacities, development, health and repair based on optimal neurologic system functioning and appropriate support of nutritional, energetic, and other health domain-specific needs.
  • An emphasis on non-drug and non-surgical services where at all possible.
  • Access to necessary services where drugs and surgery are required or important for recovery of health and function.
  • End of life transitions based on comfort, grace, support, and continuity

Given the value of our distinct ability to influence genuine health promotion by focusing on supporting the innate capacities of the human body, chiropractic should be a foundational contributor to population health. It’s up to our profession, its leaders, its schools and its practitioners to develop models to demonstrate the appropriateness of these goals and to define our material contributions. I’m afraid no one is going to bail us out on this one.

And if we don’t do this and would rather wait to be invited to sit at the table, no chair will ever open up. See ya.



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