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Focusing on populations' health

March 1, 2009
by Ronald W. Manderscheid, PhD
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Population health insurance would focus on prevention instead of illness

Last month I described state universal coverage initiatives. These efforts to extend health insurance to the uninsured are intended to insure persons and provide benefit coverage for illnesses. Hence, they more accurately could be called state universal illness insurance initiatives. Such insurance, of course, is critically important for persons with mental and substance use conditions.

This month I introduce a new concept: population health insurance. This insurance would be designed to provide coverage for a population (rather than a person) and would focus on health promotion and disease prevention (rather than on illness).

As we begin to develop the conceptual and operational framework for the Healthy People 2020 initiative (see Behavioral Healthcare January 2009, page 51), we are confronted with a situation in which we spend virtually all of our insurance dollars on illness, and virtually nothing on “upstream” activities to prevent or mitigate subsequent illnesses. The net effect is that we have rapidly skyrocketing healthcare costs-$4 trillion expected in 2016, up from $2.3 trillion now.

Yet we achieve, at best, mediocre outcomes. On some basic population health measures of quality, such as the number of low birth weight babies, the United States does not rank in the top-10 countries or even in the top 20. In our own field, public mental health consumers' 25-year shorter life expectancy is a tragic example of this lack of quality in care delivery. Anecdotal evidence suggests that the statistics on mortality of mental health consumers in the United States are considerably worse than those of consumers in Western European countries. The clear implication is that we need to change what we are doing-not just a little, but decisively and dramatically.

Population health insurance would be a key element of such a dramatic change in direction. Basic features would need to be designed, tested, and implemented, including the population benefits to be covered, implementation of population-based interventions, and payment for coverage.

Clearly, the population benefits to be covered would include evidence-based group and individual health promotion and prevention interventions, as well as evidence-based intervention strategies that can be implemented to mitigate the early stages of illness, particularly chronic illness. Interventions that promote health and wellness self-management and healthier lifestyles would serve as the framework for these benefits' design. One can envision a “population health coach” or “population health advocate” who would monitor key parameters of a population's health and coordinate interventions.

An urgent need exists to develop the evidence base for population-based interventions. Available interventions, with related evidence, need to be summarized to identify major gaps, as well as opportunities for quick progress. The National Institutes of Health's research agenda should be broadened immediately to accommodate this important work (This would be an excellent application for part of the $10 billion in stimulus funding NIH will receive shortly). As part of this effort, we will need to consider the application of health communication strategies via the Internet and modern information technology. In fact, this is likely the only way we ever will be able to reach every American with tools such as targeted population-specific health enhancement information that he/she can use to promote health and wellness.

Let's reflect on a few examples. As our analytical technology has advanced, we have become better at developing statistical predictions about persons at increased risk for depression. Information tools can be implemented over the Internet to help persons in this population understand if they are at increased risk and, if so, what steps they can take to forestall or mitigate depression. As another example, a city's or county's entire population could be targeted if it is at increased risk of developing a particular type of cancer related to environmental factors. The potential range of health communication possibilities is practically unlimited.

A very important question is how we would pay for population health insurance. Part of the initial funds could come from very modest changes to Medicare's, Medicaid's, and private insurers' benefit structures. Directing as little as $1 per month per person from each of these sources into population-based interventions would produce more than $3 billion per year for such insurance. Doing the same for the uninsured by redirecting funds from emergency rooms would produce an additional $0.6 billion. Hence, a reasonable initial national investment ought to be targeted at $5 billion per year (This is approximately the amount the Senate included in the stimulus package for a Prevention and Wellness Fund, before being reduced to $1 billion by the House and Senate conferees). This amount should be escalated to $50 billion within 5 years-slightly more than $150 per person per year. This figure ought to be weighed against the $7,500 per person per year we currently spend treating disease. Beyond this initial investment, additional funds could be directed as chronic disease rates begin to fall.

Major think tanks already have embraced this concept. For example, the Institute of Medicine and National Research Council recently released a report calling for the federal government to have a larger role in preventing mental disorders in youths. As we focus on health reform, not just healthcare reform, population health insurance can serve as a key tool to move the agenda on health promotion, disease prevention, and even wellness. Accomplishing this agenda will be a large task over an extended period. We should start working immediately.