Academic journal article Journal of Healthcare Management

Moving Upstream in U.S. Hospital Care toward Investments in Population Health

Academic journal article Journal of Healthcare Management

Moving Upstream in U.S. Hospital Care toward Investments in Population Health

Article excerpt


A cascade of evidence in recent decades has demonstrated that the root causes for most health outcomes are factors such as one's social support, job status, income, education, and physical environment- often collectively referred to as the social determinants of health (Marmot & Allen, 2014). Representative of this conclusion is the popular county Health Rankings Model of the University of Wisconsin Population Health Institute (2016), which estimates that 40% of health outcome variation is explained by social and economic factors, 30% by health behaviors, 20% by clinical care, and 10% by physical environment. Frieden's Health Impact Pyramid makes a similar point. The Health Impact Pyramid is divided into sectors based on factors that improve health for more people at the lowest unit cost. The base layer of the pyramid is socioeconomic factors. The next layer is "changing the context to make individuals' default decisions healthy." Preventive interventions are next, followed by clinical interventions and, finally, counseling and education (Frieden, 2015, p. 1749). Although the accumulation of evidence in recent years accentuates the need for attention to social determinants of health, the case for attention to the issue has deep historical roots (Lalonde, 1981; McKinlay, 1975).

Hospitals and health systems are now in the position of having to decide how much to "move upstream," or invest in programs and partnerships that directly affect the social determinants of health and in which programs to invest. Such decisions are difficult given the long-term and indirect payback from investments in prevention and other upstream activities (Fineberg, 2013) and the historical focus of U.S. hospitals on excellence in individual patient care (White & Griffith, 2016).

However, many hospitals and health systems in the United States recently have expanded their investment in population health and in activities that are upstream from clinical care (Health Research & Educational Trust, 2013). HealthPartners in Minneapolis-St. Paul, Minnesota, and Hennepin County Medical Center in the same community, with its Hennepin Health ACO, are two examples (Kindig & Isham, 2014; Sandberg et al., 2014). Kaiser Permanente, Trinity Health, ProMedica, ThedaCare, and Ascension Health are among the many other healthcare delivery organizations reporting new programs aimed at social determinants such as hunger, jobs, and housing (Avis, 2016; Kutscher, 2015). Changes in federal government policy, such as various efforts to reward value-based services, and the Accountable Health Communities Model program of the Centers for Medicare & Medicaid Services (CMS, 2016), are further stimulants to moving upstream in hospital services.

The American Hospital Association (AHA) Population Health Survey chronicles the degree to which U.S. hospitals report being aligned with population health goals and investing in upstream programs. In this article, we examine the characteristics of hospitals that are in the forefront of the movement to shift resources into upstream care. We use results of the 2015 AHA Population Health Survey to profile those hospitals and the ways they structure their population health activities.


The 2015 Population Health Survey was sponsored by the AHA, the Association for Community Health Improvement, and the Public Health Institute. The mail survey was fielded to AHA-registered hospitals between January and May 2015, with a 22% response rate (n = 1,418). Compared to the total population of AHA hospitals, the respondent sample overrepresents hospitals in the Midwest and underrepresents hospitals in the Southeast and Southwest, and overrepresents large hospitals, teaching hospitals, and not-forprofit hospitals. The sample is representative on the characteristics of rural/urban location, critical access status, size category, control (ownership), service type, and system affiliation (Health Research & Educational Trust, 2015). …

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