Healthcare In The Age Of Personalization Part 4: Where Does It Fit With Population Health?

This is Part 4 of a six-part series on Healthcare in the Age of Personalization.  Part 3 is here.

As our population gets more and more diverse, keeping people healthy will increasingly depend on how well healthcare systems understand and address diverse populations. Yet, as noted in my first article in this series, diverse populations are not homogeneous – we are all individuals.

In that opening article, I introduced the age of personalization, how it’s connected to inclusion, why it is significant for healthcare, and why healthcare in particular can help point the way for all industries to lead in the age of personalization. In the articles that followed, I discussed the real metrics of inclusion and how business models must evolve.

At its highest calling, the healthcare industry is responsible for the health of all people:

• Population health, encompassing communities as a whole.
• Individual health, treating and preventing disease person by person.

In this article I will explore where population and personalization intersect. How does a health system prepare for both – with systems for understanding and treating various patient populations, and also with systems that empower the organization to understand and treat individuals?

We have to do both. I would go so far as to say we can’t do one without the other. We can standardize for the population while also personalizing for the individual.

Here’s why it’s important. Our nation’s demographics are changing. By 2043, we will be a majority-minority nation. According to the National Institutes of Health (NIH), diverse populations are more likely than non-diverse to suffer chronic disease and premature death.

But it’s more complex than that. The data suggests a nuance that can’t be explained simply by putting people in boxes without taking into account their individuality. For example, according to the NIH, Hispanic immigrants have better health outcomes than whites – an advantage that diminishes with time spent in the United States. Also, according to the NIH, within the Hispanic ethnic group there is variation in health outcomes based on country of origin.

Childhood trauma also plays a role, and that’s something that transcends all diversity boxes. Watch this TED Talk to hear pediatrician Dr. Nadine Burke Harris (appointed to the brand new post of surgeon general for the state of California) explain how childhood stressors like abuse, neglect and high levels of trauma affect brain development and multiply the risk of heart disease and cancer later in life.

Our broad population descriptors – Hispanic, African-American, Asian-Pacific Islanders, Caucasian – certainly offer insights into our health that must be considered and planned for, but they only take us so far.

Chronic diseases are the leading causes of death and disability in America, and they are also a leading driver of healthcare costs. It’s critical that we understand what’s going on at the population level and also at the individual level. The dominoes start to topple fast if we don’t find ways to make healthcare inclusive to all individuals.

The key to building a culture of inclusion in the age of personalization is making sure healthcare organizations have systems and methods that make inclusion the de facto reality throughout an enterprise. Once again, the leaders I spoke with are passionate about the topic and realistic about the challenges.

Homelessness ‘is the challenge of our time.’

An important factor in determining whether a healthcare organization is ready for the age of personalization with a structure designed for inclusion, is whether or not the organization has strategies, processes or partnerships in place to help it identify and resolve health disparities and inequities in their communities.

Mark Laret, president and CEO of UCSF Health in San Francisco, discussed the topic of health equity in the last article. Here he expands on that.

“When we talk about diversity and inclusion, we also include the very close sibling health equity,” said Laret. “Today as I was driving, I saw a homeless camp bigger than anything I had ever seen. This is the challenge of our time. We run UCSF Health, and a part of UCSF Health is the Benioff Children's hospital in Oakland. It’s a safety net hospital for the poor-support kids. We're taking care of homeless kids.”

Laret is the one who pointed me to Dr. Burke Harris and her work helping people understand the health effects of adverse childhood experiences (ACE).

As Laret put it: “So when you think about homeless kids, or any kids who have experienced these adverse childhood events like witnessing domestic violence at home, abuse from parents, witnessed very dramatic violence, murders and shootings and so forth – each one of these events takes a huge toll. This is why I feel this so passionately. I see these kids and they've got health issues, but the health issues in some ways are the dependent variable, and the causes are all these other issues.”

This discussion is well-timed. The Robert Wood Johnson Foundation’s 2019 County Health Rankings found a correlation between housing cost burden and health: counties where a higher percentage of households struggle with housing costs also show higher rates of food insecurity, more child poverty, and more people in fair or poor health.

“The goal in the end is not to be the hospital with the biggest balance sheet or the strongest bottom line or the highest ranking or any of that,” said Laret. “It's our job to be the leaders in making sure that everyone in our community is being cared for and that we're addressing this issue of health equity. Equity not only for people of color, but for the whole diversity of individuals – the personalization that you talk about. But especially helping those who are homeless or have mental illness or other [challenges]. If we do that, then we can solve big problems.”

Laret thinks big, and I like that.

“Not to over-state it, but I've often thought and said that if you took a few of the major healthcare enterprises in California, you could put us all together and we could take on the healthcare issues of rural California – and we could do a much better job of caring for all California, if that were our charge,” said Laret. “Our business model and the incentive structure is still a competitive model, and as such we end up optimizing our individual performance and we leave many others by the side who really need help. So I'm hoping that over time we start to have a higher consciousness about what our responsibility is to our fellow humans on this ride here with us, and how we can do a better job if we act collectively to help them.”

Laret references a topic I talk about a lot. By helping the populations that are more vulnerable, we help everyone.

Not just in the holistic sense: if you’re healthier, I’m healthier. But also in a systemic sense: the process of thinking through how to welcome a particular subset of individuals into the organization (as employees, patients or customers) is a process that will serve you well no matter whom you are trying to welcome. The strategies can be different from each other. But the systemic way of thinking through the process is what can be replicated – standardized, even.

That’s why I continue to say this every chance I get: building the skill of inclusion among leaders and throughout an enterprise is not a cost. It’s an investment. Inclusion is one of the last remaining true growth opportunities.

Not just IN the community, but OF the community.

Lloyd Dean, formerly president and CEO of Dignity Health and now CEO of CommonSpirit Health, is another passionate, community-minded pursuer of health equity.

“We know there's a connection between social inequities and health inequities; that is indisputable,” said Dean. “So this issue [that you have raised] of looking at the holistic person is something that I think is absolutely critical for us to be able to effectively serve communities, to engage with patients, and to be able to attract and retain a diverse and dynamic workforce.”

I like that Dean tied workforce into the discussion of population health. The issue of workforce inclusion is such a critical one, and the way Dean described it shows how all of these subjects overlap in so many ways – physical health and economic health, individual health and population heath, family health and community health.

“Unfortunately in our journey in this country, minorities have not been at the forefront of our clinical diversity and our abilities to segment out within the communities,” said Dean. “And because of the lack of resources and investments in the communities and the whole dynamic around equality in employment, our families became the primary caregiver.”

This is something I see in my organization’s research and have experienced in my life, and I shared this example with Dean. I'm of Hispanic descent, my parents are Cuban. When I was born my father was 50 years old. We lost my dad about six years ago, and I learned a lot while tending to him as he was battling Alzheimer's. A lot of people don't know that diverse populations are often the primary caregivers for family members. In fact, we're the largest non-paid caregiver community in the United States.

It’s so common, in fact, that Dean had his own similar story: “My father had a tragic accident and my mother took on the responsibility and the accountability once he was discharged from the hospital. And the option was to put him in a home, but culturally, in African-American communities and many diverse communities, it is the family that steps up. And this was just an unbelievable burden that was put on my mother, but it was culturally embedded and there was not consideration to put my father in a home. And she ended up taking care of my father 24 hours a day.”

This brings me to another one of the questions I ask when assessing an organization’s readiness for inclusion in the age of personalization: do you have strategies in place to help better understand the factors that influence the health and wellness choices made by a particular demographic you serve? That is a starting point for helping people take the next step of asking patients questions about their individual lives and habits when it comes to health. If we assume that someone will seek care in the same way that we do, we may miss an opportunity to deliver care in a way that would actually be received.

As Dean put it: “We don't look at it that we are hiring employees, we are hiring people. We don't look at it that we are treating patients, we are treating people. And in order to do that effectively, we know that people will listen to, people will connect with, people will relate to people who understand them culturally, who understand their language, who are familiar with the environment.”

According to Dean, patients are moving from the hospitals to other access points in the communities to seek care. So it’s important to him and the organization to be able to make those referrals and to integrate with and tap into the services of the community. When he was CEO of Dignity Health they established a community grant program, “because we don't want to just be in a community, we have to be OF the community. We're proud of the fact that we focus on partnerships with others in the community.”

That’s exactly why another factor when assessing an organization’s readiness for the age of personalization is this: Do you have active partnerships with civic, faith-based, non-profit or other community groups that are tackling disease-prevention by addressing related factors like poverty, food insecurity, lack of public space, and others?

Dean gave an example that echoes the priorities mentioned by UCSF’s Laret: “What's one of the biggest challenges for minorities and for those who are financially challenged in the communities that we serve? Affordable housing. So that's why we are fully engaged and make large contributions and work with others on housing. My philosophy: it is impossible long-term to be healthy if one does not have a home.”

“We cannot fulfill our mission to deliver equitable, fair, quality care to those that we serve and all of the communities that we serve if we don't have a diverse workforce, if we don't have an inclusive leadership team, and if our employees don't feel that they're connected in the community,” said Dean. “This is a part of my soul because I grew up, like yourself, in communities that didn't have any health services. I come from a large family and we just didn't have access to care. So I know what it can do to a community. I know what it can do to a family. I know how it can shorten lives. And we can do better than this in this country, that's for sure.”

Learning about populations, then applying and sharing that knowledge.

One way to engage populations is to create a space where people can interact, share, learn, ask questions – where people can connect with experts and with each other. An online community like Healthy Hispanic Living is one example.

Another way is for health organizations to be deliberate about how they work with populations of people in their catchment areas.

To assess a health system’s readiness for inclusion, I ask questions to see if there are systems in place to make sure people within the organization know which aspects of health tend to vary by culture, gender or demographic. But I go further than that, because knowledge itself is not enough. We have to have systems for applying that knowledge and for sharing that knowledge throughout the enterprise. Otherwise it just gets stuck in a silo and probably forgotten.

One of the questions I ask is: can you think of an example of when you (or someone within the organization) learned something about how a particular population takes action to prevent disease (or doesn’t take action), and then applied that lesson to the way you promote prevention or deliver care?

I spoke with Nancy Davidson, MD, executive director and president of Seattle Cancer Care Alliance. She agreed that inclusion in this age of personalization is not only good for the business model, but it’s the right thing to do for patients.

“Cancer affects one out of two men and one out of three women in this country,” said Dr. Davidson. “It is a pervasive problem, and in some ways it's only going to get worse because, of course, one of the most important risk factors for cancer is aging. And you and I know that we are facing a maturing population in the United States and around the world, and so this is something that we take very seriously. This is our job to provide the best possible care for individuals with cancer and hopefully to provide the best possible screening and prevention to minimize the burden of cancer.”

She said in the Puget Sound and in the state of Washington they serve a diverse population that includes people who are Hispanic, Alaska natives, American Indian, African-American, Asian and Caucasian.

“We're focused on what it takes to provide the appropriate care for those individuals, both from a cultural perspective and also because cancers vary between those populations,” said Dr. Davidson. “We want to make sure that we understand the individuals we're working with, the illnesses that might affect them, and the way that we can try to effect the best possible care for them.”

For example, she said that individuals who are American Indian don't necessarily enjoy the best possible outcomes from cancer treatment, so her team is focused on that. Seattle Cancer Care Alliance had the opportunity to partner with the Snoqualmie tribe.

“They are concerned about the health of their tribal members and members of other tribes across the state as well,” said Dr. Davidson. “And they focused on what is a huge scourge for anybody who's interested in healthcare, and that's the burden that tobacco places on human health. They have partnered with us and provided an unrestricted gift to allow us to really focus on their tribal population and on the way that we can try to advance tobacco cessation policies for their tribal members, and also to try to facilitate lung cancer early detection.”

She said what they’re learning helps them serve other populations as well.

“So I look at that as a really fantastic partnership between a group in our region who have looked at a problem that they think affects their population and actually probably affects all of our native American populations in this area,” said Dr. Davidson. “They have thought about how they can partner with us as a top flight cancer center to enable appropriate medical interventions for their population, and that's going to be good for everybody everywhere. Anything we learn about how to help people quit smoking in any cultural manner is going to be incredibly important, not only for cancer – but remember that tobacco is the primary risk factor for cardiovascular disease, for pulmonary disease, for so many things.”

Not only are they learning how to better serve specific individuals, but they are also making that knowledge accessible in order to better serve all individuals. I have found that to be one of the biggest benefits of inclusion – the benefits translate to all of us.

And, once again, clinical inclusion, community inclusion and workplace inclusion overlap – as she said they are looking to hire a member of the tribe.

“We are working with tribal leaders and tribal members, to think about the best way to advance this program,” she said, “and, as part of this, we're actually hoping to be able to hire a member of their tribe who's trained and interested to be able to serve as a navigator between the tribal population and our health system and the cancer center.”

For more examples of this kind of inclusion, I turned to Keck Medicine of USC, which serves a wide diversity of populations throughout Southern California and even extending into Central California.

According to Tom Jackiewicz, CEO of Keck Medicine of USC, staying abreast of the changing demographics in Los Angeles certainly is part of the organization’s growth strategy. He said they adjust services and programs to reflect the shifts in Los Angeles and among the diverse patient population.

“Our recent ambulatory location expansions illustrate how we tailor services for certain demographic pockets and offer services in their native language,” said Jackiewicz. “For example, we have an oncology practice in Koreatown with primarily Korean speaking patients, staffed with Korean oncologists that are bilingual and bicultural. Los Angeles has the largest Korean population outside of the Korean peninsula and many utilize our hospitals and Korean cancer service, which is unique in the nation. Additionally, our Arcadia location in the San Gabriel Valley draws from a heavily populated Chinese community and thus our staff and physicians providing care are fluent in Mandarin and Cantonese.”

In addition to formal cultural sensitivity training for staff, he said they try to provide the most thoughtful interactions for patients on all levels.

“Some of our patients from our Koreatown location had to undergo treatments [in a different neighborhood] at our main USC Norris Comprehensive Cancer Center due to renovations,” he said. “Our patient experience department provided bus transportation to/from with Korean television programming to make these patients feel at ease.”

Keck Medicine of USC also considers the diversity and differences among rural and urban populations.

“We are the number one transfer hospital in Southern California for tertiary and quaternary care,” said Jackiewicz. “We have affiliations and processes in place with community hospitals and primary care providers in far-reaching locations in Kern, Inyo and Tulare Counties to increase access and ensure those transfers and referrals are handled in a coordinated and seamless manner.”

‘We live this job, we don’t do this job.’

Many hospitals or health systems have programs and initiatives specifically designated for Community Benefit. I put that in capital letters because it’s an official requirement for non-profit hospitals or health systems. They are offered tax exemptions on the basis that they provide a benefit to the community.

But in an age of personalization, a commitment to Community Benefit must go beyond the organization’s legal obligations. In fact, it should be so embedded in the ethos of an organization that it becomes a lowercase “of course we do this” activity.

Cleveland Clinic CEO Dr. Tom Mihaljevic lives this principle: “Our motto in everything that we do is pretty simple. We approach every issue in contemporary healthcare from a simple standpoint, and that is that we treat our patients and our caregivers as our family, and our organization as our home.”

He also said they know that the answers to the questions about how to appropriately serve our patients cannot just come from caregivers. “Those answers have to come from the steady and continuous conversation with our communities and the patients we serve,” he said.

But I wondered – how do you infuse this attitude throughout the organizational culture, to such a degree that you can replicate that culture in locations around the world? Cleveland Clinic is based in the United States but also has locations in three other countries. Dr. Mihaljevic previously served as CEO of Cleveland Clinic Abu Dhabi.

“You know, we live this job, we don't do this job,” he said. “So, this is nothing less than a true calling for us. We hire people who share the same sentiment. Then, we put a lot of effort into teaching the culture. We're teaching about our values. We're teaching about the way that we solve conflict. We're sharing with them how decisions are being made in the organization. That is a process that takes a long time. In Abu Dhabi, where we have people from all over the world, we spend almost an entire week speaking only about [this organizational] culture, so that people who come from all over the world, who never set foot in Cleveland, Ohio, can begin to understand what Cleveland Clinic is all about.”

Another aspect of the organization’s culture that makes Cleveland Clinic stand apart, according to Dr. Mihaljevic, is the salary model. He explained that Cleveland Clinic is a nonprofit organization in which caregivers are salaried, and a team structure of care provision has been part of the culture for the past 100 years. Caregivers are on one-year contracts – they do not have tenure. This team-based, salaried model focused around the patient's needs has been strongly embedded in the culture of the organization since its inception in 1921.

"The founders wanted to remove any obstacles in providing the best possible care for our patients,” said Dr. Mihaljevic. “They did not want to confuse the incentives of a provider with the needs of a patient. They wanted to make sure that those are absolutely aligned.”

Again, he went back to the motto: “We treat our patients and our caregivers as our family, and our organization as our home. That is a deep ethos that runs deep in the organization.”

We both share a conviction that the culture of an organization is the key to its success. As he put it: “One can put all kinds of propositions, strategies, payment measures out there. But the ability to execute on them is going to be critically dependent on the culture and the organizational framework of large healthcare providers. Probably the most inspirational part of my tenure [in Abu Dhabi] was the realization that Cleveland Clinic values can be taught, and they are warmly embraced by every culture. It's completely agnostic to geographic, ethnic, or religious [differences].”

Restoring trust.

To achieve population health in the age of personalization requires inclusion. We can’t convince populations of people that we care about them if we’re not also able to show care at an individual level – and if we don’t recognize how clinical inclusion, community inclusion and workplace inclusion are all interdependent upon each other.

In the opening article I mentioned that several leaders acknowledged the challenge of earning trust within communities of people who historically have not felt welcomed into the healthcare system – often for valid reasons.

We have to change that. We can’t help people live healthy lives if we don’t have their trust.

Innovation won’t save us without inclusion.

We are in a new age – getting more and more diverse, and more and more individualized. The standardization of the past doesn’t work anymore.  As medical innovations advance beyond what we ever could have imagined, if we’re not getting those advancements to the people who need them – as more of our population needs them even more – we risk being the most medically innovative yet unhealthy nation in history.

In Part 5, I will explore the clinical implications in the age of personalization.