Accountability to Population Health in the COVID-19 Pandemic: Designing Health Care Delivery Within a Social Responsibility Framework.

Abstract

Population Health ManagementVol. 24, No. 1 Points of ViewFree AccessAccountability to Population Health in the COVID-19 Pandemic: Designing Health Care Delivery Within a Social Responsibility FrameworkChristina M. Cutter, Christopher Nelson, and Mahshid AbirChristina M. CutterAddress correspondence to: Christina M. Cutter, MD, MSc, MS, National Clinician Scholars Program, Institute for Healthcare Policy & Innovation, Department of Veterans Affairs and University of Michigan, 2800 Plymouth Road, NCRC Building 14, Suite G100-36, Ann Arbor, MI 48109, USA E-mail Address: cutterc@med.umich.eduNational Clinician Scholars Program, Institute for Healthcare Policy & Innovation, Department of Veterans Affairs and University of Michigan, Ann Arbor, Michigan, USA.VA Ann Arbor Healthcare System, Department of Veterans Affairs, Ann Arbor, Michigan, USA.Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.Search for more papers by this author, Christopher NelsonRAND Health Care, RAND Corporation, Santa Monica, California, USA.Pardee RAND Graduate School, RAND Corporation, Santa Monica, California, USA.Search for more papers by this author, and Mahshid AbirDepartment of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.RAND Health Care, RAND Corporation, Santa Monica, California, USA.Search for more papers by this authorPublished Online:2 Feb 2021https://doi.org/10.1089/pop.2020.0096AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail In the United States, hospitals and health systems frequently function within silos and operate at or near capacity. During the coronavirus (COVID-19) pandemic, this paradigm of fragmented care delivery has proven problematic because individual hospital and health system resources can be quickly overwhelmed by a surge in health care demand.1 The continued acute response and planning for the post-acute phase of this pandemic will require reconceptualizing health systems design and health care delivery within a social responsibility framework that manifests an ethical obligation for accountability to population health—the distribution of health determinants and outcomes across a community.2 The preliminary experience with COVID-19 has revealed that regional coordination of health care resources and capacity must go beyond individual hospital and health system silos. The social responsibility principles of equitable organizational governance, consumer safeguards, community engagement, and transparency should guide strategies to optimize population health when adapting the acute response and planning for the post-acute phase of the COVID-19 pandemic.Cognitive Surge Strategies for Equitable Organizational GovernanceVariations in access to health care in the United States are well documented. Rural, critical access, independent, and community hospitals can lack access to certain health care resources (eg, intensive care units) and provider capital (eg, physicians trained in critical care). Many hospitals and health systems possess important tools to extend expertise to support the capabilities of these less-resourced systems. In response to the COVID-19 pandemic, there has been a quantum change in transitioning to virtual health care delivery to create surge capacity, decentralize care delivery, and protect vulnerable patients and staff.3 There is great potential to leverage these telemedicine platforms for electronic intensive care unit monitoring programs as well as specialty consultation to support hospitals in remote or underserved communities as a novel “cognitive surge strategy.” This would adapt current response strategies to enhance regional health care capacity consistent with crisis standards of care to overcome geographic constraints and support less-resourced health care settings to operate at their highest capability. In the post-acute phase, these strategies align hospital and health system capabilities with population health needs to address a different surge—pent up health care demand resulting from deferred medical and surgical care. These “cognitive surge strategies” could decompress overburdened sites through decentralization and further optimize population health in the post-acute pandemic phase.Protect Less-Resourced Health Care Settings with Consumer SafeguardsConsumer safeguards should align free market mechanisms with the resource needs of a rapidly evolving pandemic response. The acute phase of the pandemic has revealed that resource-constrained environments are disadvantaged by a relative lack of purchasing power when compared to larger health systems. Some under-resourced settings have suffered disproportionately from prohibitive pricing because of free market forces when purchasing needed resources that exceed their standard supply chain. This creates a double-deprivation scenario in which these settings have fewer resources and less capacity at baseline, but then are also limited in their ability to respond to a surge in health care demand. Local and federal policies should correct these market failures so equitable access to necessary resources can be achieved in the continued fight against COVID-19. When one hospital or health system suffers from resource and supply chain shortages, the spillover of adverse health consequences (eg, increased disease spread), health care provider absenteeism, and consequent capacity constraints can be significant for surrounding communities, hospitals, and health systems. Social responsibility demands advocating for fair operating and consumer practices to maximize regional health care capacity, protect health care providers, and optimize population health. This also will be imperative in the post-acute phase to support the financial viability of under-resourced settings. These hospitals and health systems frequently function on narrow operating margins that have been threatened by operations changes,4 such as canceling higher margin services like elective surgeries and procedures, in the pandemic response. Without policies and financial relief, these settings may have to close their doors, which could exacerbate disparities in access to care across the United States and adversely impact population health.Community-Based Resources to Supplement Health Care CapacityThe COVID-19 pandemic has demonstrated the need for regional systems and community partnerships to support efficient and coordinated use of health care resources and delivery of care when health care demand surpasses the capabilities of individual hospitals and health systems. Pandemic response should leverage existing multisector coalitions such as health care coalitions, which include hospitals, emergency medical services, public health, emergency management, and other partners. Unprecedented demands during the COVID-19 pandemic require community engagement5 and public–private partnerships to transcend traditional health care and emergency management domains. Partnerships with real estate, community stakeholders, as well as university leaders help to identify alternate sites amenable for quarantining those experiencing housing insecurity as well as patients with lower acuity health care needs. These strategies decompress hospital-based care to meet higher acuity demands while also providing a safety net and curbing the impact of social determinants on the spread of disease. To achieve needed hospital capacity during the continued response as well as to meet the surge of pent up health care demand in the months ahead, embracing this whole-of-community approach to optimize resource allocation for those with continued post-acute care needs will be imperative.6 Conceptualizing health care resources and delivery within a regional and whole-of-community approach rather than an individual hospital or health system context is essential to meet the current and post-acute demands of the COVID-19 pandemic.Transparency of Regional Health System CapacityHospitals and health systems actively developed preparedness and surge plans based on the harrowing experiences of other countries. Designing and implementing such plans within the confines of the walls of a hospital or health system, however, can result in a maldistribution of patients and health care resources with suboptimal population health outcomes. COVID-19 has highlighted the need for regionalization of health care capacity to maximize resources during a pandemic. Capacity information should be shared transparently with an organizing, administrative body unaffiliated with a hospital or health system so that true capacity at the local, regional, or state level can be known for a community. Some communities have such command center mechanisms in place; however, many do not. This discrepancy has the potential to exacerbate existing disparities in health outcomes and access to care. Without transparency, regional resources may not be fully leveraged and patients may not be optimally distributed, resulting in unnecessary rationing decisions, wasted resources, overburdened hospitals, and unintended loss of life.7 Social responsibility requires transparency to drive a comprehensive understanding of health care capacity in the context of a community—rather than just a hospital or health system—to optimize regional health care delivery and population health during a pandemic. In the post-acute phase of the COVID-19 pandemic, this regional awareness of capabilities and capacity will be equally important. It can inform essential strategies to accommodate deferred demand for medical and surgical care with the objectives to optimize population health and health care value through transcending silos, embracing decentralization, and adopting geographic dispersion8 of care delivery.ConclusionThe unprecedented stress test posed by COVID-19 requires reconceptualizing health systems design and health care delivery away from fragmented solutions of individual hospitals and health systems. An effective adaptive response to the acute and post-acute needs of the COVID-19 pandemic requires deliberate integration of key components of social responsibility frameworks. This approach exemplifies the necessary accountability to population health demanded by the COVID-19 pandemic and may contribute to the “new normal” of health care delivery.Author Disclosure StatementThe authors declare that there are no conflicts of interest.Funding InformationDr. Cutter receives funding from the US Department of Veterans Affairs Office of Academic Affiliations for her position in the National Clinician Scholars Program. Dr. Abir receives funding from Michigan Medicine for a health care delivery redesign initiative led by her Acute Care Research Unit at the Institute for Healthcare Policy & Innovation. Dr. Abir is also supported by the National Heart, Lung, and Blood Institute R01HL137964.