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The pace of progress in population health can be influenced by the incentives in play and the metrics that trigger them. The MATCH (Mobilizing Action Toward Community Health) articles in this issue of Preventing Chronic Disease explore the use of incentives to improve population health and hold implications for the development and application of the measures to which they are linked. Metrics in population health can serve to draw and focus attention, encourage action, and direct rewards and penalties. When those rewards and penalties take on an economic dimension, the results can be powerful.
This potential application of population health measures is especially important if the aim is to transform the allocation of social energy and resources, as it clearly must be. Currently, our national health investment profile is deeply flawed — more than 95% of every health dollar goes to treatment rather than prevention. In a system in which all our salient incentives are structured to reward volume over value, we miss virtually no opportunity to treat disease, often unsuccessfully or erroneously.
On the other hand, each day we miss countless opportunities to prevent disease and promote health. If we seek to reform health care payment systems to yield better health returns, investment in prevention has to move to the highest — not lowest — priority. If our aim is to fashion the health equivalent of indicators that shape our economic policies, the most rational social investment strategy would center around prevention and our health care payment system would follow suit.
A reformed health care payment system can advance health as the fundamental priority in 3 ways. First, every American should receive coverage for the clinical preventive services that are appropriate to him or her without copayment. Second, grant support should be set aside for community-based initiatives that are necessary to improve the health and health care of the community's residents. Finally, resources to address the overall health care needs of a population should be shaped by a blend of the community's health needs and efforts, as reflected by metrics that indicate trends for determinants of the population's health status.
The articles in this issue present a number of perspectives relevant to considering how incentives might work for population health improvement. Described below are common elements and how we might think about using incentives.
Haveman introduces the economist's perspective of the concept, structure, and function of incentives — financial and nonfinancial — including examples from education, jobs, and health (1). Mullahy reviews the conceptual challenges in transferring insights from targeting incentives for personal health services to possible effects on population health, including issues related to accounting for the production function for population health and the roles of multiple sectors (2). Rothschild shows the relevance of social marketing as a factor in improving population health (3).
Witte looks at performance metrics and rewards in education as a reference point for population health (4). Baxter identifies incentive options if no new resources are available, for example, using existing but unenforced requirements (such as those related to the nutritional content of school meals), using the purchasing power of government or emphasizing "cobenefits" (such as taxes on tobacco that offer disincentives and raise revenues) (5). Asch assesses the applicability of paying for performance in health care to population health (6).
Fox looks at the nature and evolving results of "triple aim" efforts, with emphasis on health care, population health, and cost reduction, including how a "value dividend" might most effectively be characterized (7). Oliver describes the potential incentives inherent in population health rankings such as MATCH, including how to link them to key uses such as identifying problems, setting agendas, and changing community policies (8). Smith reviews the European experience with setting heath targets, noting, for example, the challenges in setting the targets (which ones, outcomes vs process, how to quantify, cross-sector responsibilities) and in translating some of the key population health aims to the local level (9).
Each of the articles is rich with examples of economic incentives, such as the use of graduate medical education payments by Medicare to teaching hospitals (1). Many of the examples, however, can have unintended consequences:
While the authors of these MATCH articles approached their assignments differently, they touch on common elements that should be considered in assessing the intended impact of incentives:
Incentives, explicit or implicit, are inherent in metrics. Even independent of economic components, the mere establishment and monitoring of targets can impact reputation, recognition, and the inclination or disinclination toward alliances and can alter behavior. Because consequences, intended and unintended, can be both real and severe, care is needed in the choice of incentives. In effect, a certain hierarchy of consideration should be operative in their choice:
This hierarchy of uses varies by circumstance. For example, punishment could be higher on the list in the case of egregious potential public threat, for example, the potential release of a populationwide health contaminant. Nonetheless, the hierarchy frames important starting considerations.
Our understanding of how metrics and their incentives can enlighten, motivate, change, and advance population health will continue to mature. Addressing the challenges elucidated in the MATCH articles in this issue of Preventing Chronic Disease could refocus the resources available in the United States to improve population health.
This manuscript was developed as part of the Mobilizing Action Toward Community Health (MATCH) project funded by the Robert Wood Johnson Foundation.
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Suggested citation for this article: McGinnis JM. Observations on incentives to improve population health. Prev Chronic Dis 2010;7(5) http://www.cdc.gov/pcd/issues/2010/sep/10_0078.htm. Accessed [date].
J. Michael McGinnis, Institute of Medicine. 500 Fifth St NW, Washington, DC 20001, Phone: 202-334-3963, Email: ude.san@sinnigcm.