Background
Demographic and social changes such as an aging population, increasing multi-morbidity and technological developments, and the changing needs that society places on care and support, require far-reaching adjustments to the way in which care and support are offered [
1‐
4]. At the same time, financial stringencies are increasing and available workforces are limited. As a result, transformative approaches such as Population Health Management (PHM) are becoming widespread in health policy and in practice [
5,
6].
PHM is a proactive approach in which initiatives use data and risk stratification as the starting point to investigate variation in health outcomes [
5,
7,
8]. This approach allows for sharing of insights across organisations and sectors, and for a better understanding of what is happening in communities, i.e. where needs are unmet, or where people are most at risk of negative health outcomes now and in the future [
4‐
9]. These insights enable PHM initiatives to collaboratively look for solutions, and subsequently implement, evaluate and refine corresponding interventions. PHM initiatives play a significant role in the movement to improve population health and quality of care, while at the same time reducing cost growth as well as promoting well-being and reducing health inequalities across an entire population (nowadays called the quintuple aims) [
4,
5,
10‐
12]. They recognize that to implement large-scale transformations, a wide range of organisations have to work together and explore which strategies will not only strengthen connections and integrate services across public health, health care, social care and community services, but also transform how health care is delivered in order to address the full range of health determinants and build more healthy communities [
5,
10‐
13].
PHM has been more and more embraced in policy and practice in many countries such as the Dutch ‘PHM pioneer sites’ and the implementation of the national policy program ‘The right care at the right place’ in the Netherlands [
5,
13]. In England, the National Health Service Long Term Plan [
14] which has led to PHM Integrated Care Systems, has recently been updated in the call-to-action for a PHM approach as a response against COVID-19 [
15]. Another example is the implementation of a PHM approach towards secondary prevention in patients with atherosclerotic cardiovascular disease (ASCVD), involving the collaboration between the UK Government, the National Health Service, the Academic Health Science Network and Novartis UK [
16]. Although a PHM approach targeting ASCVD patients has not (yet) been implemented in Belgium, malignant tumors and ASCVD are the main causes of mortality in Belgium, accounting together for more than half of all deaths in both sexes [
17]. The conglomerate of ASCVD risk factors (which is also a common soil for chronic kidney disease, tumours, lung disease and other chronic diseases), and resulting ASCVD remain a public health issue.
The literature proposes a number of principles, building blocks, and key activities that underpin PHM. It is advocated that the development of a PHM approach is guided by principles that create commitment between stakeholders, attain understanding of respective values and roles, set conditions for accountability, gain political support for PHM, introduce financial incentives that sustain the quintuple aims, promote a permanent improvement cycle supported by a data and knowledge infrastructure, ensure community engagement and stakeholder representation [
5,
18]. When setting up an interdisciplinary collaboration around PHM, infrastructural building blocks need to be put in place that relate to social forces, resources and technologies, finance, relations, regulations, market, leadership, accountability, and community engagement [
5,
11]. Finally, a PHM approach requires the following key activities: (a) population identification; (b) triple aim assessment; (c) risk stratification and intervention selection; (d) citizen-centered interventions; (e) quintuple aim impact evaluation; and (f) a quality improvement process [
5,
6,
8,
19].
Despite policy measures of the Belgian government to move from a supply-based to a needs-based approach [
20,
21], the implementation of PHM in Belgium is still in its infancy [
22]. Therefore, the aim of this study is to raise awareness about PHM in Belgium by eliciting barriers and recommendations for its implementation as perceived by local stakeholders. These barriers and recommendations are then exemplified in the context of a case study focusing on secondary prevention in patients with ASCVD. Finally, a roadmap is provided with next steps to roll out PHM in Belgium. Although this study focuses on Belgium, barriers and recommendations may be applicable to the implementation of PHM in other countries.
Methods
Study design
Two virtual focus group discussions were held between October and December 2021 to gather insights into barriers and recommendations for the implementation of PHM in Belgium. The methodology of focus group discussion allows for interaction between participants given that the opinion of a participant can be put forward and be challenged by others [
23]. The moderator (SS) drew on this interaction to find a common ground between diverse stakeholders.
Sampling
Eleven high-level decision makers in medicine, policy and science were purposefully selected to participate in both focus group discussions. As indicated in Table
1, most participants had multiple professional backgrounds and were primary or secondary care physicians, worked for physician professional associations or a health insurance fund, and were academics with an interest in PHM or health system architecture. The purposive sampling method [
24] was chosen with a view to enroll representatives of the diverse stakeholders likely to be involved in the initiation of PHM in Belgium or individuals who have PHM expertise. Both participants from the Flemish-speaking and French-speaking parts of Belgium were enrolled.
Table 1
Professional background of focus group participants
1 | | | | X |
2 | X | | X | |
3 | X | | X | |
4 | X | X | X | |
5 | | X | | |
6 | | X | X | |
7 | X | X | X | |
8 | X | X | X | |
9 | X | X | X | |
10 | X | X | X | |
11 | X | X | | |
Focus group guide
A semi-structured guide was used to anchor the discussions and to ensure that all different aspects which can influence PHM development, were included [
5,
6,
8,
11,
18,
19]. This guide was based on a literature review examining the current state of the art with respect to PHM, and was specifically informed by guiding principles, building blocks, and key activities that give insight into the underlying barriers and recommendations for the development, implementation and evaluation of a PHM approach (see Introduction).
Focus group sessions
The focus group sessions were designed to take place sequentially with the second session building on the first session as explained below. In the first focus group session, the literature review was presented to participants by a PHM expert (BS). This was followed by a discussion of barriers and recommendations of PHM development in Belgium, based on insights written down by each participant in a MIRO board (i.e. an online collaborative whiteboard). Overall insights which emerged from this first focus group session, were validated by all participants during a second session following some final changes and additions.
Secondary prevention of ASCVD was chosen as a case for PHM development in the second focus group session. This is because ASCVD is a public health issue and a disruptive access model such as PHM which aims to prevent, treat, and support adherence in ASCVD patients, could reduce heart attacks and strokes. Also, ASCVD patients are a well-defined, substantial and relatively homogeneous population, which makes it easier to identify in databases and to reach consensus on PHM development among health care providers. Although we acknowledge that PHM is geared at the general population, this case study in ASCVD patients may serve as a proof-of-concept and the resulting experience could subsequently be applied to a broader population.
With a view to prepare a discussion on the case study, three high-level decision makers (BS, BV, ER) with expertise in PHM, primary and secondary ASCVD care, respectively, identified barriers and recommendations regarding the six key activities [
8] that make up the PHM program focusing on secondary prevention in ASCVD patients. In the second focus group session, two break-out groups discussed the practical development of a PHM program focusing on secondary prevention in patients with ASCVD, after which these results were discussed among all focus group participants.
Data analysis
With permission of all participants, both focus group sessions were recorded and responses were transcribed
ad verbatim. An inductive thematic analysis (by BS) was carried out of these qualitative data, involving the subsequent steps of data familiarization, development and review of themes, mapping and interpretation by theme, and selection of appropriate quotes [
25]. All focus group participants validated the results of the data analysis.
Discussion
This study has explored the current main barriers and recommendations for PHM development in Belgium as voiced by high-level decision makers in medicine, policy and science. The identification of these barriers and recommendations should act as a call-to-action for federal authorities, federated entities and local authorities as well as for providers and other stakeholders (including patients/citizens) to work towards a learning health system that delivers health and wellbeing. Building on the barriers and recommendations formulated by the sampled high-level decision makers, a roadmap is presented below involving multiple steps to implement PHM in Belgium.
Encourage a sense of urgency to speed up PHM development
It is expected that health care spending will double in Belgium by 2040 and even if finances would allow for it, the manpower to provide the right care and support is lacking [
20]. The recent crisis regarding the COVID-19 pandemic has strained the health care system even further [
27]. In response to this, the federal authorities, federated entities and local authorities have not been sufficiently able to build on a sense of urgency as a driver for change towards a sustainable health and wellbeing system. This is why a call-to-action in Belgium alike these in other countries such as the Netherlands [
5] and England [
15] is needed at all levels to speed up PHM development.
Develop a learning health system embedded in a learning environment supported by a data and knowledge infrastructure
The different levels of government together with all stakeholders need to enforce a learning health system embedded in an evidence-based learning environment that connects the national, regional and individual levels in order to stimulate PHM development by bringing the actual needs to the surface and tackling systemic problems [
5,
28‐
30]. In Flanders, the recently created primary care zones (similar to what is generally known as ‘district health systems’ [
31]) may be particularly well suited to advance PHM. Primary care zones plan and coordinate health care and welfare for around 100,000 inhabitants and are expectedto make an assessment of their region by the summer of 2022 in order to identify the ‘needs’ of the population, on the basis of which a policy plan should be drawn up for the following years [
32‐
34]. Tools such as visual dashboards can support this exercise [
12].
However, financial investments, knowledge and time are necessary to speed up the development of a learning environment in addition to a data and knowledge infrastructure that contributes to a population-oriented improvement cycle and accountability across organisations and sectors [
5]. Such ICT infrastructure and knowledge management can draw on data sources that are already in place in the Belgian health care system such as electronic health records and mandatory electronic prescriptions of medicines [
26]. In addition to quantitative data, the data and knowledge infrastructure should also be able to capture qualitative data about for example contextual, social and cultural issues based on a deep understanding of the local community.
Recently, an initiative to bring data suppliers and stakeholders together was launched in Belgium with a view to setting up an accessible and regional data and knowledge infrastructure. This mirrors practices in other countries. In the United States, the Centres of Medicare and Medicaid together with a network of scientific institutions and practice leaders support PHM initiatives with regard to data and technological problems amongst other things [
35]. In PHM initiatives, such as Generation Health and Gesundes Kinzigtal, investments in a learning environment including a data and knowledge infrastructure were done by private companies which served as conveners for the initiative [
5,
30].
Furthermore, the question can be raised who should take the lead in the further development of a learning environment. PHM initiatives could make agreements on issues such as privacy, indicators, and interdependence and governance of the data and knowledge infrastructure. These initiatives could also make agreements with regard to which stakeholder is going to control this infrastructure as well as about possible investments from the private sectors. It is our opinion that some of these issues, such as the right indicators and data-sharing in relation to the privacy law, need to be addressed at the national level with the involvement of the Belgian government, the federal public service of Health, Food Chain Safety and Environment, and knowledge institutions.
Reduce uncertainties to enable investments in new payment models and set up new pilots
There are still many questions about new forms of payment, such as bundled payment or a population-based payment [
5,
36]. With regard to a population-based payment for instance, a future scenario might be that new legal entities, also described as integrators, are willing to take full responsibility for the financial risks of total health care costs of a regional population [
36]. However, there is no decisive answer yet as to whether a population-based payment model actually will provide the social value it is intended to deliver [
5]. An alternative that does not require adjustments of the current way of payment is adding value-driven incentives that benefit the health of the population, the so-called mixed payment model [
37]. Until now, little is known regarding which novel form of payment is best for which situation, and numerous strategies can be used. Therefore, we recommend that the national government reduces uncertainties such as information asymmetry that hinder the development of new payment models, and sets up new payment model pilots in addition to encouraging knowledge development and sharing of information about these new payment models.
Start from a joint population-oriented vision
If a sense of urgency for PHM development is lacking in practice, a step-by-step approach based on what is already achieved in a region is important [
5,
38]. In addition, further investments in preconditions are necessary such as the right regional leadership of the PHM initiative which will stimulate joint support of regional stakeholders for the initiative based on a shared population-oriented vision [
5,
38]. For PHM initiatives whose initiators are primarily from the care sector, it is important not to start an initiative with a broad regional plan or based on payment reforms without such preconditions, as initiators might risk loosing their investments without gaining enough paybacks [
5,
38]. As a result, support for the PHM initiative could decrease.
Enforce collaborative relationships and joint responsibility, including the regional population
Collaborative ownership and responsibility are needed from all stakeholder groups, as progress in PHM cannot be achieved by any one sector or organisation alone [
4,
5,
35,
39,
40]. In addition to stakeholders within health and social care, a multi-sectoral perspective is required with input from patients/citizens [
41] and wider public services such as education and businesses, financiers, knowledge institutions and regional and national governments. This serves to build up trust and to enter into new collaborative networks that are based on developing health and wellbeing for the population and a learning health system [
4,
5]. An example of such a network approach in Belgium is the integrated care (including social care) initiatives which manage chronic patients in a geographical area [
21,
42].
Establish and take an active part in a regional community of practice and put complex problems on the agenda at the federal and regional level
The development of PHM is complex and therefore takes time to evolve, as it requires investments from a diversity of regional stakeholder organizations across health and social care and community services, as well as involvement of patients/citizens [
5,
18,
41]. It is important to be in continuous dialogue within communities of practice, and to hold each other accountable in the interest of the population. In addition, developing and exchanging knowledge between regions as well as between the national and regional governance level is important to address complex problems that go along with PHM development and to put these on the agenda [
5].
This study is subject to limitations. Our results originate from only two focus group discussions involving 11 participants. However, we were able to recruit key high-level decision makers who have experience with PHM or who are likely to be involved in shaping PHM in Belgium in the future. Also, we feel that the discussions addressed the major guiding principles, building blocks, and key activities that shed light on the underlying barriers and recommendations for PHM in the Belgian context.
Conclusions
It is clear that Belgium still has a long way to go towards PHM. Interaction between medicine, policy and science, and interaction between federal and regional levels are pivotal for the stimulation of PHM. Next steps should focus on developing a joint population-oriented vision, cultivating shared responsibility for the health of the population, encouraging collaborative relationships (at and between all levels) to gather and analyse data, building a learning health system supported by an environment and infrastructure that facilitate knowledge development and data sharing, experimenting with new policies and payment models, and installing regional PHM initiatives with a focus on patient and population needs.
Acknowledgements
We would like to convey our appreciation to the participants in the focus group sessions. Their experience, knowledge and insights in health care, PHM and ASCVD have been invaluable and contributed to the development of this manuscript. The authors would also like to thank Novartis, specifically Michel Geelhand, Silke Vermaerke and Jean-Michel Luyckx for their support in facilitating the focus group sessions.
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