7: No. 6, November 2010
Stephen M. Shortell, PhD, MPH
Suggested citation for this article: Shortell
SM. Challenges and opportunities for population health partnerships. Prev
Chronic Dis 2010;7(6):A114.
http://www.cdc.gov/pcd/issues/2010/nov/10_0110.htm. Accessed [date].
The Mobilizing Action Toward Community Health (MATCH) articles in this issue
of Preventing Chronic Disease discuss ideas, policies, and practices that can
be used to produce a healthier population in the United States and globally. The articles pose the following
questions: 1) How do we best measure long-term wellness at the population level?,
2) How do we provide incentives to organizations to accomplish better population
health?, and 3) How can effective cross-sector partnerships be formed and
implemented to help accomplish the task?
The articles in this issue have done a good job, for the most part, of
summarizing what we know or at least what we think we know about successful
partnerships. They highlight the many challenges of forming cross-sector
partnerships, given the different goals, objectives, and cultures of potential
partners. They also provide ideas and evidence for overcoming some of these
challenges; the importance of leadership, governance, measurement and
accountability, focus, and trust are all emphasized. What these discussions lack
is consideration of the interrelated practices and behaviors that may prove
useful, given widely varying community contexts — geographic, political,
economic, and social. Some examples of what is missing that I suggest as a basis
for further discussion include the following:
- Partnerships need to be both internally and externally aligned.
Partners should achieve domain consensus among themselves with
sufficient overlap of goals and should understand what is expected
of the partnership by external groups.
- The partnership should gain legitimacy and credibility within the
community. Drawing on the developing literature on social capital would
improve this process (1).
- Partnerships can gain legitimacy by understanding their centrality
in the political economy of the community. Social network concepts
involving direct and indirect ties, the strength of ties, network
density, and structural holes are relevant.
- Every partner has a core competence and comparative advantage.
Partnerships can fail because individual members either overestimate or
underestimate their comparative advantage and misdiagnose their core
- Leadership should be explored more fully: the kind of leadership
needed, the kind of partnership that can deliver it, and the stage of
the partnership’s life cycle that is best suited for it. The role of
individual leadership versus organizational leadership should be
- Forming a partnership has a transaction cost. The literature on
transaction cost economics originally developed by Williamson may be
- The process of selecting partners, including tradeoffs and timing,
should be more fully explored.
- Population health improvement can be perceived as simply a resource
for organizations to advance their own agenda and cause.
In addition to pursuing these ideas, we may take the following actions to
improve population health. First, we may consider the Healthy People 2020
objectives, which will depart from the past by emphasizing the underlying
environmental and social determinants of health. They may provide a stimulus and
framework for considering population health improvement.
Second, we should consider population health improvement in the context of
health care delivery system reform. The article by Hester, for example,
highlights the developing Vermont experience with accountable care organizations
(ACOs) (4). These entities are accountable for the cost and
quality of care provided to a given population of patients; they can be linked
to population health improvement objectives by expanding the chronic care model
to recognize community contributions to health. A promising approach is to
recognize the patient-centered medical home (PCMH) model of primary care
delivery as the foundation for ACOs (5). Payment reforms could achieve positive
health outcomes by using the framework of ACOs and PCMHs. For example, one
approach would be to provide bundled or capitated payments to public health departments that would in turn
work with ACOs and PCMHs to provide cost-effective care to defined populations.
Third is the concept of community health management systems (CHMS) that would
be organized along the lines of local security and exchange commissions as
quasi-administrative, publicly accountable bodies (6). The CHMS may be a
partnership or coalition of the local health department; community
organizations; ACOs made up of local hospitals, physician practices, and other
provider entities; and related health care providers. CHMS would have 3
functions: 1) assess and prioritize the health needs of the population from a
multisectoral approach; 2) organize the community’s assets, resources, and
competencies to deliver the needed services; and 3) be held clinically and
fiscally accountable for the health outcomes produced. They would deliver an
annual report to relevant political bodies in the community. The success of the
CHMS and related concepts depends on the availability of relevant
population-based metrics for health outcomes and on payment incentives that
encourage integration of the multiple sectors involved in producing population
Incorporating these suggestions could advance our understanding of effective
cross-sector population health partnerships. Expansion of the knowledge base
will help to promote the spread of such partnerships across the country. National health care reform
legislation provides additional impetus and opportunities for such achievement
because it emphasizes ACOs and PCMHs by providing financial incentives for their
development and increases funding for health promotion
and wellness programs.
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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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Stephen M. Shortell, PhD, MPH, School of
Public Health, University of California, Berkeley, 50 University Hall, Berkeley,
CA 94720. Telephone: 510-643-5346. E-mail:
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- Macinko JA, Starfield B.
The utility of social capital in research
on health determinants. Milbank Mem Fund Q 2001;79(3):387-427.
- Shortell SM, Zukoski AP, Alexander JA, Bazzoli GJ, Conrad DA,
Hasnain-Wynia R, et al.
Evaluating partnerships for community health
improvement: tracking the footprints. J Health Polit Policy Law
- Williamson OE. The economics of organization: the transaction cost
approach. Am J Sociol 1981;87:548-77.
- Hester J. Designing Vermont’s pay-for-population health system. Prev
Chron Dis 2010;7(6).
- Rittenhouse DR, Shortell SM.
The patient-centered medical home: will
it stand the test of health reform? JAMA
- Shortell SM, Gillies RR, Anderson DA. Remaking health care in
America. 2nd edition. San Francisco (CA): Jossey Bass; 2000. p. 247-98.
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