BHAGs for Aligning Incentives and Building a Learning System to Improve Total Population Health

ABSTRACT

Neither care delivery nor public health systems have grappled with widening disparities as life expectancy gaps increase in the US. Reimagining health care and public health requires aligned incentives including attention to vulnerable populations, financial incentives to improve total population health, effective deployment of community assets, and adoption of a continuous learning system. We argue that Big Hairy Audacious Goals—targets for a Health GDP (similar to the economy’s gross domestic product [GDP]), Life Expectancy, Safe and Sound Children, One Earth Policy, Social Spending, and Political Healing—can focus our attention and propel needed action.

Am J Manag Care. 2024;30(Spec. No. 13):SP1013-SP1023

The litany of US health challenges is well known. Neither care delivery nor public health systems have grappled adequately with widening disparities as life expectancy gaps increase in the US. Kindig asserts that “population health improvement will not be achieved until appropriate financial incentives are designed for this outcome.”¹ This article offers a population health perspective, using the definition of “health outcomes of a group of individuals, including the distribution of such outcomes within the group.”² For those defining public health as “the health of the public,” these definitions converge. However, much of US public health activity does not have such a broad mandate even in the “assurance” functions, “since major determinants such as medical care, education, and income remain outside of traditional governmental public health authority and responsibility.”²

Why have we struggled to improve total population health and equity? As a nation, we do not have a system to pay for population health performance.³ Our nation is dominated by a biomedical model of disease embodied in our resource-rich health care system that focuses almost exclusively on individuals and their diseases to the neglect of the more important social and environmental determinants.⁴ The US health care system is incentivized and rewarded to treat disease symptoms rather than root causes and prevention. Public health embraces the comprehensive multifactorial model of health, but that has not translated into sufficient funding or an expanded mandate for an already overburdened system. Without bolder goals, aligned incentives, and learning systems, we have scant chance of success.

Big Hairy Audacious Goals for Total Population Health

Big Hairy Audacious Goal (BHAG) is a concept developed by Collins and Porras as a powerful way to stimulate progress.⁵ A BHAG is easily understood and compelling and motivates short- and long-term change. A famous, albeit dated, BHAG is President John F. Kennedy’s proclamation in 1961 “that this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the Moon and returning him safely to the Earth.”

Without BHAGs (also called moonshots), health care, public health, and population health do not have the urgency or memorable umbrella. BHAGs can change the mental model, compel action and learning, and unite stakeholders to achieve visionary purposes. To reimagine the health of the public, BHAGs can form a powerful strategy (eg, doing multisector work, lobbying policy makers, or making an elevator-speech funding appeal). BHAGs need not include full details; Kennedy did not know the specifics of putting a man on the Moon, but his speech galvanized attention, action, funding, and learning to accomplish that goal. Others have used BHAGs to spur their work, such as RedBalloon, a gift experience provider in Australia⁶; Possible, a nonprofit international health care organization using BHAGs and objectives/key results in Nepal⁷; and Canadian health care proposals for innovation capacity and clinical entrepreneurship.⁸

We used a Delphi method to derive 6 ambitious BHAGs for total population health (Table).^9-13 A group of 5 population health experts individually developed candidates. At an initial meeting, they collated and discussed these; at a second, they selected the final set, which was modified during publication submission and editorial review. A “meta-BHAG” on political healing is discussed in our conclusion as a pathway to create progress on the others.

Health GDP: GDP Without Health Is Gross

How would we answer a president or governor inquiring about the state of total population health? We argue that a summary measure of Health GDP (similar to the economy’s gross domestic product [GDP]) should be developed to guide policy makers as they strive to improve our national and community health. Attempts began in the 1970s with measures combining mortality and other metrics. The generic idea was the quality-adjusted life-year, with specific adaptations such as the EuroQol and disability-adjusted life years in Europe and years of healthy life (YHL) used by the CDC’s National Center for Health Statistics.¹⁴ There also has been an attempt to broaden the concept beyond health with the well-being–adjusted life-year.¹⁵ Although these ideas have received scholarly attention, they have not achieved widespread adoption for a variety of reasons, both quantitative and value based. Although the optimal balance of health outcome drivers is conceptually empirical, the components comprising such a summary are value-based choices for populations of interest. Disparities are so important from a policy and equity perspective that their inclusion requires dedicated attention. The Population Health Performance Index¹⁶ combines infant mortality and unhealthy days with disparities at the state level, allowing user choice of the balance, but does not combine mortality and nonmortality components. We recommend that a federal agency undertake the development of a practical Health GDP for accountability and tracking of population health improvement. The measure could also be used to develop targets for medical and nonmedical health influencers to facilitate appropriate investments by policy makers.¹⁷

Life Expectancy: Life—Your Most Valuable Asset

Because life expectancy in the US compared with that in other Organisation for Economic Co-operation and Development countries is so abysmal and has fallen even further due to the COVID-19 pandemic,¹⁸ we have included a life expectancy BHAG. The causes of death vary by race and ethnicity (eAppendix Table 1 [eAppendix available at ajmc.com])¹⁹ as well as by upstream and downstream determinants—a conceptual framework contained in the 2021 National Academies of Sciences, Engineering, and Medicine (NASEM) report High and Rising Mortality Rates Among Working-Age Adults (eAppendix Figure).²⁰ Causes for alarm in the US are the relentless rise in overdose deaths and the lag in decreasing major causes of death in rural areas. We do not emphasize behavioral factors such as tobacco, alcohol-related health harms, et cetera, but cigarette smoking remains the leading cause of preventable death, disease, and disability in the US,²¹ and physical inactivity contributes to 1 in 10 premature deaths.²²

Safe and Sound Children: Children = Future

America’s demographics are changing; by 2060, approximately two-thirds of children will be of a race or ethnicity other than non-Hispanic White.²³ Black and Hispanic children have higher rates of adverse childhood experiences (ACEs) than non-Hispanic White or Asian children.²⁴ ACEs are preventable, potentially traumatic events that occur during the ages of 0 to 17 years, such as child abuse and neglect; violence in the home or community; being in a household with substance misuse or mental health issues; or instability because of parental separation, divorce, or household member incarceration. Although not an exhaustive list—other events include economic hardship, racism, and bullying—these examples highlight experiences that can threaten a child’s “sense of safety, stability, and bonding.”²⁵ ACEs often cluster, can result in “toxic stress,” and are associated with low education and earnings potential, substance use, suicide, obesity, and chronic diseases. ACEs are listed in Healthy People 2030 as a summary developmental measure, indicating significant health implications as well as evidence-based interventions.²⁶ The National Survey of Children’s Health includes many ACEs, and surveying appears well received by participants.²⁷ Given that nearly 1 in 6 adults in a 25-state survey reported 4 or more ACEs,²⁸ it is imperative to include a BHAG of decreasing ACEs and disparities for the health of future generations.

Climate Change and Health: One Earth Policy

Global climate change threatens humankind’s very existence. Drought, severe storms, heat waves, and the mass extinction of species stem from human hubris and careless actions. Our long-term survival depends on mitigating climate change.²⁹ We need concerted individual, local, state, national, and international action. Many interventions are underway, including stopping ecosystem destruction, adopting sustainable agricultural practices, reducing meat consumption, building compact cities and designing them for efficient heating and cooling, radically reducing fossil fuel consumption, transitioning to an economy that does not require growing consumption, limiting population growth, expanding wetland protections, decreasing air travel, and accelerating renewable energy production. Incentives to achieve each of these interventions have been or can be implemented.³⁰ Mitigating climate change will improve our health, but the health care system also needs to contribute to the solution by committing to greener strategies, such as using solar panels and geothermal energy on hospital campuses or switching to light-emitting diode lights, et cetera. Many hospitals are working to decrease their carbon footprints and become net carbon zero by 2050.

Spending on Health and Well-Being, Not Only Health Care: Social Drivers Take the Wheel

The US spends too much on health care and not nearly enough on health, well-being, and public/population health.³¹ Although striking the right balance can be difficult, we need to progress toward value-based care, health care cost control, global budgeting, and higher spending on social determinants of health (SDOH). Social spending boosts health outcomes and well-being, and although there are methodological issues, such as benefit accounting and endogeneity, there is likewise substantial evidence of the value of social spending on health impacts.³² Countries with higher social spending enjoy better health outcomes, and governmental activity appears to have especially large positive impacts. A testament to SDOH importance is the new U.S. Playbook to Address Social Determinants of Health, which “lays out an initial set of structural actions federal agencies are undertaking to break down these silos and to support equitable health outcomes by improving the social circumstances of individuals and communities.”³³

Aligning Incentives

What incentive alignments are required to achieve progress? McGinnis, in reviewing the Mobilizing Action Toward Community Health initiative, summarized important elements.³⁴ We propose 6 aligned incentives for population health in targeted actors, measures, types of incentives, sectors, and other dimensions (eAppendix Tables 2 and 3).

Incentives in Health Care

For metrics and as targeted actors, geographic regions are optimal settings for health care incentives. For example, the state of Maryland collaborated with CMS on its Total Cost of Care Model, which includes incentives for the population health measures of reducing body mass index and overdose mortality.³⁵ Pennsylvania, using global budgeting, aims to decrease rural health disparities and deaths from substance use disorder. CMS has announced it will build on these, plus the Vermont All-Payer Accountable Care Organization Model, with a new model for 8 states (or substate regions) that started in 2024, with goals of decreasing health care cost growth and improving population health and health equity. This Advancing All-Payer Health Equity Approaches and Development model lasts for 11 years, affording time for incentives to improve outcomes.³⁶

Other Incentives

What are other incentives besides health care payment reform or health care dollar reallocation?³⁷ Possibilities include the following:

• Hospital community health and well-being (CHWB) reform
• Foundations and philanthropic initiatives
• A compelling business case made to private-sector companies³⁸

Leaders question the transparency of CHWB programs and whether nonprofit hospitals’ community activities warrant their tax preferences.³⁹ Requiring hospitals to conduct community health needs assessments (including a measure of life-years lost) and report not only their own investments but also those that their health improvement initiatives leverage can accelerate growth of multisector collaboratives. It may fulfill the aims of the BHAGs, especially the Health GDP.

The federal government can devise financial incentives to align agencies to strengthen the vital conditions necessary for improving individual, community, and state well-being. Children’s health–oriented philanthropies can augment this work by investing in upstream drivers of health, such as by selecting Healthy People 2030 objectives pertaining to children and devising incentives to improve those evidence-based measures.

The Nature Conservancy, the world’s leading conservation organization, has created the Blue Bonds for Ocean Conservation model, which represents an “innovative approach to work with governments on refinancing a portion of their sovereign debt, securing long-term sustainable financing for large-scale protection and management of valuable natural resources that lives and livelihoods rely on.”⁴⁰ In the US, the Inflation Reduction Act of 2022 contains the most consequential incentives ever to fight global climate change via promoting electric vehicles, renewable energy production, and other initiatives.⁴¹ There is an unprecedented investment boom underway from both the private and public sectors.⁴²

Businesses could support improving childhood reading by third grade, math proficiency, and high school graduation rates to decrease disparities and create a more productive workforce. Joining forces with other businesses to support educational systems provides a reputational incentive. In a United Kingdom study that compared financial and reputational incentives for physicians to improve quality of care, researchers concluded that reputational incentives (once benchmarks are established) can be equally as effective as financial ones, may be longer lived, and could save money because no payments are required after the initial investments (other than dollars for ongoing reporting).⁴³ These physician incentives could be tested for improving total population health.

Learning Systems

Once BHAGs are established (eg, in regional strategic planning) and incentives are aligned, how do stakeholders engage and learn collaboratively to achieve the goals? The National Academy of Medicine lists the characteristics of a Continuous Learning Healthcare System (CLHS): engaged, empowered public and patients; science and informatics (real-time access to knowledge, digital capture of care); patient-clinician partnerships; incentives (aligned for value, full transparency); and culture (leadership-instilled learning, supportive system competencies).⁴⁴ This CLHS focuses on the health care delivery system, which has a vital role, but it should not be the center for improving total population health (ie, the danger of the medicalization of population health).⁴⁵ The mechanism/centers should be multisectoral organizations or collaborations in areas willing to advance population health. Models must build on partnerships including nonmedical influencers such as education; the environment; and food, housing, and economic security for vulnerable families and individuals. To evolve the SDOH framework to a “more useful guide for creating measurable systems change,” ReThink Health created the Vital Conditions framework to work with partners to understand the conditions needed for transformative change: mental models, power dynamics, relationships and connections, policies, practices, and resource flows.⁴⁶ The steward partners join to explore regional goals, build an interdependent portfolio, and align their work for equitable change.

Ideally, the federal government and private entities will create data systems for tracking and learning from results across populations to spur innovators. On the public side, an extraordinary development is the Trusted Exchange Framework and Common Agreement (TEFCA),⁴⁷ which increases nationwide interoperability. HHS Secretary Xavier Becerra noted in a news release, “TEFCA allows patients, providers, public health professionals, health insurers, and other health care stakeholders to safely and securely share information critical to the health of our country and all of our people.”⁴⁷ From the private side, there is progress on closed-loop referral systems and social-return-on-investment analyses.⁴⁸ Although we are awash in health care–oriented data systems, we believe that the research for the Health GDP BHAG will identify improved metrics to monitor total population health and take advantage of data already collected by health plans.

Looking to the Future

We desperately need a population health moonshot—BHAGs that stimulate imagination, create urgency, focus our attention, and align short- and long-term incentives. They should be joint endeavors of the public and private sectors to inflect the US health trajectory upward. Despite the enormous challenges, we strongly believe in developing BHAGs and building on recent initiatives. But what about our politics?

Meta-BHAG: Political Healing

Perhaps the greatest challenges to improving health and equity are the polarization and fragmentation of our civic and political dialogues. We propose the meta-BHAG of repairing our politics so that meaningful dialogue and action are met with constructive conversations about tradeoffs and alternative strategies rather than eye rolls and polarizing mischaracterization. Relevant initiatives can take many forms, such as empowering voters, generating an expectation of national service, creating community conversations for building trust, and strengthening civic ties for engagement.⁴⁹ One organization leading the way is Braver Angels, the nation’s largest cross-partisan, volunteer-led movement to bridge the partisan divide. Another nonprofit that encourages empowerment is Vot-ER, a nonpartisan organization that works to integrate voter registration into health care for a healthier democracy. According to a speaker at a 2023 NASEM Symposium, framing preventable early deaths as 16 million lost birthdays may help Americans see that “these are our grandparents, our children, our aunts and uncles, [and] our neighbors who are not able to live their most fulfilled life because of that health disadvantage.”⁵⁰ The power of such nonpartisan narratives can be leveraged to effect policy change. Absent sustained efforts on this meta-BHAG, it will be difficult to galvanize the collective action that setting BHAGs in the population health domain will spark.

Did we select the ideal BHAGs? Likely not. Splitters (those favoring more specific BHAGs) and lumpers (those favoring fewer BHAGs) should take aim at our list. Some might argue that only the Meta, Health GDP, or Climate BHAG matters, but a longer list has the advantage of bringing more armamentaria to this battle, increasing the odds of success. We did not address BHAGs related to individual behavioral changes, such as tobacco or alcohol use, other than within life expectancy. Many of these are already covered under objectives in Healthy People 2030. We did not include an artificial intelligence (AI) BHAG, although that topic is ubiquitous currently. Who at this juncture understands exactly how AI will impact population health?

The quintessence of BHAGs is “think big, aim high.” We are not alone in our thinking: New York City has set an ambitious longevity goal,⁵¹ innovations to address SDOH abound,⁵² and the new Advanced Research Projects Agency for Health has launched its Health Care Rewards to Achieve Improved Outcomes solicitation.⁵³ The US unquestionably has the resources to do big things. As Kennedy said, “We choose to go to the Moon in this decade and do the other things, not because they are easy, but because they are hard.”⁵⁴

Acknowledgments

The authors especially thank David Kindig, Steven Teutsch, and Marc Gourevitch for significant contributions to earlier drafts. The authors also benefited substantially from the comments of anonymous reviewers. They also thank Elliott Fisher, Alina Baciu, Lauren Taylor, and the members of the National Academies of Sciences, Engineering, and Medicine’s Health Care Expenditure Collaborative for helpful suggestions.

Author Affiliations: Independent health policy and economics consultant (PH-C), Ann Arbor, MI; HealthPartners Institute (SJM), Bloomington, MN.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (PH-C, SJM); acquisition of data (PH-C, SJM); analysis and interpretation of data (PH-C, SJM); drafting of the manuscript (PH-C, SJM); critical revision of the manuscript for important intellectual content (PH-C, SJM); and administrative, technical, or logistic support (PH-C, SJM).

Send Correspondence to: Paul Hughes-Cromwick, MA, CBE, 4450 Boulder Pond Dr, Ann Arbor, MI 48108. Email: phughescromwick@gmail.com.

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