![]() Both primary care and referral surgeries are market based and patients can determine their own willingness to travel for care. Primary Care Service Areas were developed in the mid-1990’s as a part of a contract by the Health Resources and Services Administration to understand utilization patterns for primary care. The Dartmouth Atlas 24 has led efforts to describe the relationship between geography and health, but Hospital Service Areas and Hospital Referral Regions were created from Medicare hospitalization records more than 20 years ago based on where patients received cardiovascular and neurologic surgeries. This is due in part to the absence of a geographic unit that accurately captures healthcare utilization for unplanned critical illness 11, 13, 23. To date, however, no regional performance benchmarking or incentive to improve “total population health” for ECSC exists. Regionalization of care improves clinical outcomes for ECSC 19– 22 through the use of strategic emergency medical services (EMS) design, inter-facility transfer agreements, and the designation of specialty centers (e.g. Optimizing outcomes for emergency care sensitive conditions (ECSC) 14 such as trauma, stroke, ST-segment elevation myocardial infarction (STEMI), cardiac arrest, and sepsis requires an inclusive systems-based approach that aligns incentives across multiple components of the healthcare delivery system 15– 18. Patients with unplanned critical illness and injury are inherently linked to hospitals by geography rather than by health system network affiliations due to the time-sensitive nature of care 6– 13. ![]() The IOM perspective offers an opportunity to measure outcomes differently, and critical illnesses and injuries that require a regional response represent a compelling use case for this approach. The Institute of Medicine (IOM), however, noted that “Although the healthcare delivery system is increasingly focused on population health, the committee found that focus reflects a relatively narrow interpretation of the term – populations as the patient panel or group of covered lives” and instead recommended that the more inclusive term total population health be used to refer to “the health of all people living in a geographic area” 5. ![]() The dominant framework for defining population health focuses on patient panels (Accountable Care Organizations, Patient Centered Medical Homes), or the payer’s perspective of covered lives 1– 4.
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