Ethical Concerns in an Era of Population Health: A Challenge of Identity for Tomorrow's Hospitals

Abstract

Background: After focusing on episodic, clinical encounters, U.S. health care is beginning to acknowledge the need for population-level, preventive health strategies. Largely driven by new regulatory measures, new payment programs, and greater appreciation for the social determinants of health, this shift aims to reduce per capita cost and improve population health. In addition to the financial, clinical, and operational challenges, population health strategies raise new ethical questions.

Methods: This study used an exploratory sequential mixed methods design. Qualitative data were based on interviews (n=38) with supervisors of Community Benefit or population health management at nonprofit hospitals across the country, recruited through chain referral and stratified sampling methods. The interviews solicited information on organizational structures, community engagement, and ethical concerns in population health work. Ten focus groups in five cities with hospital employees and community partners (n=43) provided examples of ethical concerns in hospital-community collaboration and helped define the characteristics of community health projects for a conjoint analysis. Interviews and focus groups were analyzed with open coding text analysis. Quantitative data were generated from an online survey completed by a convenience sample of hospital employees (n=225) and leaders of nonprofit community organizations (n=136). The survey included a discrete choice experiment, which asked respondents to choose between funding one of two community health initiatives based on the characteristics of those projects. The characteristics of projects were: priority from community need assessment; time until measureable impact; kind of community partnership; type of intervention; evidence of intervention effectiveness; and target population. Discrete choice results were estimated with an effects coded, conditional logit model. The survey included questions on how often respondents have faced certain ethical dilemmas. Sensitivity analyses and latent class analysis were conducted to determine differences between respondent subgroups.

Results: Interviews revealed a complex process for Community Benefit and also provided evidence that those in the field do not readily frame population health work in ethical terms. After being prompted, most interviewees gave examples of ethical challenges, and survey respondents indicated they regularly experience ethical dilemmas. The interviews also provided information to map the many challenges nonprofit hospitals face as they allocate limited resources for community health initiatives, including how to best involve community members in the process. The discrete choice experiment showed strong agreement between hospital employees and community members as to what kind of community health initiatives are most important to fund. Projects were more likely to be selected if they included a top priority from the community health needs assessment, were supported by a coalition of community partners, and there was some evidence of intervention effectiveness. Latent class analysis revealed four respondent subgroups who differed on project priorities but who did not differ by demographic characteristics.

Discussion: As we enter an era of population health, hospitals must grapple with their changing identity in the community. They are no longer just experts in clinical care; they must also contribute to population-level, preventive strategies. The study identifies several implications for both policy and practice, such as the need to include investment in social determinants of health as part of the Community Benefit portfolio and the need to build educational infrastructure for population health ethics. Rather than using existing ethical principles, this study proposes virtue ethics and a new concept called structures of virtue as resources for evaluating ethical challenges in population health.