Dr Seth Berkowitz on Whole-Person Health Indexes, the "Wrong Pocket" Problem

There are many challenges when developing a single index to measure the effectiveness of whole-person health interventions. There is a need for a multidisciplinary approach that incorporates mixed methods and patient-reported outcomes to gain a more comprehensive understanding of health care delivery and financing, Seth Berkowitz, MD, MPH, associate professor of medicine, University of North Carolina at Chapel Hill, said.

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Can you elaborate on the concept of a whole-person health index and how it could be developed and utilized to measure the effectiveness of interventions aimed at supporting whole health?

This might be a bit of a nerdy answer. I think there's actually a sub question as to whether an index is possible, or whether you're talking about different components that can't really be combined. So, the idea of an index, to me at least, is that you've got various commensurate outcomes. You can put a couple of different ones together, maybe you weigh some more than others, but fundamentally, you can generate a single kind of score, number, or something to it. And then once you have that, you can either minimize it or maximize depending on whether you think it's a good thing or a bad thing. So, highest level of health or lowest level of disability, or something like that.

If things aren't commensurate though, then you can't necessarily put them all into a single index. And so, you instead have a couple of different outcomes. And then instead of minimizing or maximizing, you actually have to optimize over those. So, a combination of things that can't necessarily be traded off with each other. And I think one of the challenges of whole health is that it might be more like this kind of optimization problem, where you have a couple of different things that aren't exactly equivalent to each other or can't be weighted to make them equivalent. And so, what you're trying to do is pick patterns of different aspects of health that are important to look at. That's a challenging thing. But I think in some ways, it might better capture just sort of the nuance and the distinctiveness of the different aspects of health that whole health is trying to get at.

In addressing the "wrong pocket problem," what strategies do you recommend for effectively accounting for the value of interventions across different sectors?

This might be a bit of an unpopular answer, but the “wrong pocket problem” to me really speaks to the need for state or government involvement in these issues. I think, classically, we think of different sectors as being able to operate effectively when things are kind of self-contained, right? The resources they need to put in to produce an outcome are the outcomes that those resources then produce, are sort of all within the same sector. And when that doesn't happen, then the ability to organize the production of whatever you're trying to do, health services or something like that, by sector, kind of breaks down. And this, I think, has become sort of a justification for having state involvement, because the state is sort of the actor that can take this broader perspective and say, “Alright, resources put in one domain produce an outcome that's in a different domain, but because we're responsible for people's lives as a whole, then we can do this."

I fundamentally think a lot of the issues that are brought up by the “wrong pocket problem” become an argument for having the state be involved. To sort of give that more concretely, I do a lot of research on food insecurity. And so, a way that a “wrong pocket problem” might develop in that space is if an organization that is providing food insecurity interventions improves health, but then the benefits of that health improvement accumulate to a health care system that didn't have to expend as much on health. And so that creates the problem.

The solution might be that instead of having a private human services organization or something like that, you instead, focus more on state or government programs to alleviate food insecurity or prevent food insecurity from occurring in the first place, which might even be better. And then the state or government organization can sort of see the benefits of that in terms of an improvement in population health.