Improving Population Health

Reform vs. Transform

By Jonathan Fielding, MD, MPH, MA, MBA

Health insurance reform has been passed. Those of us who feel health care is a right can now see the path to get 95% of the population covered. The evidence is clear: health insurance reform can save lives. But what was missing in the rancorous debate over “health reform” was a sense of context. How important is health care compared with other factors that influence individual and collective health? Are we making investment decisions that flow from the answers to this question? The truth is that health care coverage expansion, albeit overdue and an essential social good, will have a relatively small effect on our relative position of 37th among the nations of the world in life expectancy.

If we want longer, healthier lives, lives with more years of independence and high functioning, we need to complement health insurance reform with more fundamental reform—a transformation of the health enterprise. Transformation requires answering the fundamental question: “What determines our individual and collective health?”

The studies provide a clear but surprising answer. The conditions in which we live, work, and play are the most important health influences. A high school graduate lives on average seven fewer years less than a college graduate. Smoking, other drug use, obesity, inadequate physical activity, and a diet too rich in processed foods are major contributors to our health and functioning—on balance, more important than whether we see a doctor for a routine physical. Medical care is important, and can be life prolonging—but it is only part of the opportunity to minimize most health problems.

This is not fresh news. But there is an almost total disconnect between the fight over “health reform” and what investment would provide the highest value in terms of quality and years of life along with reducing the gaping health disparities among different groups, defined by ethnicity, race, culture, and geography. What we need is a  nation that thinks differently about how we get to be healthy. We must view and act as if health is a necessary characteristic of populations, not just individuals. If we did, we would invest more heavily in evidence-based prevention—both for patients and communities. 

Thinking differently about what determines our health can be transformative. We will ask better questions of ourselves and of those who make policy, both public and private. Thinking differently could cause us to encourage our elected representatives to consider how policies in agriculture, transportation, housing, and social services can support health.

Does subsidization for growing corn, the source of the inexpensive high fructose corn syrup ubiquitously present in foods, improve our health? Does it make sense to have schools with the best local playgrounds declare them off limits to neighbors in their communities? Should almost all our investment in transportation be for roads and highways rather than mass transit and more bikeable, walkable communities? Why should medical care be tax advantaged while we pay after tax for fruits and vegetables or fitness clubs or smoking cessation classes?

The passage of health insurance reform has helped answer the nagging question of access to medical care. Now we have the opportunity—and the imperative—to ask the larger questions about how to improve our health. Shouldn’t the first question be, “If we want to invest cost-effectively to improve health for everyone in our country, what would we do differently—as a nation, as communities, and as individuals?”

Commissioner Jonathan Fielding, MD, MPH, MA, MBA serves as Director of Public Health and Health Officer for Los Angeles County, where he is responsible for the full range of public health activities for 10 million county residents.

Is Population Health Finally Coming into Its Own?

By David A. Kindig, MD, PhD

Why am I starting a blog on issues and perspectives in the field of population health?  It is because I believe we are at a "tipping point" in which a convergence of scholarship, policy, and practice initiatives seem poised to bring an overdue population health perspective to thinking about and acting on health and health improvement. The challenge of the next decade will be to find practical ways in which new approaches to financial and non-financial incentives and multi-sectoral partnerships can be applied to improve population health outcomes here and elsewhere.

Although the roots of broad population health thinking go back for centuries, in the United States, the second half of the 20th century was dominated by the rise of biomedical science and clinical medicine. Many in public and population health (how are these different?) have been critics of the dominance of health care emphasis and investment, but these advances have been critical and will continue to be so. The end of the century has seen additional growing understanding and support that such behaviors as tobacco use, diet, and exercise also make substantial contributions to the health of individuals and populations. My own population health epiphany came with my exposure in the early 1990s to the thinking of Bob Evans and Greg Stoddart and their population health "field model" from the Canadian Institutes of Advanced Research (1). At once simple and profound, it captured the basic population health principles:

• that health outcomes were more than the absence of disease;
• that these outcomes were produced by complex interactions of multiple determinants (health care, behaviors, genetics, the social environment, the physical environment); and
• that in a resource-limited world, the relative cost effectiveness of these determinants was critical for policymakers.

While this Canadian work has provided an important framework for international population health scholarship and policy development, the last 15 years in the U.S. have been dominated by such issues as health care access and costs and pressing immediate public health issues like emerging communicable diseases (e.g., HIV-AIDS and H1N1). Periodic activity and reports from government agencies and foundations have addressed parts of the broad issue of outcomes and determinants, but not in visible and sustainable ways. Notable exceptions have been (A) the Institute of Medicine (IOM) and Centers for Disease Control and Prevention’s (CDC) emphasis on a broad public health “system,” (B) the creation of the Robert Wood Johnson Foundation's (RWJF) Health and Society Scholars Program to grow a new generation of multidisciplinary scholars for this emerging field, (C) the RWJF Commission to Build a Healthier America, and (D) the WHO Europe’s 2003 report on the social determinants of health. (I will return in a future post to the challenge the social determinants of health pose for policymakers.) In 2010, however, this emerging field has still not matured in either scholarship or policy. However, the last several years have seen growing attention from a policy perspective. Here are some examples:

• Decades of work from the Dartmouth group demonstrated how communities that spend the most on health care may not have the highest quality or outcomes.
• The groundbreaking documentary Unnatural Causes provided wide exposure to the multiple determinants of health.
• The California Endowment is making a major long term investment in the broad health of 10 communities in California.
• The State of Minnesota has invested $43M in its State Health Improvement Plan to create "accountable health communities" that address obesity and tobacco through policy, systems, and environmental changes.
• The Institute for Health Improvement has endorsed population health improvement as one of the three legs of its Triple Aim strategy and is considering moving to a regional strategy
• CDC has funded a cooperative agreement with the National Business Coalition on Health to work with business-led health coalitions and the business sector on building the capacity of members to be leaders of health reform and advance value based health and health care.
• Concerns about obesity have underscored the complexity of addressing this critical issue (look for a future post on the tension between free will and the social context with regard to behavior choices).
• Obama administration officials have been discussing a “place-based” approach for social investments as well as a major Community Health Data Initiative.
• The National Quality Forum and the National Priorities Partnership are discussing the need for new broad measurement tools such as a national index of health.
• Our own Robert Wood Johnson Foundation MATCH project in February released the first ever National County Health Rankings of 3,014 counties in all 50 states according to a broad population health model that has been used in Wisconsin since 2003. 

When I published Purchasing Population Health: Paying for Results in 1996, this list of activities was much shorter. Now every day we learn of some new policy, practice, or research finding that is aimed at population health improvement. Keeping track of and commenting on these exciting developments is the purpose of this blog. We plan to post on a weekly basis, with content from our own team as well as guest posts from prominent policy and practice leaders.The University of Wisconsin Robert Wood Johnson Health and Society Scholars Program will each month identify several recently published papers that make important contributions to policy, practice, or scholarship. All posts will in some way relate to our underlying population health model, including key concepts of outcomes and factors.

My hope is for this blog to prompt lively and provocative dialogue--and even action--toward improving population health.I welcome comments on this first post and all contributions to follow. I look forward to hearing from you!

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Reference:

 1. Evans R. Stoddart G. (1990). Producing health, consuming health care. Social Science and Medicine, 31(12), 1347-63.

 

 

 

 

Dynamic Duo: Healthy Food and Jobs

By Kirstin Q. Siemering, DrPH, RD

According to PolicyLink, 23 million Americans living in low-income communities don’t have access to a supermarket. In round figures, this translates to the combined populations of New York, Los Angeles, Chicago, Houston, Philadelphia, Phoenix, San Antonio, and San Diego.

Without supermarkets, people tend to have limited options when it comes to feeding themselves and their families. The corner stores and fast food outlets that often predominate in low-income areas offer an abundance of relatively inexpensive foods that are high in calories and low in nutrients—but little if any fresh fruit, vegetables, and other nutritious staples. Not surprisingly, people living in these communities suffer disproportionately high rates of diet-related chronic—and preventable—diseases such as obesity and diabetes.

But this hasn’t always been the case. These “food deserts” have developed in response to various economic and social forces affecting demographic shifts over the past 30-40 years.

This transformation dates back to the 1970s and ’80s, when the landscape of food availability in densely populated, largely poor city centers began to shift. Grocery stores expanded their square footage, consolidated into chains, and many closed their urban doors, taking jobs with them as they headed to the suburbs to build bigger stores more cheaply and expand their profits by serving more affluent clients. Food deserts also have sprung up in rural areas over the last decades. Hanna, Wyoming (population 800) lost its only grocery store just months ago; the nearest grocery store is now 80 miles away.

So what to do?

There’s a movement afoot to turn things around, store by store, community by community. One example is the effort is being led by Pennsylvania’s Fresh Food Financing Initiative (FFFI). In only four years—and with just $30 million in state seed funding—this innovative program has brought 83 supermarkets to underserved areas throughout the state and created 5,000 local jobs for local residents.

The program works by providing gap financing to prospective grocers who would like to open or renovate stores in underserved areas but have special needs that can’t be met through conventional financing. For example, for his downtown Philadelphia Shop-Rite store, grocer Jeff Brown needed additional funds for training and security. Funding from the FFFI helped him put what was needed into place while keeping his prices reasonable. Brown’s now profitable store caters to the ethnic and cultural food preferences of his clientele, including a pork-free meat room for Muslim customers. 

The project brings together The Food Trust, The Reinvestment Fund, and the Greater Philadelphia Urban Affairs Coalition in a public-private partnership that has won national acclaim, including a Smart Growth Award from the Environmental Protection Agency and recognition from the Harvard Kennedy School of Government. Most recently, in his 2011 budget, President Obama has requested $400 million to create a national Food Financing Initiative.

With luck and favorable fiscal and political winds the national FFFI will become an important driving force to enhance the food and employment landscape in underserved communities across the country.

Kirstin Siemering DrPH, RD is a researcher with the University of Wisconsin Population Health Institute.

Resources for Population Health Improvement: What About the Savings from Waste in Health Care?

By David A. Kindig, MD, PhD

The release of the national County Health Rankings demonstrates how large the gaps are across our communities in both health outcomes and the factors producing health. Particularly in the lowest ranking counties in any state, there are significant resource constraints in all the factors producing health. These include health care access, disease prevention and health promotion programs and policies, early childhood and health literacy efforts, jobs and economic development, air and water quality, and the built environment. Where might the resources come from to make improvements toward better health—particularly for our most under-resourced communities?

One place to look is at the waste in our health care system. For years organizations as prominent as the Institute of Medicine have been observing that 25% to 33% of all of our health care expenditures may be wasted because they are ineffective in improving health. Dr. Elliott Fisher and colleagues at Dartmouth have been calling attention to the approximately threefold regional variation in per capita Medicare expenditures from $5300 to $16,300 without differences in health care quality and health outcomes (1). They have also recently observed inflation adjusted Medicare growth rates varying from 2.3% in Atlanta and Pittsburg to 5.3% in Dallas over the period 1992-2006. The Dartmouth group indicates that reducing the spending rate from the national average of 3.5% to the 2.3% experienced by San Francisco would save Medicare $1.3 trillion by 2023.

Looking at it another way, total health expenditures in 2009 were projected to be $2.5 trillion. If 25% of that could be saved, that would amount to $625 billion per year. Providing health insurance to everyone would require an estimated $100 billion per year. That would leave more than $500 billion for smoking cessation, exercise and nutrition efforts, education enhancements, job creation, and creating safer communities. To put this in context, total national expenditures in 2005-2006 for all K-12 education in the entire country was $461 billion.

However, achieving these savings is challenging. Republicans and Democrats alike are skeptical that cost-containing provisions of the Obama Health Insurance Reform law will be strong enough to reduce expenditures substantially. Even in places that have low health expenditures and good outcomes, cultures of cost effective practice have been developing for decades; they cannot develop overnight. A current proposal is to develop Accountable Care Organizations, in which financial incentives would be provided for developing efficient practices. Discussions have begun around the concept of shared savings, in which savings are divided between the providers who produce them and insurers. Vermont has already been using savings to hire staff for community clinical prevention while leaders in Minnesota have raised the possibility of using part of the savings to create Accountable Health Communities.

These are only initial ideas and beginning steps; vast resources will be necessary to fully implement the plans described above. Dan Fox, a careful observer of American health politics, has observed that policymakers “most likely would ration spending to improve overall population health in order to avoid rationing health care…there is no reason to expect that a value dividend, if one accrues, would be used for any other purposes than slowing the growth of spending or providing more access to health care (2).” Bentley similarly observes that “as a society we may prefer to provide care to the sickest, most vulnerable patients even though our money could buy greater improvements in life span or quality of life if used for another purpose (3).”

While common sense suggests a systemic streamlining that involves exchange of ineffective resources for those shown to be most (or at least more) effective, political realities are not necessarily rooted in common sense. Paul Starr’s book The Social Transformation of American Medicine sums up 150 years of medical history by saying that “the dream of reason did not take power into account.”

We must hope that approaches to shared savings in health care develop more robustly and gain traction. But they are not the only hope. We have to look for other inefficiencies as well. Governments, philanthropies, and businesses will have to make additional resources available. Promising current examples include the California Endowment's Building Healthy Communities initiative and the Minnesota's State Health Improvement Plan (SHIP).

In summary, waste and inefficiency in our health care system are one potential source for investing in the broader determinants of health. A fundamental population health challenge is to identify incentive structures and cross-sectoral allocation models to bring such possibilities into policy and practice.

A future post will expand on these ideas and examine additional sources of funding for fundamental population health improvement.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

References:

1. Fisher ES, Bynum JP, Skinner JS. (2009). Slowing the growth of health care costs—lessons from regional variation. The New England Journal of Medicine, 360(9), 849-852.

2. Fox DM. (2010). Realizing and allocating savings from improving health care quality and efficiency. Prev Chronic Dis, 2010;7(5). In press.

3. Bentley TGK, Efros RM, Palar K, Keeler EB. (2008). Waste in the U.S. health care system: A conceptual framework. The Milbank Quarterly, 86(4), 629-659.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.