Improving Population Health

Can Healthcare Organizations Lead in Population Health Improvement?

By David A. Kindig, MD, PhD

Two weeks ago I floated the concept of a “Super-Integrator” to play an effective but neutral coordinating role in population health improvement. I believe there are multiple, equally effective forms such integrators could take. Although we don’t yet have complete exemplars for this concept, we do have examples of organizations moving in the right direction. This week, we’re showcasing one of them.

The Institute for Health Improvement is a highly regarded healthcare improvement organization that has moved beyond solely health care through its Triple Aim strategic initiative. The initiative illustrates how healthcare organizations are reaching beyond their traditional roles to address a broad range of health factors.

John Whittington, MD is IHI’s Lead Faculty for the Triple Aim. We met through my response to IHI’s Health Affairs article on the Triple Aim.  I recently invited John to describe the IHI current movement into a Triple Aim regional population strategy.

DAK: John, would you first briefly describe the IHI?

JW:  The Institute for Healthcare Improvement was founded in 1991 by Don Berwick and a small group of colleagues who were committed to redesigning health care into a system no longer plagued by errors, waste, delay, and unsustainable social and economic costs. Today IHI is a small, not-for-profit organization based in Cambridge, Massachusetts, helping to lead the improvement of health care – making care better, safer, and more affordable – throughout the world.

DAK: What is the Triple Aim, and how did it evolve from IHI traditional work?

JW: In 2005, IHI had a vision to work on three simultaneous aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. In 2006, research and development began on this Triple Aim. In 2007, 13 organizations joined in a partnership with IHI to work together. Today, over 70 organizations from around the world work with the IHI on the Triple Aim. Each organization that partners with IHI acts as an integrator of care for a defined population, working on five change principles: (1) encouraging prevention and health promotion, (2) improving and broadening primary care, (3) helping individuals co-create care, (4) improving front line care that builds social capital with other health producing organizations in a community, and (5) working directly on cost control.

DAK:  Can you also tell us about the regional strategy that is evolving from Triple Aim work?

JW: Some of the 40 organizations that work on the Triple Aim in the US are focused on small homogenous populations, such as their own employees. The 30 international sites focus on total populations in geographic regions such as a primary care trust in England. By observing the international sites and some US sites, much has been learned about regional work. IHI sees the need to push the work of the Triple Aim to entire populations in geographic regions in the US. Our regional approach is based on the work of Tom Nolan (a key architect of the Triple Aim), and shaped by the belief that regions (1) are self-sufficient and contain all the necessary components for constructing a health system, (2) tend to have common values, (3) allow solutions to be driven by local context and expertise, (4) have existing platforms for dialogue (or opportunities for creating them), and (5) are characterized by a full range of health factors or determinants, including but not limited to healthcare.

DAK:  Many readers of the blog will be aware that IHI’s founder Don Berwick has recently assumed a new post as Administrator of the federal CMS (link). Who has taken over at IHI, and what impact dies this have on the Triple Aim or regional plans?

JW: IHI is honored that President Obama has chosen Don to lead CMS, and that he’ll have the opportunity to advance the cause of health care improvement especially at this time. IHI’s Board immediately named Maureen Bisognano, IHI’s former Chief Operating Officer, as IHI’s next President and CEO.  Maureen has been Don’s chief partner in IHI’s management and vision since she joined IHI in 1995, so IHI’s not missing a beat in carrying the work forward to meet the challenges ahead. Our Triple Aim work is more important than ever.

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.

How to Spend $15 Billion to Make America Healthier

By David A. Kindig, MD, PhD

Last week, the U.S. Senate defeated the Johanns amendment to the Small Business Jobs and Credit Act of 2010. In doing so, legislators spared (for now, at least) the 10-year, $15 billion Prevention and Public Health Fund established by the Patient Protection and Affordable Care Act (PPACA). The purpose of the fund is “to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs.” (For more information about PPACA’s prevention-oriented provisions, see the recent New England Journal of Medicine perspective coauthored by Assistant Secretary for Health Howard Koh and Secretary of Health and Human Services Kathleen Sebelius.)

The landmark Prevention and Public Health fund represents a tremendous victory for health advocates throughout the country, and many have offered suggestions on what to do with the money.

Secretary Sebelius announced in June how the fund’s FY 2010 $500 million would be allocated. Those of us who celebrate the fund’s creation share a desire for the dollars to actually make a difference and the 2010 allocation provides a good starting point for improving population health. But we must seek out continued opportunities for advocacy as the allocation grows over time to an annual $2 billion in 2015-2020.

I’ve tracked the dialogue and debates surrounding the fund over the last year and have some thoughts on how a population health perspective might guide our next steps.

First, keep in mind that the fund is quite small relative to ambitious goals established by the PPACA. On an annual basis, the amount is less than 0.01% of that spent on health care services. We must be both realistic in our expectations and strategic in our spending.

Second, funding should be related to the determinants of health model. While research does not yet allow the precise identification of the investment balance across determinants, we know a balance is required. The County Health Rankings assigns weights of 20% to health care, 10% to the physical environment, 30% to health behaviors, and 40% to the socioeconomic environment.

I’d suggest that the Prevention and Public Health fund take a similarly broad Community Prevention approach. The relatively small amount of money will likely have the largest impact if efforts emphasize creating policies and programs that create healthy environments, as has been emphasized by Dr. Jeffrey Levi’s Congressional testimony. The Convergence Partnership has urged for a similar approach, noting that “while clinical prevention is important…we must focus on changing the policies and systems that shape neighborhoods so that they foster health.” Additional recommendations are likely to emerge from the new National Prevention, Health Promotion, and Public Health Council, which is mandated by the PPACA to “develop and make public a national prevention, health promotion, and public health strategy” by March 23, 2011.

Third, priority should be given to communities who have the lowest health outcomes and are improving less rapidly or even losing ground. A recent letter from prominent population health leaders to Secretary Sebelius emphasizes the importance of focusing assistance on places where health outcomes are poor and health disparities are high. Communities with comparatively healthy populations should be applauded, recognized for their achievements, and serve as examples to others – but they should receive fewer new resources. If this is rationing, so be it. With limited resources, a population health perspective requires investments that produce the most health improvement and disparity reduction per dollar invested.

What we’ve got is a relatively short period of time and relatively few dollars. But ten years from now, when we assess what we’ve accomplished through the Prevention and Public Health Fund, we should be proud of the choices we make now.

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.

Do We Need a Population Health Super-Integrator?

By David A. Kindig, MD, PhD

In a previous post, I raised the question of who is accountable for population health outcomes, and suggested that some cross-sectoral integrating mechanism might be required. The outside line in the figure below suggests that this mechanism could be that of a Super-Health-Integrator. Such an integrator, with appropriate financial resources and authority, could align investments and activities across the multiple sectors which can impact population health, such as health care, public health, schools, employers, and community organizations. 

 

An alternative to a super-integrator might be that one sector takes lead responsibility for population health improvement, using informal or formal authority to ensure that others play their roles. Regardless of which sector or organization took the lead (this could vary from community to community), the process would likely involve conflict and/or have limited effectiveness. Some concerns would be that healthcare organizations may overemphasize biomedical approaches, that governmental public health is too under-resourced for even its critical traditional functions, and that businesses would be challenged by competing goals. So, I believe that many communities would benefit by having a strong and neutral coordinating entity or mechanism at the helm.

Another alternative is the status quo where each sector makes investments to optimize its own goals, which may or may not include population health improvement. We have ample evidence to show that under this current situation few—if any—communities are as healthy as they could be.

This is why I proposed “health outcomes trusts” in my 1997 book and am proposing Super-Health-Integrators today. To my knowledge nothing like this has been fully developed, although pieces exist in many healthy community partnerships. Such an entity would likely not be governmental or corporate, but would certainly need active public and private sector involvement. And, as noted above, it would need some authority and financial resources to do its work (such as from a redesigned IRS Community Benefit stream). Such Integrators or Trusts might draw on the principles of social entrepreneurship by emphasizing strategic partnerships and leveraging resources to raise levels of performance and accountability (look for the essay by Jane Wei-Skillern in the upcoming issue of Preventing Chronic Disease, available online in mid-October).

I am not naive about the potential challenges such non-traditional structures pose, but the “inconvenient truth” is that addressing the multiple determinants of population health to optimize our communities’ health will almost certainly require some form of coordinating authority. I would love to hear the opinions of others on this point, as well as feature on this blog any examples of existing structures already performing these functions.

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. 

Will the Prevention and Public Health Fund’s $15 Billion Be Spared on September 14th?

By David A. Kindig, MD, PhD

On September 14, 2010, the U.S. Senate will vote on two opposing amendments to the Small Business Jobs and Credit Act of 2010. The outcome could save or eliminate the $15 billion that has been set aside through the Prevention and Public Health Fund to support national, state, and local programs to promote health and reduce health disparities.

At issue is a small tax reporting provision within the Patient Protection and Affordable Care Act (PPACA). Specifically, the provision mandates that businesses, charities, and state and local governments file one form 1099 for each business providing in excess of $600 in property, goods and services (the current requirement is for services only and has been associated with significant underreporting).

There is bipartisan consensus that the new provision (scheduled to go into effect in 2012) excessively burdens small businesses with paperwork, but differences in the two proposed solutions are dramatic.

On one side is Senator Mike Johanns (R-NE), who is calling for a full repeal of the tax reporting requirement. He proposes to make up the lost revenue by completely eliminating the $15 billion Prevention and Public Health Fund and by lowering the individual mandate from 8% to 5% of income.

Senator Bill Nelson (D-FL) has offered a competing amendment that keeps the Prevention Fund intact. Nelson’s amendment scales back the reporting requirements: businesses with fewer than 25 employees would be exempted from the reporting, and the reporting threshold would be increased from $600 to $5,000 per vendor or service provider. Senator Nelson’s amendment proposes to make up lost revenue by repealing tax cuts for the five largest oil companies.

The Senate will vote on both amendments on September 14. Each will require 60 votes to pass, and the voting is likely to be close.

Please contact your senators to express your concerns and let them know how you’d like them to vote next week.

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.

Population Health: If It's Everything, Is It Nothing?

By David A. Kindig, MD, PhD

As you know, I’m new to blogging, and still getting used to it from a career of more academic writing. Several of you, as well as our MATCH staff, have observed that the topics seem to be a bit random and “out of the blue” from week to week. In addition, a respected colleague emailed a response to the post on advance directives that “it could imply that everything is about population health (which, as you and I agree, I hope) doesn’t do much to advance the cause of purchasing population health.”

Hmmm…if it’s everything, is it nothing? A look at the population health model underpinning this blog and all I work on in population health, suggests that indeed it is perhaps everything: a broad set of outcomes produced by a comprehensive set of determinants which are influenced or activated by programs and policies in the public and private sectors.

You will not, however, find me blogging on each and every micro-determinant or program/policy that theoretically and actually has some detectable impact on population health outcomes. What is then the decision rule that makes a topic of program or policy of importance not only for this blog but for public and private policy makers?

In this resource-limited world, I believe the criterion should be largely based on economics, and in particular, the relative effectiveness and cost-effectiveness of the determinant or the program and policy on health outcomes. I have previously noted that we do not yet have adequate evidence to make this an easy exercise. Research is needed to explore the effectiveness and cost effectiveness of broad policies and programs designed to effect health improvement at the population level. Some investments have an evidence base, like smoking cessation and immunization and early childhood programs. Other investments, such as removing the LAST microgram of a toxic substance in a Superfund site, would probably have some marginal effectiveness but extremely low cost-effectiveness.

Of course, determining what action to take toward health improvement is hardly straightforward. Decision makers must weigh not only on available evidence on effectiveness and cost-effectiveness but must also take into account many other factors, especially resource (financial and nonfinancial) and political supports and constraints.

As we try to cover topics that address all parts of our population health model, I would welcome feedback as to whether you either KNOW or SUSPECT that any program or policy we discuss is of such low cost-effectiveness as to not meet my criterion above.

Your feedback and suggestions are always welcome and appreciated!

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.

A New Play for Baby Carrots and Other Population Health News

By Kirstin Q. Siemering, DrPH

In Wisconsin, late summer breezes often have a certain nip that reminds us that winter is coming—whether we like it or not. Kids are heading back to school and farmers are harvesting their bounty. In past weeks we've struggle to find #2 pencils on picked-clean store shelves and had tomatoes coming out of our ears. So in honor of the role farms and schools play in promoting population health, we're drawing your attention this week to an assortment of late summer news around the themes of school health and healthy harvests.

• The Senate passed (by “unanimous consent” of all 100 members and didn’t even require a vote) the long-awaited child nutrition reauthorization, called the “Healthy, Hunger-Free Kids Act.” The House version also has broad support and a passing vote is expected before the end of September. For more information, check out this fact sheet and this Culinate article.

 

• The USDA established the People’s Garden School Pilot Program to bring school gardens to low-income schools (applications are due November 8, 2010).

 

• The USDA has also awarded Massachusetts $20 million for a groundbreaking fruit and vegetable incentive pilot that will test whether providing incentives to low-income families to purchase fresh produce will influence food purchasing patterns.

   

• In San Mateo, California, where schools are facing 10% budget cuts, the Sequoia Healthcare District (which manages Sequoia Hospital) is making up some of the difference by providing $4.5 million to hire school staff, including a nurse, a counselor, a wellness coordinator, a physical education teacher, and a nurse’s aide.

 

• General Electric Foundation has granted $2 million to the Louisiana Public Health Institute to benefit school-based health centers (this is part of a $25 million, 3-year campaign to increase access to care for underserved youth throughout the United States).

 

• The September issue of the American Journal of Public Health has many articles devoted to child and school health, including a collection on the role and value of school-based healthcare.

And finally,

• 50 carrot growers have joined Bolthouse Farms to create a new $25 million marketing campaign (watch for the new tv ads). Bolthouse CEO Jeff Dunn (former President of Coca Cola North America) says the approach takes a page out of junk food’s playbook.

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