Improving Population Health

Healthcare Cost Containment Part I: Getting Serious About Controlling Healthcare Expenditures

By David A. Kindig, MD, PhD

For decades, attempts across the political spectrum to control health care expenditures (through either market-based or regulatory policy) have been resisted. I was privileged to represent Secretary-designate Shalala in early 1993 at the Governor’s mansion in Little Rock when then President-elect Clinton was informed that his new health care plan would significantly increase costs before containing them. The expected political repercussions were clear by Clinton’s quip that he might as well just slit his throat – except that would increase costs even more.

As difficult as it is, healthcare cost containment is essential for both strengthening our global economic position as well as improving population health. We must figure out a way to both eliminate excess healthcare spending and create new revenue streams for investing across key drivers of health status and outcomes.

Determining how much we should be spending has been a particularly thorny issue for policymakers, who have historically been reluctant to set spending targets. While many state and national health plans have clear and measurable objectives for health outcomes like infant mortality and smoking rates, we rarely see specific targets proposed for either annual per capita health care expenditures or expenditure growth rates. But as I’ve said before, you can’t manage what you don’t measure.

Although not well-publicized, the Patient Protection and Affordable Care Act actually contains goals for healthcare cost control: beginning in April 2013, CMS will determine whether Medicare per capita spending exceeds the average of the overall Consumer Price Index and the Medical Cost Inflation rate. If it does, CMS will be required to make recommendations for how to reduce spending. If Medicare spending exceeds the (GDP per capita + 1%) threshold by 2018, CMS will be required to submit recommendations to Congress and the President for immediate consideration. Interestingly, this is quite similar to the 1993 Clinton Health Security Act, which called for a reduction of 0.5% per year (over 5 years) in the difference between Medicare spending and GDP increases to force alignment of health care costs with overall economic growth.

A similar approach was proposed in The  New York Times’ recent interactive budget puzzle challenge for eliminating the national deficit by 2030.  The puzzle offers a wide-ranging menu of options across nine categories and includes both spending cuts and tax increases. Of 39 choices provided, a cap to Medicare spending (tied to 1% over GDP per capita) would provide the greatest projected cost savings, erasing over 40% of the deficit. New York Times economics columnist David Leonhardt noted that this option was an overwhelming favorite among those who (tweeted their solutions and) preferred spending cuts over tax increases.

But, models themselves can’t reduce expenditures. Where do we look for expenditures that do not harm us if eliminated? Stop by next week for Part II on healthcare cost containment.

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.

Is Population Health Finally Coming Into Its Own?

By David A. Kindig, MD, PhD

No new perspectives this Thanksgiving week. We began this blog 6 months ago with the same title as above…and the following statement:

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.

Tune back in on December 1 as I continue our quest to meet this challenge with  the first of a two-part post on healthcare cost containment and population health.

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.

Sam Brownback of Kansas (R): A Population Health Governor?

By David A. Kindig, MD, PhD

I can understand how readers of this blog could think that population health improvement is an agenda owned by liberals. After all, reducing disparities and social determinants do not at first blush have a conservative or free market ring.  But I think it is short sighted and ideologic to draw the conclusion that there cannot be substantial conceptual and political common ground.

An old friend and colleague, Dr. Robert St. Peter of the Kansas Health Institute, spoke earlier this month at the National Health Policy Forum. During his talk, he mentioned Sam Brownback’s recent and successful gubernatorial campaign in Kansas, which focused on Five “Roadmap” Policy Priorities:

• Increase in net personal income
• Increase in private sector employment
• Increase in the percentage of 4th graders reading at grade level
• Increase in the percentage of high school graduates who are college or career ready
• Decrease in the percentage of Kansas children who live in poverty

If this isn’t a population health agenda that everyone in our field could embrace, I’ve not seen one. Of course the devil is in the details and implementation, and there are some strategies that liberals will not be comfortable with. But the metrics are clear and solid; at the very least this Kansas/Brownback Roadmap deserves understanding and careful tracking over the next 12-24 months.

Last week’s post highlighted the importance of income as a health determinant, operating through multiple pathways such as behavior, health insurance, health literacy, and the physical environment. Liberals often think of increasing income through income supplementation and welfare policy; these are powerful tools that need to be effectively deployed. A recent paper by two economists showed that modest increases in the Earned Income Tax Credit in 1993 produced measurable increases in physical and mental health outcomes.

Both parties are acknowledging the political and economic imperative of jobs creation, prioritizing the need for better jobs with livable wages. Common ground on this and similar population health policies needs to be cultivated not only between sides of the aisle but also with the business community. Business leaders have an inherent interest in population health policy, recognizing the importance of both employee health and education for their impact on health care costs and productivity. In the past, businesses have tended to emphasize wellness and incentives for individual behavior change. However, there is increasing recognition of the need to shift to a broader perspective. Andy Webber, CEO of the National Business Coalition on Health, recently noted in a MATCH project essay published in Preventing Chronic Disease:

“An employer can do everything right to influence the health and productivity of their ‘captured’ workforce at the worksite, but if that same workforce and their dependents live in unhealthy communities these employer investments can be neutralized.” 

Certainly the Brownback Roadmap would go a long way in helping employers achieve these goals. He could make it stronger by calling for elimination of ineffective healthcare practices and using the savings to fund his roadmap. The population health agenda is too large for a single party and political perspective. Our current bipartisan concerns about the economy provide fertile common ground for a population health policy agenda that would reap benefits for decades to come. That would be political cooperation worth working for.

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.

Are We Individually Responsible for Our Health Behavior Choices?

By David A. Kindig, MD, PhD

The answer is yes…and well, not really. This answer is often framed yes or no: either we have free-will,  “just say no” responsibility for our behaviors, or we have no responsibility because of the life situations we find ourselves in. Of course the truth is somewhere in between – but what is the balance between them? The answer has important policy implications, particularly with regard to informing investment priorities.

I’ve often noted (as in last week’s Child Health post) that currently available evidence is insufficient to effectively guide public and private policy makers’ investment decisions with regard to population health improvement. That said, we must recognize the cutting edge research being done in this area. For several decades, Paula Lantz and Jim House and colleagues at the University of Michigan have used a longitudinal database called the Americans’ Changing Lives Survey (ACLS) to explore answers to important questions using the most sophisticated social science methods available. The ACLS has tracked 3600 adults from 1986 to 2005, querying them 4 times over that period.

In their most recent paper (published in the May 2010 issue of Social Science and Medicine) they developed models to explore relationships among various factors (such as age, gender, ethnicity, education, income, smoking status, physical activity level, and many others) and risk of death. They were particularly interested in connections between income and behavior and wanted to determine if poor people have worse health because they have poor health behaviors – or if something else is going on.

Not surprisingly, the findings showed that people with lower incomes tended to have more unhealthy behaviors and people with higher incomes tended to have healthier behaviors. Regardless of income, smoking and low levels of physical activity were both associated with an increased risk of death. But more importantly for this blog, the findings revealed that unhealthy behaviors are far from the only reason low income populations are at increased risk of death. Independent of health-related behaviors and other control factors, the risk of death among those in the lowest income category was 76% greater than those in the highest income category (which was similar to the risk differential between smokers and nonsmokers). In addition, the independent effect of the lowest level of physical activity was nearly triple that of income and smoking.

The authors conclude with a call for health policy and clinical incentives to enhance income security, promote smoking cessation/prevention, and support physical activity. While these results do not tell us exactly what our population health investment strategy should be across behavioral and non-behavioral factors, they make clear that a balance is required. To improve population health, policy and programmatic resources are needed to help make the healthy choice the easy choice – not only with respect to health behaviors but for healthcare, employment, and education as well.

The concept of behavioral “choice” is often interpreted to mean individual choices independent of external (and often constraining) factors. Careful studies like this one provide evidence that keeps us from operating from such a simplistic perspective. To improve population health, we all need to make better health choices – but we also need to understand and remedy the economic and educational upstream factors which determine the extent to which this is possible.

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.

Can We Afford to Wait for Better Evidence on Improving Child Health?

By David A. Kindig, MD, PhD

I recently spent two days at a terrific small conference in Madison, sponsored by the Institute for Research on Poverty. The conference focused on Child Health and Well Being, with many leading thinkers and researchers on socioeconomic disparities in child health.  Researchers highlighted what we’re learning about the relationship among prenatal environmental factors, body system and brain development, and health outcomes over the life course. While I was extremely impressed with the meeting itself, I was quite frustrated by the lack of evidence regarding causal pathways and cost effectiveness of programs and policies. As a former pediatrician, many of these linkages seem...well...almost obvious. And they're gaining mainstream attention through popular media outlets. Time magazine recently ran a cover story on Annie Murphy Paul’s new book entitled Origins: How the Nine Months Before Birth Shape the Rest of Our Lives.

From a research perspective, these complicated relationships take enormous time and effort to untangle, and researchers venturing into the sphere of policy and practice is seldom encouraged or rewarded. We also can’t expect policy makers to invest resources and take political risks without sufficient evidence, especially in cases where there is a risk for potential harm. There are many examples where things we thought to be true were not, and people suffered. Remember that the first rule of medicine is “First Do No Harm.”

On the other hand, the reality is that many current policies emerge from political advocacy (often not even in the public interest) rather than on the strength of scientific evidence. Former Milbank President Dan Fox has noted that “policy is the sum of anecdote.” In the case of child and fetal health policy, failure to act on the best -- albeit imperfect -- evidence could potentially cause a great deal of harm. Public and private policy environments influencing maternal health, fetal development, and the first five years of life have substantial health and development ramifications over a lifetime. While we study and debate the causality and cost-effectiveness of our options over the next decade, the adult health of the 40 million children born in the United States during that time period will have already been determined. Investments in healthcare in middle and old age can only partly remedy poor health outcomes determined earlier, and often at great individual and social cost.

How can we remedy this?  Unfortunately, I don’t have any silver bullet answers. I’ve often lectured that if I were Czar, and if 25% of health care spending ($500 billion per year) is inappropriate or ineffective, I’d allocate $100 billion to covering the uninsured (we are now doing that), $100 billion to prevention and public health, and the remaining $300 billion to early childhood, prenatal, and K-12 education to have the most impact on later health. But at this point, nobody knows exactly what programs or policy packages are the most cost-effective to produce these results.

We of course need more research to figure this out – this was the point of my recent JAMA commentary with John Mullahy called Comparative Effectiveness – Of What? -- but not at the slow pace of the past several decades. An August New York Times article described the massive and coordinated public-private “moon-shot” approach in the last decade on Alzheimers research, which has led to many important recent discoveries in a challenging field. We should use a similar approach to understand what policy approaches are most cost-effective for improving the health of our children. Given the certain costs associated with inaction, we may, in the meantime, need to relax our policy investment standards somewhat. Such an approach is not without precedent. In the 1990s, while pharmaceutical researchers were working hard to develop HIV drug therapies, the seriousness of the disease resulted in conditional approval of some drugs pending more complete and relevant evidence.

We know enough right now to predict that doing nothing will result in poor adult health outcomes of babies being born today. Aside from the obvious moral dimensions, my main argument for expediency is pragmatic: the health and economic competitiveness of our nation over the next 50-100 years is at stake. Surely investing in maternal and early childhood health should be a priority. We should focus our research efforts on figuring out what approaches are most effective and waste no time in directing current investments based on the best available evidence.

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.