Improving Population Health

New Year’s Resolutions and Population Health Improvement: Anything in Common?

By Kirstin Siemering, DrPH and David Kindig, MD, PhD

The U.S. government’s official web portal lists ten ever-popular New Year’s resolutions (actually, it lists 11 but we left off “take a trip” since it’s a good idea but not relevant to this discussion!):

1. Drink less alcohol
2. Get a better education
3. Get a better job
4. Get fit
5. Lose weight
6.  Manage debt
7. Manage stress
8. Quit smoking now
9. Save money
10. Volunteer to help others

From an individual perspective, the list is basically what we might expect. As a society, our default frame for New Year’s resolutions is that they require tremendous willpower and against-the-odds discipline to accomplish. Not surprisingly, the majority of us fail in our behavior change endeavors. Time magazine reported at the start of this year that 35% of those who resolve to make changes don’t even make it “out of the gate.”

But, we were somewhat surprised to realize that these individual priorities are also population health priorities (although a balanced agenda would also have to include attention to healthcare and the physical environment). Since experts always offer advice this time of year for how to keep resolutions, we thought it would be interesting to assess if their advice also has population health relevance.

As it turns out, tips for success for New Year’s resolutions have a familiar ring. Wall Street Journal Work and Family Columnist Sue Shellenbarger’s suggestions are fairly typical (and actually align quite well with content from our work from the County Health Rankings and this blog):

1. Get a little help from your friends (Work together)
2. Take one step at a time (Pick priorities) 
3. Figure out your attachment to bad habits (Assess needs and resources)
4. Change your environment (Find programs and policies that work)
5. Announce your intentions (Set ambitious but realistic goals)
6. Expect setbacks (Evaluate efforts)

So, as you’re contemplating your own resolutions for 2011 (such as what approaches to adopt for losing weight and getting fit), don’t forget to think about resolutions for your neighborhood, community, or even state. Mobilizing Action Toward Community Health will happen one step at a time, as we figure out our attachment to bad habits and announce our intentions. And with a little help from our friends, we’ll overcome setbacks and ultimately change our environment.

Happy New Year from Improving Population Health!

Healthcare Cost Containment Part IV: Dollars and Sense at the End of Life

By David A. Kindig, MD, PhD

Throughout this series, I’ve challenged health care advocates to consider the importance of reducing healthcare costs in a resource-limited world.  A balanced population health investment portfolio should include resources for prevention and the social determinants of health as well as healthcare. To create this balanced portfolio, we not only need to find new revenue streams but we have to take a hard look at our current expenditures and consider specific opportunities for reducing costs. Research by the Dartmouth group has identified two categories where healthcare costs tend to outweigh the benefits: (1) excess subspecialty visits and procedures and (2) end of life care.

Too many subspecialty visits and procedures can potentially be brought under control through a combination of market forces and regulation. But the high cost of dying is a sensitive topic that most policy makers would understandably rather avoid.

This is an area where policymakers need not and should not be involved. End of life decisions are and can be made voluntarily by individuals and families with their health professionals. They can be made solely on the basis of the kind of death an individual wishes to have. For some, trying every treatment or procedure that may hold promise of extending life or quality of life is important. Others may reject treatment of uncertain or unlikely benefit in light of potential disadvantages (such as prolonged discomfort and/or loss of dignity).

Such decisions should be made by private choice, through legal instruments called advance directives. Recent research by Dr. Maria Silveria showed that patients who had such instruments  were more likely to want limited care (93%) or comfort care (96%) than all care possible (2%). This study also showed a strong correlation between having a  document  that explicitly stated preferences for or against all care and receiving care that reflected those preferences.

In a recent New Yorker article called "Letting Go", physician and author Atul Gawande highlights a 20-year effort by health care providers in La Crosse, Wisconsin to get patients to be clear about end of life wishes. By 1996 85% of patients who died had advance directives, and he reports that end of life costs were half the national average. My first wife was a skilled geriatric social worker, and spent much time encouraging patients to discuss and make their wishes known. Health care costs never entered her mind, but I always wanted to quantify the financial impact of each week of her work, which I imagined to be as great as the La Crosse experience cited above.

Containing health care costs is extremely difficult, and has frustrated policy makers and academics and policy makers for decades. I do not mean to over simplify such decisions, which often have to be made with uncertain evidence. Both of my parents made decisions to forego treatment with possible but unlikely benefit, and died with dignity at home. This issue presents a rare win-win opportunity for personal choices to translate into significant healthcare savings. If circumstances allow, I’m planning for a less invasive death. And if someone would let me, I’d donate the savings to improving the health of low-income children.

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.

Healthcare Cost Containment Part III: How to Bend the Curve

By David A. Kindig, MD, PhD

I’ve been blogging for a couple of weeks now about healthcare cost containment. I’ve described the Affordable Care Act’s provisions for realigning Medicare expenditures with GDP increases and addressed the “R” word. The lead editorial in last Sunday’s New York Times notes that the Bowles-Simpson deficit reduction commission sets similar targets, but says “the commission punts on what do to should the growth cap be exceeded, as many experts deem likely.”

At the start of this series, my friend and colleague David Riemer, who directs Milwaukee’s Community advocates Public Policy Institute, issued this challenge to me: “I hope (you) explicitly address the multiple perverse incentives in today's health care system that drive its hyper-inflation, and how those incentives require a fundamental realignment if costs are ever to be controlled. Setting goals without realigning incentives will just be happy talk--it will get us nowhere. Sorry to be so brutal about this, but it's the brutal truth.”

We know that healthcare cost does not predict healthcare quality. Drs. Jack Wennberg, Elliott Fisher and colleagues at Dartmouth have for years been calling attention to the dramatic regional variation in per capita Medicare expenditures that bear no correlation to health outcomes. They observed Medicare growth rates varying from 2.3% in Atlanta and Pittsburg to 5.3% in Dallas over the period 1992-2006. Reducing the spending rate from the national average of 3.5% to the 2.3% experienced by Atlanta would save Medicare $1.3 trillion by 2023.

So what change in incentives would begin to “bend the curve” towards the Affordable Care Act’s 2018 goals? The concept of value-based payment systems is one approach that has been gaining traction in recent years. In fact, the Affordable Care Act establishes one such approach as a new Medicare payment model: the Accountable Care Organization (ACO). ACOs are designed to improve quality and reduce costs by incentivizing (via shared savings) collaboration among health care organizations and providers. While the ACO model is certainly no silver bullet (Fisher and Shortell underscore in their recent JAMA commentary that effective tools for performance measurement and evaluation are lacking), it provides a promising place to start thinking about realigning incentives.

Using the Dartmouth observations, policymakers should be required to identify specific targets in regional per capita total health expenditures and their growth rates (such as the Affordable Care Act’s goals for Medicare increases). As in the Clinton plan, geographic areas in which incentives for ACOs and other market forces are strong enough to meet these goals would avoid regulation. But in those that fail to meet targets, federal regulation should be invoked, limiting the annual increases in Medicare and private premiums that could be charged until target growth rates are achieved.

Of course value-based purchasing (as illustrated here with ACO) represents just one of many possible approaches for shifting incentives toward cost containment. The McKinsey Global Institute’s 2008 report entitled “Accounting for the Cost of U.S. Health Care: A New Look at Why Americans Spend More” provides excellent further reading for those interested. The report frames the issue from an international perspective and devotes an entire chapter to issues of demand, supply, and intermediation which address the “perverse incentives” to which David Riemer referred (if you have just a minute or two, be sure to check out the interactive graphic).

Why does a population health advocate spend so much blog space on health care expenditures? The answer is a central theme on this blog. In our resource-limited world, we urgently need to rebalance our health investments to expand resources for prevention and the social determinants of health. While we can’t presume that savings from ineffective health care could or would be redirected to these ends, we should all agree that this is a worthy goal.

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.

Healthcare Cost Containment Part II: Can Rationing Be Rational?

By David A. Kindig, MD, PhD

Rationing: A systematic method for limiting access to a good or service when demand exceeds supply. New World Dictionary

Arizona has had a lot of attention this past week for its recent decision to eliminate certain transplants for Medicaid recipients. The New York Times’ coverage alone included a general article, an analysis piece, and an op-ed that together prompted intense and mostly negative feedback from over 900 readers before comments were finally closed.

If the Times is correct in asserting that the Arizona cuts are a “sign of the times,” we’ve got a challenging road ahead in navigating the politics and ethics around the difficult and often contentious topic of healthcare rationing. As I noted last week, the Affordable Care Act charges CMS with developing recommendations to keep Medicare inflation in line with GDP increases over time. But the Act specifically prohibits proposals “that would ration care, increase revenues or change benefits.” Yet, how rationing will be defined in the context of the Affordable Care Act remains unclear. How might a population health perspective guide our thinking?

First, a population health perspective suggests that investments be prioritized according to the degree to which they will improve overall health outcomes and reduce disparities, be they racial, geographic, or socio-economic.

Second, a population health perspective encourages us to be relentless in identifying and eliminating excess and ineffective practices and procedures. This is not rationing, it is simply good medicine and good economics. A Baltimore cardiologist’s alleged misuse of cardiac stents (he supposedly implanted 585 medically unnecessary stents over a 2-year period at a cost to Medicaid of $3.8 million) provides a vivid example of a relatively common problem. As Cleveland Clinic’s Chief of Cardiovascular Medicine, Dr. Steven Nissen, said, “We’re spending a fortune as a country on procedures that people don’t need.”

Finally, a population health perspective implies that the reality of scarce resources requires difficult decision-making along a cost-benefit continuum. I believe that if caps are to be put on investments with limited or very expensive benefits, they should be made with the best evidence available and with maximum transparency. The best example of this was the Oregon Health Plan, which was prompted by a commitment to expand health care coverage for the state’s low-income population without additional funding. In 1989, the Oregon legislature created the Oregon Health Services Commission, which invited public input through town hall meetings on the process of ranking health care services according to importance, health impact, effectiveness, and cost. Although the approach was not perfect, it is an excellent example of a rational rationing process. This prioritization has resulted in healthcare coverage for 1.5 million Oregonians. In the United Kingdom, ”league tables” are used to guide investment decisions, ranking the quality adjusted life years saved per dollar invested for a given procedure.

So, can the Arizona decision be defended from a population health perspective? Perhaps, but only if the evidence is clear that new or deeper cuts in other sectors would be more damaging, that these are the least cost-effective programs in their Medicaid program, and that this evidence is transparent. And they would get more population health points if the savings went to preserving other more cost-effective health promoting programs instead of simply balancing the overall budget or reducing tax rates. Can we lower healthcare cost increases to close to GDP increases by just getting rid of wasteful and ineffective investments? I doubt it -- reform will likely require some form of rationing and continued clashing of goals and values. Stay tuned.

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.