Improving Population Health

Spring Has Sprung for the Health Wonk Review

While many of us were still wearing our winter coats this week in Wisconsin, spring sprung over at the Health Wonk Review. The new issue, hosted by the Incidental Economist, features our recent post by Daniel Fox and David Kindig on the new ACO draft rules and much more. Highlights include Leighton Ku (from the Health Affairs blog) on the history of the Medicaid program, Maggie Mahar (of Health Beat) on the market response to health care reform, and Avik Roy (of Forbes) on escalating healthcare costs in the U.S. vs. Britain.

ACOs and Population Health: Strong Goals, Weak Requirements

By Daniel M. Fox, PhD and David A. Kindig, MD, PhD

The Accountable Care Organizations (ACOs) described in the draft rules for the Medicare Shared Savings Program, published in the Federal Register on April 7, 2011, have a “three part aim”: achieving “better care for individuals…better health for populations…and lower growth in expenditures.” For the first time a federal program that finances health care has set improving population health as a prominent goal.

There is, however, a contradiction in how the draft rules address population health. The rules recognize that health has multiple determinants, but they make stronger demands for engaging in clinical prevention than for addressing these multiple determinants. This post gives examples of this contradiction and suggests ways to address it. We invite readers to comment and add their suggestions; and to note that the Centers for Medicare and Medicaid Services has established a deadline of June 6th for submitting comments.

The National Prevention Strategy Framework: Applause and Critique

By David A. Kindig, MD, PhD

Last week the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health Council met for the first time and discussed its draft National Prevention Strategy Framework.

This Council and Strategy represent an unprecedented opportunity. By emphasizing integration across federal departments, the Council creates the possibility for a Health-in-All possibilities approach to health improvement that embraces a robust population health framework. The Advisory Group is ably chaired by Jeff Levi, CEO of the Trust for America’s Health (TFAH). He and TFAH have been critically important in the efforts to promote prevention and public health in health reform and other federal budget efforts.

Medicare Cost-Cutting Controversy

By David A. Kindig, MD, PhD

A front page article in today’s New York Times discusses the controversy over the yet to be appointed Medicare Payment Board. Readers may recall that I have previously and strongly advocated for eliminating Medicare (and non Medicare) expenditures that are wasteful and ineffective (see Controlling Healthcare Expenditures and Can Rationing Be Rational?). Yesterday, New York Times columnist David Leonhardt was awarded a 2011 Pulitzer Prize for work that included his deficit reduction interactive puzzle. Of 39 choices provided by the puzzle, a cap to Medicare spending (tied to 1% over GDP per capita) yielded the greatest projected cost savings and eliminated over 40% of the deficit. This option was an overwhelming favorite among those who preferred spending cuts over tax increases.

Most serious commentators have indicated that Medicare cost savings of some kind are necessary. Population health advocates see the potential for using these savings in part to rebalance our health investments and expand resources for prevention and the social determinants of health. Those opposing regulatory intervention when and where market forces are inadequate have a responsibility to show how other approaches will produce the needed results.

 

Population Health Disparities: Rates or Burden?

 

By David A. Kindig, MD, PhD

In my March 14 post Bending Health Disparity Curves, I focused exclusively on differences in mortality rates, such as deaths per 100,000 persons. Rates are very useful measures, because they allow comparison across populations of different sizes. But from a population health perspective, rates alone are not enough, because large disparities in very small populations have a different impact than similar disparities in larger populations. Burden refers to the impact of a health problem in a population, combining both the rate and the number of people affected.

Although our disparities focus tends to be on race and ethnicity, disparities also exist in other domains such as geography, socioeconomic status, and gender. The table below shows a surprisingly high male mortality rate, but it is the size of this population (146 million) that transforms the rate into a significant population health burden.

                               Mortality rate per 100,000*         Population Size

Black                      1009                                           39 million

White                      780                                             240 million

Male                        945                                            146 million

Female                    672                                            150 million

*Average rate 2003-2007. Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 1999-2007. CDC WONDER On-line Database, compiled from Compressed Mortality File 1999-2007 Series 20 No. 2M, 2010.

Disparities Dialogue

By David A. Kindig, MD, PhD

Over the past couple of months, I’ve given some attention to the issue of health disparities by asking how we should focus our efforts and giving a perspective on bending health disparity curves.

I always appreciate when readers respond, whether to agree, disagree, or offer an alternative perspective and I’d like to share a couple of comments on the disparities posts that expand on my ideas.

Honoring Population Health Heroes for National Public Health Week

By Kirstin Q. Siemering, DrPH, RD

Each year, the first week in April marks National Public Health Week (NPHW). NPHW was created in 1995 with a proclamation by President Bill Clinton who called upon “all Federal, State, and local public health agencies to join with appropriate private organizations and educational institutions in celebrating this occasion with activities to promote healthy lifestyles and to heighten awareness of the many benefits good health brings.”

 The NPHW proclamation underscores a major theme of this blog: that health for all remains a key challenge of our times, despite rapid advancement of healthcare technologies. Efforts to “build healthy communities, meet the needs of our diverse population, plan appropriate responses to natural disasters, educate individuals about workplace hazards, and encourage responsible behavior in all that we do” are as critical for this 16^th annual NPHW as they were for the first.

Food Assistance: Growing Need, Shrinking Resources

Food assistance programs have had a high profile lately. Participation in the SNAP Program (Supplemental Nutrition Assistance Program) – better known as food stamps – is at an all-time high and the House is considering cutting benefits. As the debate continues, we’d like to highlight a couple of resources that may be of interest to readers:

The Map the Meal Gap interactive feature developed by Feeding America allows communities to look at food insecurity at both state and county levels.

A recent Institute of Medicine (IOM) workshop summary examined priorities for research, policy, and practice to help understand the complicated relationship between food insecurity and obesity. This workshop was held in November, 2010 at the request of the United States Department of Agriculture’s Food and Nutrition Service and the report was released last month.

Mobilizing Action Toward Community Health: Community Grants Program

A new Community Grants program from the Robert Wood Johnson Foundation (RJWF) called Mobilizing Action Toward Community Health (MATCH) will help spark action in communities to address the many factors that influence health. As the County Health Rankings illustrate, social and economic factors such as education and employment can affect health directly and indirectly, and those negative effects may accumulate over individuals’ lifetimes and continue unbroken through generations. The first round of the Community Grants program is open to communities that are ready to take action to address the social and economic factors that affect health—factors which have a significant impact on health outcomes, yet are often ignored in community health improvement activities.

An informational web conference will be held on April 5, 2011 at 2 pm ET (registration required); brief proposals are due April 27, 2011.