Locally Customized Population Health Policy Packages?

By David A. Kindig, MD, PhD

In my last post I suggested that those who allocate resources must provide ample guidance to ensure that local level health improvement strategies actually align with the best available evidence. I mentioned the University of Wisconsin What Works data base as well as the approach that the previous administration allocated its State Health Improvement Plan (SHIP) resources in the state of Minnesota. But I indicated that What Works is not tailored to individual communities and that the Minnesota example is limited to health behavior interventions, not all population health determinants.

We know from the County Health Rankings and our own experiences that communities vary widely in both their health outcomes and the factors or determinants of those outcomes. There are many examples of both high and low ranking counties which vary on their determinant profile…some have high health care quality and access but poor behaviors, others have high social factors like education and income but poor air and water quality. Given limited resources, it is critical that investments be made carefully to have the most impact.

Would it be helpful to identify a set of Population Health Policy Packages that suggest the best options for local communities to make, given their outcomes and health determinants profile? 

While there is enormous variation across the country in such profiles, it is likely that a reasonable number of representative situations exist for most communities/counties. For each profile, using the best evidence available from sources like What Works and the CDC Community Guide, a set of investment priorities would be developed, covering all the determinants of health. It would be as broad as the global evidence allows, but would be tailored to a community’s strengths and weaknesses. Options for improving behaviors like smoking would not be as highly suggested for places already doing well in this factor. The packages would not be prescriptive, but merely a menu of the investments likely to produce the best health outcome improvement. Where possible, options would include the strength of public and private sector policies beyond dollar investment in specific programs.

The initial set of Policy Packages would not be ideal, for a variety of reasons. We still have incomplete evidence of effectiveness of different programs and policies, particularly regarding cost-effectiveness beyond effectiveness itself. It is not clear which level of investment in a particular determinant or factor is optimal, or where diminishing return sets in and when resources should be moved to other factors. We are limited in evidence for different types of outcomes, particularly disparity reduction.

However, we shouldn’t let the perfect be the enemy of the good. A beginning set such as in the Minnesota SHIP example (i.e., improving nutrition, increasing physical activity, and reducing tobacco use and exposure) might be helpful in many places where discussions are taking place regarding improving the health of their communities. It would help ensure that local passion and commitment would be channeled in an evidence based direction, while preserving autonomy and sensitivity to community preferences.

What do you think about this? How long will we say we don’t have adequate evidence to guide population health investment decisions?

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.

Comments

[Ronald Cossman]

Dr. Kindig;
Actually, there may be locally customized health status in the works. The IRS is going to require all not-for-profit hospitals to complete a Community Health Needs Assessment every three years in order to maintain their tax exempt status. Those assessments must quantify both met and unmet health care needs in the hospital's service delivery area, set forth a plan to meet unmet needs and make that Assessment and plan public. The instrument is IRS Schedule 990-H.
Ron Cossman
Social Science Research Center, Mississippi State University

[Kirstin Siemering]

Dear Dr. Cossman,
Thanks for raising this important point -- we are also paying close attention to how nonprofit hospital community benefits are evolving. You may be interested in a couple of previous posts on this topic: "IRS Invites Comments Regarding Community Health Needs Assessments" http://www.improvingpopulationhealth.org/blog/2011/07/irs-invites-comments-regarding-community-health-needs-assessments.html and Hospital Community Benefit: An Update on Opportunities and Challenges http://www.improvingpopulationhealth.org/blog/2011/06/community_benefit_update.html
Kirstin Siemering
IPH Associate Editor

[Amy Heydlauff]

In 5 semi-rural communities in SE Michigan we're using BRFSS, County Health Rankings, PAC & NEAT survey results to develop customized, comprehensive wellness plans for each town. Comprehensive means the towns' Wellness Coalitions will develop a plan aimed at creating a culture in which residents 'eat better, move more, avoid unhealthy substances & connect with others in a healthy way'. Altarum & researchers from the University of MI are working with us to evaluate the process & outcomes - we're hoping any successes will be supported by data & be replicable. You can learn a bit about what we're doing on our website (geared toward community members). www.5healthytowns.org