AcademyHealth’s Public Health Policy
Breakfast briefing: 3 February 2009
Hugh H. Tilson MD, DrPH
UNC Public Health Leadership Program

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Health Care Reform(er)s focus on remedy of the nation’s ailing (broken) medical care system
And equity DOES demand enfranchising the uninsured and underinsured (the quiet dignity of a single hard oak bench)
And the need for economic stimulus creates a
GREAT opportunity for long overdue reform
SO don’t misunderstand this talk as not in support of addressing uninsurance head-on!
BUT …

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Universal insurance is necessary but NOT sufficient because …
Not all insurance is created equal
Payment (alone) doesn’t guarantee ACCESS
And Access alone doesn’t guarantee access to
… comprehensive, quality assured, culturally sensitive …. Well, you know the rest!

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Universal insurance is necessary but NOT sufficient because …
Not all insurance is created equal and …
Most plans do NOT include the full inventory of evidence-based preventive interventions
(or even those with proven cost-effectiveness
**data available upon request!)
And those plans which DO include preventive medicine also include barriers to access/use, such as deductibles and co-payments

2%
Prevention
98%
$2 Trillion Health Care Budget, United States

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Even the best personal preventive services cannot ‘deliver’ on the promise of a healthier
America
We need a NEW system built on a solid foundation of evidence-based community
(non-personal) preventive services

Individual level
Clinical settings
Delivered by healthcare providers
Screening, Counseling, etc.
Group level
Health system changes
Insurance/benefits coverage
Access to/provision of services
Community, population-based
Informational
( Group Education, Media)
Behavioral, Social
Environmental & Policy Change
Clinical Guide
(USPSTF
Recommendations)
Community Guide
(TFCPS
Recommendations)

Changes in the environment
Infectious disease threats
Including MAN-
MADE ONES!!
Advances in biotechnology and information technology glumbert/media/shift
Disparities in health status and access to care
Globalization
A social and political environment that prioritizes health

• Prevents epidemics and the spread of disease
• Protects against environmental hazards
• Prevents injuries
• Promotes and encourages healthy behaviors
• Responds to disasters and assists communities in recovery
• Assures the quality and accessibility of health services
3/13/2009 11

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Even the best personal preventive services cannot ‘deliver’ on the promise of a healthier
America
Even the best community preventive services cannot ‘deliver’ on the promise of a healthier
America
We need a NEW SYSTEM built on a solid Public
Health FOUNDATION

• Monitor health status
• Diagnose and investigate
• Inform, educate, and empower
• Mobilize community partnerships
• Develop policies and plans
• Enforce laws and regulations
• Link people to needed services / assure care
• Assure a competent workforce
• Evaluate health services
• Research
3/13/2009 13

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The reformed Medical Care System partners with and depends upon a reformed Public
Health System (N.C./Vermont)
Every Community is served by a competent public health agency with the staff, budgets, and mandates to ensure the ten essential services of public health (many already are … it’s the “EVERY” that is NEW)
Every Public Health agency functions effectively as the convener and mobilizer of an integrated public health system (many already do … it’s the INTEGRATED SYSTEM that’s NEW)

The Public Health System
Police
EMS
Community
Centers
MCOs
Health
Department
Churches
Home Health
Corrections
Parks
Schools
Doctors
CHCs
Laboratory
Facilities
Hospitals
Philanthropist
Drug
Treatment
Civic Groups
Elected
Officials Nursing
Homes
Environmental
Health
Mass Transit
Tribal Health
Mental
Health
Employers
Economic
Development
3/13/2009
Fire
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Society's Health
Response
General protection
Safer,
Healthier
Population
Targeted protection
Demand for response
Becoming no longer vulnerable
Vulnerable
Population
Becoming
Vulnerable
Primary prevention
Becoming
Affected
Demand for response
Secondary prevention
Population with
Disease
Demand for response
Developing
Complications
Tertiary prevention
Population with
Complications
Dying from
Complications
Adverse Living
Conditions more inter-organizationally complex, slower rate of improvement
Public Work
(organizing, governance, citizenship, mutual accountability) organizationally complex, faster rate of improvement
Professional Work
(customers, products, services)
Milstein and Homer 2003

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38% of all U.S. deaths attributable to 4 behaviors*:
◦ Tobacco use
◦ Diet
◦ Physical inactivity
◦ Alcohol misuse
Obesity expected to increase Medicare spending by 35%**
Clinical measures (alone) cannot accomplish the work of prevention … nor can population measures (alone)
*Mokdad et al., 2001
**Lakdawalla et al., 2005

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First … we need the will and the resources to build the government public health infrastructure and distribute it to EVERY community in the country
Second … the competent public health department needs the trusted competent leadership to effectively CONVENE the system
Third … the system partners, particularly the medical care system, must agree to work together accountably and “OWN” the health of the community as a shared objective

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We have agreement on the basic functions of the official agency (NACCHO “Operational
Definition”)
We have the basic tools for system accountability (CDC: the public health system performance standards), tested, validated, and in use
The public health agency network has launched its own Public Health Accreditation
System and Board (isn’t that just PHAB?)

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Accreditation requires effective functioning of the whole PH SYSTEM (METRICS and accountability)
Oh, yes … and of course, the system must be a LEARNING SYSTEM …
…AND the field of Public Health Systems
Research (AcademyHealth/Council on
Linkages/CDC/RWJ) now has the tools to build the evidence base to do this

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Medical care does what medical care does best … and does it better
Medical care leaders work with community partners to mobilize networks to help them to do this job … better
Population based efforts of public health include medical care access and quality assurance (e.g. the “health home”) …
… and, where it is required, even providing personal services (e.g. FQHCs)

1.
‰ Provide coverage in federally-sponsored health insurance programs and create incentives for Medicaid and SCHIP to cover them
‰ Increase reimbursement in government-sponsored health insurance programs for cost-effective preventive services, offer first-dollar coverage of the services to consumers
‰ Provide incentives to health care providers for achieving high delivery rates, and to system partners, e.g. employers, for establishing community and workplace health promotion programs and policies

‰ Create a discrete, sustainable funding source to support state and local core public health activities and provide incentives for states to meet specified public health objectives
‰ Establish a Public Health Advisory Commission to recommend strategies for achieving key national health objectives and for allocating core public health funds
‰ Support consumer education initiatives encouraging individuals to adopt healthy behaviors

3. Increase knowledge about the effectiveness and delivery of preventive services
‰ Expand support for research on effective clinical and community preventive services and systems, and effects of policies that fall outside the health sphere
‰ Invest in data systems to monitor progress toward achieving national health objectives and reducing health disparities in access to preventive services

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Achieving a TRUE HEALTH System is up to US!
THANKS.

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“The committee defines the mission of public health as fulfilling society’s interest in assuring conditions in which people can be healthy”
“The committee finds that the core functions of public health agencies at all levels of government are assessment, policy development, and assurance”

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Assessment: … regularly and systematically collect, assemble, analyze, and make available information on the health of the community …
Policy Development: … Agencies must take a strategic approach, developed on the basis of a positive appreciation for the democratic political process

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Assurance: … assure their constituents that services necessary to achieve agreed upon goals are provided … encouraging actions by other entities …. Requiring such action through regulation, or by providing services directly
… a set of high-priority personal and communitywide health services that governments will guarantee to every member …

T
HE
F
UTURE OF
THE
P
UBLIC’S
H
EALTH in the 21st Century
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

“The Committee had hoped to provide specific guidance elaborating on the types and levels of workforce, infrastructure, related resources, and financial investments necessary to ensure the availability of essential public health services to all of the nation’s communities.
However, such evidence is limited, and there is no agenda or support for this type of research, despite the critical need for such data to promote and protect the nation’s health.”
—Institute of Medicine, 2003

Prevention
Treatment
Disease
Years

Highest Ranking Preventive Services for U.S. Population H.I.
C.E. Total
Discuss daily aspirin use—men 40+, women 50+ 5 5 10
Childhood immunizations
Smoking cessation advice and help to quit—adults
Alcohol screening and brief counseling—adults
Colorectal cancer screening—adults 50+
5
5
4
4
5
5
5
4
9
8
Hypertension screening and treatment—adults 18+
Influenza immunization—adults 50+
Vision screening—adults 65+
Cervical cancer screening—women
Cholesterol screening and treatment—men 35+, women
45+
Pneumococcal immunization—adults 65+
Breast cancer screening—women 40+
5
3
4
Chlamydia screening—sexually active women under 25 2
3
4
5
4
5
3
3
4
2
4
2
4
7
6

Cost Saving
Advising at-risk adults to consider taking aspirin daily
Childhood immunizations
Smoking cessation advice and help to quit
Screening adults for alcohol misuse and brief counseling
Vision screening (adults 65+)

Cost Saving
Advising at-risk adults to consider taking aspirin daily
Childhood immunizations
Smoking cessation advice and help to quit
Screening adults for alcohol misuse and brief counseling
Vision screening (adults 65+)

$14,000 to $34,999/QALY
Cervical cancer screening (all women)
Counseling women of childbearing age to take folic acid supplements
Counseling women to use calcium supplements
Injury prevention counseling for parents of young children
Hypertension screening (all adults)