Public Health and Health Care:
Upstream, Downstream and Our Future
John R. Finnegan Jr., PhD
Professor & Dean
April 6, 2012
Disclosures
Board member,
HealthEast Care System
Opinions are my own, not those of
HealthEast or the UMN
A Wicked Problem for the USA
What will it take to enable the USA to
make available affordable, quality
health care for all of our citizens?
Total Health Expenditure Per Capita,
U.S. and Selected Countries, 1970, 1980, 1990,
2000, 2008
$8,000
Per Capita Spending - PPP Adjusted
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$-
Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en
(Accessed on 14 February 2011).
Notes: Data from Australia and Japan are 2007 data. 2008 figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. 2000
figured for Belgium are OECD estimates. Numbers are PPP adjusted. Break in Series AUS (1998); AUSTRIA(1990); BEL(2003, 2005); CAN(1995); FRA(1995);
GER(1992); JAP(1995); NET(1998, 2003); NOR(1999); SPA(1999, 2003); SWE(1993, 2001); SWI(1995); UK (1997. Starting in 1993 Belgium used a different
methodology.
1970
1980
1990
2000
2008
Life Expectancy vs. Per
Capita Health Spending
Expect
Less.
Pay
More.
Source: Shah U (2011)
Management in Health
15:3.
Life Expectancy, Per Capita Spending,
Percentage Total Costs Private Sector
2003/2006
Spending for health determinants
and health expenditures, 2011
Misalignment!!
Government spending
on public health
Now What?
• Paying more, getting less is neither
good economics, good politics, nor
certainly good health.
• Our spending is misaligned with
the factors that improve health.
• We are wrongly incentivizing
patients AND healthcare providers.
• The private sector is bearing a
major portion of the burden.
Now What?
• Less than 5% of US health care
spending is on public health
• The current situation is not
sustainable no matter what you
think of the Affordable Care Act
• How do we approach such a
wicked challenge?
An important insight
about wicked problems
“For every complex problem,
there is a single solution that
is simple, neat, and wrong.”
Henry L. Mencken
A Wicked Problem for the USA
What will it take to enable the USA to
make available affordable, quality
health care for all of our citizens?
Linking Health Care
& Public Health
Enter
The Triple Aim
Linking Health Care
& Public Health
Improve:
 Population health
 Care for individuals (Access, Quality)
 Cost reduction
Berwick, Nolan, Whittington (2008). The Triple Aim:
Care, Health, and Cost. Health Affairs 27:3, 759-769
Health Reform Era
Accountable Care Environment
Pay for Performance
Fee for Value
Continuum from:
Patient outcomes to Physician
Performance to Reimbursement
To Achieve Triple Aim
 Enrollment of an identified population
 Commitment to universality for its
members
 An organization (an “integrator”) that
accepts responsibility for all three aims
for that population.
Berwick, Nolan, Whittington (2008). The Triple Aim:
Care, Health, and Cost. Health Affairs 27:3, 759-769
Roles of the “Integrator”
 Partnership with individuals and
families
 Redesign of primary care
 Population health management
 Financial management, and macro
system integration.
Berwick, Nolan, Whittington (2008). The Triple Aim:
Care, Health, and Cost. Health Affairs 27:3, 759-769
Roles of the “Integrator”
 Partnership with individuals and
families
 Education, communication re: health status
 Shared decision-making, management
 Change “more-is-better” culture
Berwick, Nolan, Whittington (2008). The Triple Aim:
Care, Health, and Cost. Health Affairs 27:3, 759-769
Roles of the “Integrator”
 Redesign of primary care
 Expanded role primary care team
 Physicians not necessarily sole or main care
provider
 Long-term relations, plans of care, coordination,
navigation, infrastructure and capacity
Berwick, Nolan, Whittington (2008). The Triple Aim:
Care, Health, and Cost. Health Affairs 27:3, 759-769
Roles of the “Integrator”
 Population health management
 Anticipating, shaping patterns of care for
important subgroups
 Prevention with a focus on behavior and other
health determinants
 Chronic disease management (e.g., Congestive
Heart Failure)
Berwick, Nolan, Whittington (2008). The Triple Aim:
Care, Health, and Cost. Health Affairs 27:3, 759-769
Roles of the “Integrator”
 Financial management and macro
system integration
 Defining, measuring, making transparent per
capita cost of care to beneficiaries
 Reducing waste in care areas
 Value added by producing the best health
outcome(s) at lowest cost over longest period of
time
Berwick, Nolan, Whittington (2008). The Triple Aim:
Care, Health, and Cost. Health Affairs 27:3, 759-769
Approaches to the Triple Aim
Technology:
 EHR, HIE and computerized provider
order entry
 population analytics
 clinical transformation
 care management solutions
Cozzens, T (2012 Jan 10) Hospital and Health Networks Daily
A Wicked Problem for the USA
Does public health have anything to
offer? If so, what? Any track
record?
Upstream-Downstream
Chronic Care>
Acute Care>
<Preventive Med Upstream:
•
•
•
•
Populations
Systems
Environment
Methods
Upstream-Downstream
Public Health>
Methods:
<Preventive
Med
Chronic Care>
• Scientific
Acute Care>




Biostatistics
Epidemiology
Env. Health
Social &
Behavioral
Sciences
 Policy &
Economic
sciences
Upstream-Downstream
Public Health>
Methods:
<Preventive
Med
Chronic Care>
• Intervention
Acute Care>
 Education
 Technology
 Policy
Impact of Public Health
Since 1900, the average life expectancy
for Americans has increased by about
30 years. Public health initiatives
account for about 25 of those additional
years.
*Turnock, BJ. Public Health: What it is and How it Works, 3rd Edition.
Sudbury, MA: Jones and Bartlett Publishers, 2004.
Top 10 Public Health Achievements
 Increased average lifespan
1900: 49 years
1999: 75 years




Sanitation and water
Vaccination
Control of Infectious Disease
Safer Workplaces
Top 10 Public Health Achievements





Healthier mothers and babies
Family planning
Safer food
Heart disease and stroke prevention
Smoking
Public health improvements = 20 years added to lifespan
Medical improvements = 5 years added to lifespan
Minnesota’s Response:
Health Reform Act 2008
Redesign primary care:
 Health Care Homes
Population Health:
 SHIP (Weight, Smoking)
Quality & Cost Payment Reform
Supporting:
 Health Care Reform Review Council, E-Health
Affordable Care Act 2010
• New insurance marketplace
 Expanded access to coverage
 State-based exchanges
• Insurance market reform
• Changes to Medicare; expansion Medicaid;
close Part D “donut hole” by 2020
• Prevention, public health & wellness
programs, IT, waste & fraud reduction
Affordable Care Act 2010
• Redesign Primary Care
•
Accountable Care Organizations (ACO’s)
• Integrated systems
• Team-based care
• Cost control
• CQI the patient experience
• Outcomes driven
• Pay for value, performance
Will ACO’s Work?
Skeptics:
“…ACO’s just new name for HMO network
formation of the 90’s; now physician hospital
organizations and group practices without
walls…large, locally dominant provider
systems will just get bigger and run up
prices…”
Allan Baumgarten, Health Market Reviews & Consulting,
(Association of Health Care Journalists listserv 4-5-12)
Will ACO’s Work?
Skeptics:
“…physician groups receive performance
payments tied to shared savings and to
achieving certain quality and cost targets for
[their] Medicare beneficiaries…Physician
Group Practice R&D Project funded by CMS
showed mixed results…N Engl J Med 2011; 365:1659-1661
Allan Baumgarten, Health Market Reviews & Consulting,
(Association of Health Care Journalists listserv 4-5-12)
Affordable Care Act 2010
Established:
The National Prevention, Health Promotion,
and Public Health Council
(Ch. Surgeon General; 17 agencies)
“…provides coordination, leadership at the
federal level and among all executive
agencies regarding prevention, wellness, and
health promotion practices…”
Affordable Care Act 2010
Established April 2011:
Advisory Group on Prevention, Health
Promotion, and Integrative and Public
Health (non-federal, no more than 25 members)
 develop policy and program recommendations
 advise the National Prevention Council on lifestylebased chronic disease prevention and management,
integrative health care practices, and health
promotion.
Affordable Care Act 2010
Established:
Prevention & Public Health Fund
 “…expanded and sustained national
investment…in public health”
 Advance effectiveness of communitybased prevention
 FY13 amount: $1.25 billion
National Prevention Strategy
America’s Plan for Better Health and Wellness
Broad Strategic Directions
• Build Healthy and Safe Community
Environments
• Expand Quality Preventive Services in
Clinical and Community Settings
• Empower People to Make Healthy
Choices
• Eliminate Health Disparities
National Prevention Strategy
America’s Plan for Better Health and Wellness
Priority Areas







Tobacco-free living
Prevent drug abuse and excessive alcohol use
Healthy eating
Active living
Injury and violence-free living
Reproductive and sexual health
Mental and emotional wellbeing
So what keeps medicine and
public health from closer work?
• Prevention and Public Health Fund of the
ACA labeled “slush fund” by the right
• Culture: Public health “too government;”
Medicine “too private sector” to effectively
identify common goals
• Austerity alone won’t cut it
• Any joint process to aim at common goals?
Stine & Chokshi (2012) NEJM
Community Health
Improvement Process
IOM (2012)
Improving health
in the community:
a role for
performance
monitoring.
Social Ecology Model
Theory
Change assumptions
Causal paths
Applications
Interventions
Measures
Organizations
Family
Interpersonal
Individual
Questions about change
How do public health applications differ through
each “lens”: psychosocial, community,
economic, policy?
What does “change” look like with respect to
the level of the individual and the collective?
If we had to make a hard choice about
strategies we think will be more effective, what
would we choose?
The Prevention Paradox
“A prevention measure that
brings large benefits to the
community affords little to each
participating individual”
Geoffrey Rose
How much change?
• An additional mean intake of 1/2 serving
of fruits and vegetables in the population
would reduce cancer incidence by 7%
• For every pound of extra weight, the risk
of Type 2 diabetes increases by 4%
• A reduction in serum cholesterol of 1%
results in a 2% reduction of CVD risk
Challenges of promoting
population health
 Adequate and steady funding
 Provides for future rather than immediate
benefit
 Solutions multi-factorial, multi-sectoral
 Challenges entrenched commercial interests
 Fragmentation of public health
Bovbjerg, Ormond, Waidmann (2011 Nov) What directions for
public health under The Affordable Care Act? Urban Institute
Health Policy Center. www.urgan.org
So what are the opportunities?
• IRS Community Benefit requirements
ACA
 To qualify, non-profit hospitals must do
Community Health Needs Assessments (CHNA)
 Identify metrics for outcomes
 Public health: informatics, data mining, outcomes
and effectiveness analysis
Stine & Chokshi (2012) NEJM
So what are the opportunities?
• ACO status – Accountable Care
Organizations – implementing the
Triple Aim
 Track health outcomes
 Track per capita costs
 Active intervention, management of
populations
Stine & Chokshi (2012) NEJM
Minnesota
How well are we doing to achieve the
Triple Aim?
What are we doing right?
What do we need to improve?
Triple Aim: 1) Population Health; 2) Affordability, Quality of
Outcomes, Patient Experience; 3) Cost Reduction
Minnesota
1) Population Health
2) Affordability, Quality of Outcomes,
Patient Experience
3) Cost Reduction
Grade: A-F
Minnesota
Identify and discuss three priorities
for bringing public health agencies
and health care organizations
closer in alignment with the goal of
population health improvement.
How about obligations of other
organizations, institutions?
Public Opinion, ACA
Ten Essential Public Health Services
• Monitor health status to identify community health
problems.
• Diagnose and investigate health problems and
health hazards in the community.
• Inform, educate, and empower people about health
issues.
• Mobilize community partnerships to identify and
solve health problems.
• Develop policies and plans that support individual
and community health efforts.
Ten Essential Public Health Services
• Enforce laws and regulations that protect health and
ensure safety.
• Link people to needed personal health services and
assure the provision of health care when otherwise
unavailable.
• Assure a competent public health and personal
healthcare workforce.
• Evaluate effectiveness, accessibility, and quality of
personal and population-based health services.
• Research for new insights and innovative solutions.