Healthy People 2020: even "Uncle Sam" can strategically plan

(My impressions of the Healthy People 2020 development process)

Long-term planning has never been a great strength of policymakers in this country, with one possible exception being FDR’s New Deal (which one could argue deserves some critique). Too often nowadays, policy is drafted, revised, combined with other initiatives and amendments, and implemented without critical debate as to the long term consequences of the policy itself. However, every now and then some of us have the opportunity and privilege to sit in a room and observe experts in the field working with members of the public, thinking critically, listening to one another and then taking definitive steps toward the creation of a really fantastic end-product. My visit to Washington D.C. last weekend was one such opportunity.

The Healthy People Campaign, initiated in 1979 with the Surgeon General's report Healthy People, establishes national health objectives and serves as the basis for the development of State and community plans. Today, the mission, vision, goals and objectives for Healthy People 2020 are being developed. It is as much a strategic planning process as a public awareness campaign; it strives to be as much a nationwide dialogue as a tool for experts and practitioners in the field.

Now, it seems obvious that developing a strategic plan for a small health care business (like a private group practice) or a hospital might be difficult; leaders need to spearhead the process without micromanaging, and employees must be involved in the very development of the plan. Ideally, everyone in the organization understands how the mission, vision and goals make sense in the context of their individual and day-to-day work. Now try creating a strategic plan for a company as large as General Motors, with the knowledge that a strategic planning process never really ends – the final product is ideally, and necessarily, dynamic. Now think of our nation as one gigantic and diverse organization, and imagine putting together a visionary document that is not only a strategic plan, but a guide for an over-burdened health system, and a tool with many different end-users. The thought alone is overwhelming.

Yet there are dedicated people who have done this work, and who continue to do this work, over the course of every decade since the 1980s. Other countries face the same challenge in setting national agendas for their health systems, and in developing appropriate implementation strategies to act on their developed goals. The Secretary’s Advisory Committee is charged with making recommendations which will inform the objective setting process for Healthy People 2020 over the next two years, and the committee is striving to make HP2020 an action-oriented, motivational, inclusive document that sets a dynamic agenda to improve population health in the United States. This is no easy task in a country where no national health system exists, and where perverse incentives often encourage practitioners to treat with technology and medication. Questions peppered the two-day committee meeting: What are the resources behind the promotion of this campaign? Can it be a living, breathing document? Can individuals and the federal government take equal ownership? Should they? Is Healthy People a tool kit, an agenda or a plan? Is it all three things? It was fascinating to listen to the debate.

Healthy People, and the individuals working to develop it, have a Herculean task: setting priorities and goals, reaching multiple audiences, being useful to the lay public as well as local health departments. Such a process/outcome cannot be all things to all people, but it can inform how we as a society improve our collective health and well-being. Watching, and briefly participating, in this debate was fascinating as the draft vision and mission were developed and refined. Eventually the committee had drafted a vision and mission, using input gathered over the course of the previous year and multiple regional meetings with members of the lay public. At present, Healthy People 2020 envisions “a society in which all people live long and healthy lives.” In order to achieve this vision, the committee developed the following mission: “to improve the health and well-being of the public by:

• increasing public awareness and understanding of the underlying causes of health, disease and disability
• providing nationwide priorities and measurable objectives and goals
• catalyzing action using the best available evidence
• identifying critical research and data collection needs"

While this language is not yet final, and therefore likely to change, as it stands now it does address many of the issues confronting local public health departments, policy makers, individuals and clinicians:

• In general, very few people pay attention, or are aware of, HP2020. One colleague at this meeting shared that only one in three of his medical students know about the campaign.
  
• Health reform debates are ongoing throughout the nation, but the proposed plans are virtually identical to the concepts proposed by Nixon’s administration in 1972. The lack of an overarching vision for our health system makes for fragmented care that is frustrating for patients and providers alike.
• Evidence is important, yet research still shows that physicians tend to rely more on their own anecdotal experiences rather than evidence-based practice recommendations. There is a time and a place for experience to inform practice, and we should change our practice if good evidence exists and indicates that action is necessary.
• No offense to white men, but there are other populations of people in our country receiving treatment and care. However, white men still comprise the majority of research study patient populations. Without adequate funding for research to address our diverse national population, we cannot begin to improve the nation’s health.

There is obviously a lot of work to be done in many areas of health, but now is the very best time for this dialogue to occur. We are witnessing an evolution of how we think about health, to whom we assign responsibility for health, and how we fund the care we give and receive. Our population demographics are changing, which may change how we as a nation focus our resources in the health (and other) industries.

The exciting thing is that we can each be a part of this process…wouldn’t it be fantastic to have a hand in developing a national strategic plan? One that meant something or that changed the national approach to health? The Secretary’s Advisory Committee will soon present its recommendations to the Secretary of Health and Human Services, Michael Leavitt, incorporating all public comment and work over the course of this previous year. The vision, mission, and goals that are developed out of this process will inform the development of objectives, and will direct how the new plan will be presented in 2010. If you would like to review the current draft, and comment on any issues that you think are important, visit http://www.healthypeople.gov/hp2020/.

Can health be a political commitment?

Absolutely....

although there hasn’t been much discussion focused on the repair of our “ailing national spirit” as a core component of our work as public health professionals. However, as Virchow once stated, “medicine is a social science, and politics is nothing but medicine on a grand scale.” It makes tremendous sense to view health in this manner; not only as a quality to be measured at either the individual or the population level, but as an essential component of our national philosophy and identity.

As public health professionals, we have the opportunity to effect change at many levels within our society, regardless of our scope of practice. As clinicians, we have the capacity to improve the lives of individuals suffering from physical, emotional or mental illness. We may also be able to reach across disciplines, educating providers and promoting community education. Beyond that, some public health professionals can foster coalitions, form networks, and work to change organizational practices at the corporate, city, county, state or federal level. Ultimately, the mobilization of communities in this manner can influence policy at county, state and federal levels of governance. Using this framework, it is easy to see how a focus on health policy can inspire and promote change.

If we accept that a focus on health is a central component of U.S. diplomacy that can bring resolution to long-standing international conflict, as is advocated by institutions like the UCSF Institute for Global Health (IGH), can we also accept the challenge to employ this approach in order to bring resolution to long-standing national strife? If health inequities can destabilize a region of the world, can they not also destabilize a city, a county, or a state?

I believe that diplomacy, focused on the health of the people in countries with whom we collaborate, can be a highly effective lever to improve international relations. However, I question why we do not think to employ such an approach here, within our own borders. We have already seen the evidence that health status is not equal across every population in the United States, and that level of income and educational attainment underlie existing health disparities.[1] It therefore may be reasonable to ask whether our national society would be greatly improved if we as public health professionals focused our attention beyond the health of populations with whom we work. If we focused our efforts on national diplomacy as a core component of our work in public health, might we see greater improvement in the population health? Such an approach may be just as important for our national security as for our international reputation.

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[1] McGinnis J.M., Williams-Russo P., and Knickman J.R. 2002. The case for more active policy attention to health promotion. Health Affairs. 21(March/April): 78-93.

How can we improve program planning and evaluation in public health?

Use Continuous Quality Improvement techniques.

One of the most important issues to address in the public health profession is how we effectively work to change practice, behavior and policy through programming on every level of the Spectrum of Prevention. The application of continuous quality improvement techniques to public health practice is one of the most useful – and flexible – change strategies to employ when developing and managing programs primarily because the process is iterative, and necessitates evaluation of the process at every step. It also has the added benefit of using a common language that is can be consistently used across the industry.

Designing an effective program to address any aspect of public health (a particular chronic disease, inequity in access to care, disparities in breast cancer screening rates) requires that a practitioner ask a set of particular questions - questions that may seem overly simplistic, but can be difficult to answer:

(1) where are we?
(2) where do we want to be?
(3) should we do something?
(4) what should we do, and how?
(5) how will we know it’s working?

These questions focus a practitioner's work at each step of the process. However, a fundamental aspect of program planning is that it is a necessarily continuous process; which may be a detail that is easy to neglect as program managers and other stakeholders become invested in the programs they design and implement. Nonetheless, a judiciously applied quality improvement approach to program planning may actually be effective in ensuring that program goals are prioritized, and that the program is feasible! Continuous quality improvement (CQI) also encourages program evaluation and therefore can improve the effective allocation of resources within a local, state or federal public health department.

Presently, continuous quality improvement (CQI) techniques, such as the “Plan Do Study Act” cycle, are used in many areas of the health care system in the United States, to both improve quality of care and address issues of patient safety and health inequities. These techniques have shown a great deal of promise at the individual program level, as well as within individual health care facilities (hospitals and nursing homes, for example). However, the challenges remains to use these techniques to create lasting system-wide change. At present, resources are mostly devoted to CQI programming that is focused on improvement at the individual facility level. A great deal of of pressure exists to focus the work of public health practitioners on individual medical services which we perceive to be related to health outcomes. However, we must move beyond the present focus of CQI programs to address the improvement of individual programs or facility performance alone. While CQI techniques have been used widely to address patient safety concerns in the hospital setting, these programs fail to translate to systems-wide improvements which address the root causes of the identified problem. Therefore, while a program may be effective on a facility level, it appears difficult to translate this approach across the spectrum of care in a public health system. To address this issue, the aspects of program planning that emphasize evaluation and revisiting program goals should be applied more rigorously, especially if the program is attempting to address an issue (like obesity) that is by definition beyond the scope of an individual health care facility.

To learn more about Continuous Quality Improvement, visit the Institute for Healthcare Improvement at www.ihi.org.

Should we redefine the CDC's Ten Essential Public Health Services?

No...there are more important issues that deserve our focus!

Historically, the Ten Essential Public Health Services, promoted by the Centers for Disease Control, [i] have served as a framework to define the scope of the public health profession in the United States, and justify much needed federal funding.[ii] However, while this list of services provides a context for public health as a discipline on many levels (federal, state, county), it provides an incomplete framework for practice. The Ten Essential Services document is a framework that is constrained by the system in which it was developed; one that is primarily oriented towards public health solutions that are focused on the individual. Some public health practitioners have suggested that the Ten Essential Services are outdated - or at best inappropriate - for practical application in the field of public health. At present, a work group of California's public health officers has coalesced to redefine and/or update the existing Ten Essential Services, in the hope that such efforts will engender more relevant public health practice. However, if we believe the fundamental goal of public health practice is to improve population health, it is worth asking whether it necessary for county public health officers to spend their time, energy and resources redefining the Ten Essential Services, or whether there might be a better use of such efforts.

The Ten Essential Services can be relevant to current public health practice, to the extent that this framework reminds practitioners of the fundamentals of the discipline, how broad the scope of work can be, and the importance of a multilateral approach to problem solving at the population level. And yet, the scope of the framework is so broad as to be almost undefined. The first two goals of Healthy People 2010 [iii] offer an example of the applicability (or lack thereof) of the Ten Essential Services. Current California mortality data suggest an overall positive trend - that we are doing better in our efforts to improve years of life (part of HP 2010 goal number one), but illustrates the challenges we face in eliminating health inequities (HP 2010 goal number 2). As public health practitioners, we struggle to describe health inequities beyond their medical definitions, emphasizing that health is attributable in large proportion to environmental, social and economic factors. However, measuring longevity as a proxy for population health may be misguided. Rather than identifying the root cause of a particular health inequity, the use of a mortality rate as a health indicator may in fact limit public health efforts to develop policies that can address this inequity beyond those solutions that are traditionally focused on individuals.

The lack of available morbidity data, the lack of validated measurement tools, and the lack of widespread dissemination of the “place-based” approach to public health solutions suggest that California's county level health officers should shift their focus away from further redefining the Ten Essential Services, and instead focus on development of better measures of population health. Simply measuring longevity, and the use of such data to inform policy decisions, ultimately undermines the community-based approach to public health:

Measurement can, and in this context does, function as a trap. We measure a thing because it can be measured, and then we find our system trying to supply what we measure, not because it is what we want, but because it is what we can measure, and thus disseminate.[iv]

Health policy decisions that allocate resources to address or eliminate a particular health disparity are informed by trends that we can measure. With federal policy that is increasingly focused on measurement as a mechanism to improve quality of care in the US, it may be not only useful but strategic to focus some effort towards developing validated measures of population health. Insofar as public health officers can bring daily practice to bear on health policy discussions, it seems clear that – rather than redefining the Ten Essential Services – their efforts may be better dedicated towards developing measures that reflect more appropriate indicators of “place-based” health, and that will serve to reframe discussions of national health policy.

References:

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[i] Centers for Disease Control and Prevention. The Essential Public Health Services. Office of the Director: National Public Health Performance Standards Program. Available at: http://www.cdc.gov/od/ocphp/nphpsp/EssentialPHServices.htm. Accessed March 18, 2008.

[ii] Institute of Medicine (US). The Future of Public Health. Washington: National Academies Press; 1988.

[iii] Healthy People 2010: Fact Sheet. Department of Health and Human Services: Office of Disease Prevention and Health Promotion. Available at: http://www.healthypeople.gov/About/hpfact.htm. Accessed March 18, 2008.

[iv] Fine, M. The Nature of Health: How America Lost, and Can Regain, A Basic Human Value. Radcliffe Publishing Ltd. Oxon, UK: 2007.

Is it time for gender-specific medicine?

YES...and about time, too!!!

I've just returned from the annual meeting of the American Medical Women's Association, better known as AMWA. This is an organization that exists to develop women physician leaders and advocate for quality women's health at the local, state and national level. (You can find more information about AMWA at their website: www.amwa-doc.org). This year, the conference theme was focused on Women and Aging, and in addition to getting some medical education credits, I also had the privilege of connecting with some amazing women leaders. Enthusiastic discussions ensued for a full two days, focused on everything from the viability of recent California health reform to the relevance of gender-specific medicine. What a great event for someone like me...who is just itching to connect the dots between what we do as clinicians (who provide healthcare services to individuals, in the short term) and what we do as public health professionals or policymakers (who provide or regulate healthcare to populations, with significant health and economic consequence in the long term).

As I mentioned, the theme of the conference was care of elderly women. What I found troubling, as did several of my colleagues, was the lack of educational sessions that emphasized differences in symptoms, and response to treatment, between men and women who are living with the same disease (like diabetes or coronary artery disease). We now have substantial evidence that suggests women and men tend experience the same disease with different clinical manifestations, to the extent that sometimes women have symptoms that are completely different, or completely absent from the typical man's experience. Women may also respond to a different treatment regimen for the same disease! However, throughout the conference, few presenters actually acknowledged these gender differences as a significantly important issue for continuing medical education.

Heart disease is a great example. More women than men die yearly of coronary heart disease (CHD) than from all cancers, AIDS, and violence combined. However, women tend not to come into the emergency room complaining of chest pain when they are experiencing a heart attack (what we in the clinical realm call a myocardial infarction). In fact, most women usually have normal stress test results even if they have significant blockage in their coronary arteries. As a result, different screening tests, and potentially treatments, are needed to adequately address the burden of this disease in women. I was pleased to hear such a thorough presentation of the testing and treatment protocols for women with CHD at the conference, but there are at least two potential barriers to the future development of comprehensive policy that might allow for the implementation of gender-specific curricula nationwide. First, most medical education curricula continue to reflect the diagnosis, management and treatment of a male patient, often fo the purely historical reason that the best evidence we have is often drawn from studies where men were the population of reference, and we generalize these protocols to women. Second, even when strong evidence or best practices exist, this information is poorly disseminated among practicing physicians. Despite these (and other) challenges, more gender-specific training is needed for both newly-trained physicians and experienced practitioners. Nationwide organizations like AMWA are often one of the best ways to distribute new clinical information to practicing clinicians, and are uniquely suited to meet challenges like the ones I have presented here. A push for medical education policies that acknowledge the importance of gender-specific curricula from medical school to continuing education, also seems appropriate given the national emphasis on quality improvement and patient-centered care. It may be a first, albeit incremental, step towards dramatically improving the quality of care that women receive nationwide.

Learn more about gender-specific medicine at: http://partnership.hs.columbia.edu/