Place-based policy

I recently had the privilege to attend the semi-annual CCLHO (California Conference of Local Health Officers) meeting in Oakland, California. This meeting represents an opportunity for county public health officers (often physicians) to collaborate with each other face-to-face. It is a time for those involved in the day-to-day work of public health to connect withpeers, discuss county-wide approaches to current public health issues (like H1N1 flu), and to attend educational sessions about new or alternative approaches to improving the health of Californians. An incredible amount of thought, hard work, and creativity filled our three-day conference, and there was no shortage of discussions about H1N1 preparedness, vaccine distribution and disaster planning. However, one portion of the conference focused our energies toward a more fundamental topic: that of health inequities in California.

Health inequities are probably best defined as “differences in population health status and mortality rates that are systemic, patterned, unfair, unjust, and actionable, as opposed to random differences or differences caused by those who become ill” (1). The implication is that there are structural or system effects in our society which are borne out by how we each live our daily lives. If you think about it, "health" is a result of not only what we choose to do on a daily basis (eat healthy food, exercise, connect with our family and friends), but what we are able to do based on our surroundings. For example, can everyone readily obtain daily servings of fruits and vegetables? Do we have time to sit down and enjoy our lunch with co-workers? Are we able to go jogging every other day? Can we take our kids out to the park on the weekends for some fresh air?

These questions bring us to the idea of place. What role do our physical surroundings play in our health decisions and our health status? If you consider that for some of us it is easier to obtain locally grown fresh fruits, and that for some of us going jogging in the evening is considered extremely unsafe, then place has a lot to do with our daily health choices, and with our overall health status both as individuals and as members of a larger community. This is not a new idea, but it is becoming continually important as local health departments and public health officials seek to reduce rates of chronic disease and mortality in their own communities. It might not be “health policy” as we usually think of it (changing how we deliver care in community clinics or reducing health insurance premiums), but it turns out that small changes in certain place-based policies can have a profound effect on health status. The 2008 report Health Inequities in the Bay Area, produced by a collaboration of public health departments, elegantly demonstrates that our collective health status and life expectancy is directly tied to where we live, our levels of income and wealth, our ethnicity, immigration status, educational attainment and the degree of inequality in our surrounding communities (2). Other data suggest that only approximately ten percent of our health can be directly attributed to improvements in health delivery; in one study reviewing data from the years 1991 - 2000, an estimated 177,000 deaths in the U.S. were averted because of advances in medical technology. However, that same study estimated that if we were to eliminate the disparity between African Americans and Whites, we would have avoided over 886,000 deaths (3).

Many people have written on this topic and it is a well-known concept in many public health departments in California, but the applicability of the ideas are only slowly being realized in state legislation or county regulations. Not that any of this is easy; it takes true collaboration and coalition building to make our communities into healthy places for all. The essential point that I want to reiterate with this blog post is that we can’t necessarily get better health outcomes if we focus solely on changing health care delivery, health care institutional policy, or health insurance policy. We need to think about health in broader terms, because health policy is education policy as well as insurance policy; it is social policy as well as health care delivery. It is how we live our lives, and how we are able to live our lives that determines the degree to which we use and need the current health care system. If we consider the current national health reform process in the context of place-based policy, it is clear that health insurance is only one of the determinants that affect our overall health.

(1) Whitehead, Margaret M. 1992. The Concepts and Principles of Equity and Health. International Journal of Health Services 22(3):429.
(2) Health Inequities in the Bay Area. BARHII 2008. Available at: http://www.barhii.org/press/download/barhii_report08.pdf. Accessed 11/3/09.
(3) Wilkinson R., Marmot M. (eds). Social Determinants of Health: The Solid Facts. 2nd Edition, Copenhagen: World Health Organization, 2003.

Health insurance reform and the importance of the medical loss ratio

Last weekend, I eagerly went to a town hall hosted by Congresswoman Doris Matsui. The topic was the current health reform process, and I was interested to hear the discussion and possibly have a chance to participate in the forum. (For additional news coverage of the town hall, see the article in the Sacramento Bee). No one threw a chair or defaced public property, but it was clear that health reform was a hot topic and there was a great deal of shouting, clapping, booing and placard waving. Constituents voiced their frustrations, and perspectives about health insurance reform in many ways and from many different perspectives. A common theme, however, was heard as one participant after another voiced frustration with high health insurance premiums, limitations of care, and escalating personal costs of care. I didn't have an opportunity to ask a question of Representative Matsui, but I think it was particularly revealing that so many people asked her to comment on how the reform process would address insurance company practices.

In reality, the current health reform is health insurance reform, rather than full system reform. Health insurance is one, and only one, part of the larger system of health care in this country. I think many people would agree that aspects of care delivery, patient safety, pharmaceutical sales policies and other elements of the health care system are in need of reform. Nevertheless, health insurance companies are a major driver of cost of care in the US health care system, and the town hall discussion was so focused on health insurance policies and company profits that the term medical loss ratio was actually mentioned several times. Though not a concept well known outside the circle of health economists, it is one that serves to illustrate the importance of the current reform efforts.

The medical loss ratio is a term which describes the ratio between what a health insurance company pays out in claims for actual health care services, and what the company spends on sales, marketing, administration, and profit. If a relatively healthy person is insured at company A, and paying a premium of approximately $2500 per year (1) but does not visit the doctor regularly or uses minimal health services, the health insurance company can devote most or all of that premium towards non-health related expenses (advertising, shareholder dividends, etc). In this case, their medical loss ratio is relatively small. Compare that to a person with multiple medical conditions who sees a physician multiple times a year, and you can imagine that the insurance company is paying more per month towards health services for that person and less money towards non-health expenses. Right now, there are no federal laws that require health insurance companies to devote any percentage of premiums towards health services. This means that if a really sick person is insured at company A, the company might require that individual to pay a certain percentage of care out-of-pocket in order to limit the companys' medical loss. Essentially, a health insurance company is likely to earn more profit if it has to pay less for health services. To "drive down medical loss," a health insurance company could choose to selectively insure relatively healthy people so that the company will be more profitable.

This is one of the main reasons we need the current reform effort to succeed; so that policies developed at the national level will limit the degree to which insurance companies can drive down their medical losses. Yes, health insurance companies are a business and therefore have a responsibility to demonstrate profit to shareholders. In most markets, the incentive to increase profits can provide a powerful stimulus to innovate, create and drive further efficiencies in an industry. However, in the health industry, this profit incentive also stimulates creative mechanisms to drive down medical loss, such as rescinding health coverage for people who are found to have pre-existing conditions, or raising premiums to unrealistically high levels in the hopes of losing some customers who cannot afford the rate increase. This results in higher costs (both monetarily and clinically) for the sickest people in our country and for all of us who pay insurance premiums.

The basic premise currently serving as a foundation for ideas and proposals within the House and Senate health reform bills is that health care is, primarily, a business. As one who believes there are serious market failures in the system (as illustrated by the medical loss ratio), I have struggled with the business premise as a place to begin forming my opinions about the current reform effort. It's not that I believe health care is not a business, but that it is much more than a market-based business. I believe health care represents a service, a public good, and a business that serves both individuals and communities nationwide. This changes the ways we could structure our economic and policy analyses of the current system and of reform. That said, I do accept that (a) reform must start somewhere and (b) the current economic climate makes a "start from scratch" approach less-than-feasible. Nevertheless, I hope the current reform effort is a starting place for further discussion about improving the overall health care of the nation, and not just a debate about how to create fair health insurance policy.

(1) Trends and Indicators in the Changing Health Marketplace. Exhibit 3.5: Average Monthly Employee Premium Contributions. http://www.kff.org/insurance/7031/ti2004-3-5.cfm
Accessed 10/15/09.

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.