Public Health and Health Reform: Recommendations for an Integrated Approach

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Americans agree that reforming the health system is a national priority. In fact, in a poll conducted just before the November elections, 77 percent of respondents said they would be more likely to vote for a presidential candidate whose top priorities include health care reform.¹ While increasing health care costs are not a new concern among Americans, the recent economic downturn may be strengthening the current call for reform. There is consensus that controlling these costs may prevent further economic hardship, and that revamping the system is a key strategy for long-term economic renewal. Even before taking office, President Obama confirmed this notion by linking health reform to his economic recovery plan. His administration's commitment to health reform was further signaled by the creation of the new White House Office on Health Reform.²

While the U.S. health care system has the highest spending per capita among industrialized countries, we rank only 29 th for life expectancy and 38 th for infant mortality.^3,4 And, recent projections suggest that life expectancy in the U.S. is in decline. 5 Despite increased investment, including higher costs and technological advancements, the population's overall health may be worsening. Obesity and chronic diseases plague our system, creating a relatively new urgency around preventable disease.^6,7 

Could prevention be the key to both reducing costs and improving overall health status? Some recent studies suggest prevention may be too expensive while others point to prevention's potential to enhance quality of life, including recent reports suggesting that non-medical interventions may reduce long-term health care costs.^8,9 At issue is whether primary prevention—preventing disease in the first place—is preferential to secondary and tertiary prevention—disease detection and control—as well as how to pay for it and how to structure a system that supports it. Perhaps an integrated system, incorporating population-based health improvement strategies, may be the ideal health reform model for addressing the joint concerns of cost and well-being.

Primary Prevention & Public Health

Because population-based services are the cornerstone of public health, public health policymakers are calling for a seat at the health reform table.¹⁰ Public health leaders' suggestions for health reform include expanded access to quality health insurance and clinical preventive services, increased funding for community services and training programs, and continued investments in emergency preparedness; yet, prevention lies at the center of public health's core mission.  Since governmental public health agencies are positioned throughout states and localities to perform public health's core functions, they are well suited to provide primary prevention services. Several grants funded through HCFO are investigating public health agencies and their role in primary prevention. These grants include projects that look at:

Health agency performance

• Structural Capacities, Processes and Performance of Essential Public Health Services by Small Local Public Health Systems

• The Influence of Accreditation on Local Health Department Performance in North Carolina

• Improvements in State Health Outcomes: State Public Health Systems Performance and State Health Department Responses to America's Health Rankings

Health agency capacity

• Incorporating Disparities into State Strategies to Monitor and Improve Health Status

• Local Public Health Capacities to Address the Needs of Culturally and Linguistically Diverse Populations
   
• Mapping the Gaps: Enhancing Local Health Departments Capacity to Match Services to Health Needs

Value of agency activity

• Measuring the Value of Public Health Systems
   

Prevention at the Crossroads of Public Health and Health Care

While primary prevention occurs mainly outside of a medical setting, secondary and tertiary prevention are provided by both the public health and the health care systems. This intersection is traditionally where collaboration occurs, for example, in targeting populations at high risk for contracting disease, such as smokers, with interventions, such as smoking cessation.¹¹ According to a recent analysis of cost savings and prevention, secondary prevention is “where the debate about cost savings is most pronounced” while “the economic benefit of tertiary prevention is still in dispute.”¹² HCFO grants investigating issues such as care coordination and disease management may shed light on these more downstream prevention efforts. These grants include:

• Can Disease Management Control Costs?
   
• Impact of the Washington State Diabetes Collaborative on Patient Health and Economic Outcomes
   
• Uptake and Impact of Health Risk Appraisals
   
• Medicare Spending, Disparities, and Returns to Healthy Behaviors State Strategies

The health care system's cost burden weighs heavily on states, many of which have been actively engaged in health reform and systems redesign efforts for decades. With escalating costs as a primary focus, states are looking toward prevention as a key cost saving strategy. While they are still seeking best practices, states are exploring a range of efforts to integrate the spectrum of prevention activities into their health reform strategies.¹³ Examples of such activity include: 

• Primary Prevention: Iowa 's 2008 health reform legislation calls for prevention and chronic care management, disease prevention, and wellness initiatives including reimbursement incentives for preventive care, a requirement for physical activity in schools, and strict nutritional content standards for food sold at schools.¹⁴
• Primary & Secondary Prevention: In response to an unsustainable rise in health care costs as well as an increase in the number of uninsured, Minnesota's state legislature passed a bill in 2008 requiring health reform. The bill includes a package of comprehensive reforms as a result of the Governor's Transformation Task Force which was charged with developing actions that would reduce health care expenditures by 20 percent by 2011 and limit rate of growth of health spending to CPI plus 2 percent, while improving the health status of Minnesotans and reducing the rate of preventable illness. Due to the increasing burden of chronic disease in the state, the Task Force was able to make the case for and garner $47 million in annual funding for public health improvement from the legislature as part of this reform package. The state plans to filter a majority of funds to local public health efforts in support of community health boards and tribal governments.¹⁵
• Secondary and Tertiary Prevention: Vermont 's Blueprint for Health built a community-based infrastructure to address preventable chronic diseases. The plan's medical home model supports multi-disciplinary community-care teams that include a prevention specialist. Additionally, the Blueprint's community activation plans include the development of community profiles and risk assessments, to support evidence-driven intervention.¹⁶

The catalyst for change in these examples included active and influential leaders or task forces demanding a role for public health in state reform efforts. This is not a surprise. During key informant interviews conducted recently with state leaders in public health and in health care finance and delivery, ‘leadership' was determined to be a key driver in securing sustainable, comprehensive reform initiatives. Key informants suggested that leaders can promote coordination, and that many leaders have enough power to insist upon it.¹⁷

Conclusion

Whether prevention drives change, or is an after-thought once costs are analyzed, more research is needed to examine prevention's role in reducing health care costs and improving health status. Further research into the public health system can identify efficiencies to be gained through primary prevention services. Concurrently, state and local experiments to integrate a spectrum of preventative measures will provide valuable best practices and identify potential pitfalls to such a collaborative approach. Ultimately, quality of life may be extended, while costs may be saved, through the transition from a “sickness care system” to a culture of wellness.

HCFO has funded research supporting the public health system through its special topic solicitation in Public Health Systems Research (PHSR). Projects funded through this effort explore how inputs (system structure, funding, organization) influence outputs (agency performance, quality) and ultimately health outcomes. By suggesting adaptations to system inputs, this body of research will yield important information on enhancing public health's influence on outputs, and may signify strategies for health system improvement overall. The most recently awarded grants can be view at http://www.hcfo.org/topics/public-health-systems.

For related HCFO-sponsored research, see the grants listed below. Also, visit www.hcfo.org for all HCFO grants, and http://www.hcfo.org/topics/public-health-systems for grants funded under the special topic solicitation in PHSR.

Title: The Influence of Accreditation on Local Health Department Performance in North Carolina
Institution: University of North Carolina at Chapel Hill
Principal Investigator: Mary Davis, Dr.P.H.
Duration: February 2009—January 2011

The researchers will explore the influence of accreditation among North Carolina's local health departments (LHDs) on improvements in service delivery and health outcomes measures. Specifically, this study will examine if accredited LHDs in North Carolina demonstrate greater improvements in service delivery outputs and health indicators when compared with non-accredited health departments, and examine other factors that could influence this relationship. It will explore the extent and rate by which LHD accreditation influences service delivery and health indicators as well as factors that affect this influence, and key outcomes which are of interest in implementing an accreditation program. The objective of this project is to inform the development of the national public health accreditation model.

Title: Improvements in State Health Outcomes: State Public Health Systems Performance and State Health Department Responses to America's Health Rankings
Institution: University of Tennessee
Principal Investigator: Paul Erwin, M.D.
Duration: February 2009—January 2010

Researchers will examine the relationships between changes in characteristics, Inputs, and activities of state health departments (SHDs) and state public health systems, and changes in state-level health outcomes over the past 15 years. Researchers will also examine how states have responded to America 's Health Ranking (AHR) reports in order to explore whether policy translates into action with positive effects on health outcomes. The overarching questions to be examined are: 1) Why have some states made significant improvements in the AHR rankings, while others have not?; 2) What is the association between these changes in health outcomes and state public health systems performance?; and 3) How have SHDs responded to the AHR reports, and can we identify any specific changes in characteristics, inputs, and activities that might explain changes in health outcomes during the timeframe of the reports (1990-2007)? The objective of this project is to provide a clearer evidence-base for public health practice by effectively showing how state-level changes in inputs, processes, and outputs are connected to health outcomes.

Title: Mapping the Gaps: Enhancing Local Health Departments Capacity to Match Services to Health Needs
Institution: RAND Corporation
Principal Investigator: Tamara Dubowitz, Sc.D.
Duration: February 2009—January 2011

The researchers will assess whether and how geographic information systems (GIS) can be employed by local health departments (LHDs) to inform planning efforts so that they more closely align community health needs with public health services and programs. Specifically they will: 1) examine how LHDs in California and Florida collect and use data to quantify community health needs and distribute LHD services and expenditures; and 2) work with LHD partners to create a gap analysis that identifies spatial congruencies and mismatches between community health needs and the distribution of LHD programs and services. The objective of this project is to help shape decision making by policymakers by providing them with clear illustrations of the need for additional resources or redirection of current services and programs.

Title: Local Public Health Capacities to Address the Needs of Culturally and Linguistically Diverse Populations
Institution: Social and Scientific Systems, Inc
Principal Investigator: Claudia Schur, Ph.D.
Duration: May 2008—December 2009

The researchers are examining the public health needs of culturally and linguistically diverse populations. Specifically, they are developing detailed community multicultural profiles describing the cultural and linguistic diversity of populations served by local health departments (LHDs). They will then use these profiles to analyze the relationships between population characteristics and existing public health capacity and to identify and survey select communities for more in-depth information about serving these populations. Among other questions, they'll research the specific strategies that local health departments engage in to meet the needs of diverse populations, whether community partnerships influence the delivery of culturally appropriate services, and what types of services are most difficult to deliver. The research team intends to develop policy recommendations for implementing strategies for providing better services to diverse populations.

Title: Can Disease Management Control Costs?
Institution: Mathematica Policy Research, Inc.
Principal Investigator: Deborah N. Peikes, Ph.D.
Duration: March 2008—August 2009

The researchers will test the ability of disease management (DM) and care coordination (CC) programs to control health care costs, examine which features make certain programs effective, for which target populations, and how they can be replicated. They will build on prior work for CMS' Medicare Coordinated Care Demonstration that estimated program impacts over the first four years of program operations, described the basic features of the 15 programs' interventions, and linked program features to overall program effectiveness. Five interrelated studies would determine: 1) the effects of DM/CC on costs over a longer follow-up period and the types of beneficiaries for whom DM/CC is most effective; 2) the operational features of DM/CC programs that were able to reduce costs and how they can be replicated; 3) what features of the DM/CC programs did not work and why; 4) whether intensifying contacts at the time of hospital discharge contributes to reducing costs; and 5) whether DM/CC interventions are more effective at reducing costs if the doctor has a greater number of patients receiving the intervention. The objective of this study is to help decision makers determine whether to offer disease management and care coordination to Medicare beneficiaries, as well as chronically ill patients with commercial insurance and Medicaid, and will provide information about how best to implement this intervention.

Title: Medicare Spending, Disparities, and Returns to Healthy Behaviors
Institution: University of Maryland, Baltimore
Principal Investigator: Bruce C. Stuart, Ph.D.
Grant Duration: March 2008—August 2009

The researchers will examine persistently low cost Medicare beneficiaries and determine the extent to which health behavior, preventive services, race and socioeconomic status (SES) appear to be related to low spending. Specifically, the researchers will (1) estimate cost savings in traditional Medicare spending associated with persistently good health behavior and preventive measures; (2) identify population characteristics that can be used to optimally target preventive interventions; and (3) develop simulation models to show how selectively reducing beneficiary cost sharing for primary and secondary preventive measures can achieve significant costs offsets in reduced spending on traditional Medicare services – this mechanism is referred to as “value-based insurance design.” The objective of the proposed project is to identify which disease states and beneficiary segments show the greatest promise for improved compliance and persistency in use of preventive therapies.

Title: Incorporating Disparities into State Strategies to Monitor and Improve Health Status
Institution: Mathematica Policy Research Inc.
Principal Investigator: Marsha Gold, Sc.D.
Duration: January 2007—March 2008

The researchers examined state capacity to develop the 10 leading indicators defined in Healthy People 2010 overall and by geographic group. In particular, they studied 1) the strengths and weaknesses of data available within states to adequately assess the health of a population that includes diverse groups; and 2) the organizational, political, and other forces that promote or impede use of such data to intervene in ways that improve the health of the state's population. The three part study included: 1) an inventory of state practices with respect to available data on leading indicators; and 2) case studies of two states to learn about how the indicators and disparities in the indicators across subgroups are viewed in developing initiatives to improve public health. The objective of this project was to further the vision articulated in HealthyPeople 2010, setting health goals that explicitly link overall improvements in public health to reduced disparities in health status across diverse subgroups of the population.

Title: Impact of the Washington State Diabetes Collaborative on Patient Health and Economic Outcomes
Institution: Washington State Department of Health
Principal Investigator: Amira El-Bastawissi, Ph.D.
Duration: July 2006—February 2009

How do the clinics and primary care physicians participating in Collaborative III of the Washington State Diabetes Collaborative affect the health and economic outcomes of diabetic patients? The collaborative combines elements from Collaboratives of the Institute for Healthcare Improvement and the Chronic Care Model developed by Edward Wagner and colleagues. The researchers would capture the later-stage results of the collaborative, “thus offering an impact evaluation of a mature system-change model.” In particular, the researchers would explain how different components of the collaborative approach to diabetes care management directly affect health and economic outcomes (utilization and costs). The objective of the study is to better inform health plans, public payers, health care providers, and employers about the economic impact of the collaborative, to inform their quality improvement, benefit design, and payment decisions for diabetic patients.

Title: Measuring the Value of Public Health Systems
Institution: The University of Michigan
Principal Investigator: Peter Jacobson, J.D.
Duration: March 2006—May 2007

How can the value of governmental public health systems (GPHSs) be defined and measured? The GPHS is a state and local governmental apparatus designed to assess and respond to threats to the public's health through population-based and individual health services. The researchers examined how other public or quasi-public entities define and measure value; the methodologies used to measure value; the criteria for determining and measuring value; and how measuring the value of these services will affect other important dimensions of public health systems, such as accountability. The objective of this study was to develop ways for policymakers to incorporate value measures for governmental public health system activities into resource allocation decisions.

Title: Structural Capacities, Processes and Performance of Essential Public Health Services by Small Local Public Health Systems
Institution: University of Wisconsin
Principal Investigator: Susan Zahner, Ph.D.
Duration: February 2006—January 2009

What factors influence the performance of small local public health agencies (LPHA) in Wisconsin? The researchers will identify key factors by determining the contributions of specific structural capacities and processes in providing three public health services: 1) monitoring health status, 2) mobilizing community partnerships, and 3) developing policies and plans. The objective of the study is to gain insight into specific factors that can improve the quality of small local public health systems in order to assist policymakers and administrators with targeting resources and technical assistance.

Title: Uptake and Impact of Health Risk Appraisals
Institution: Harvard University of Public Health
Principal Investigator: Meredith B. Rosenthal, Ph.D.
Duration: December 2005—May 2007

In this study, the researchers explored the potential role of HRAs as a tool for managing health care quality and costs in employer-sponsored insurance using HRA responses and health care billing data from CIGNA HealthCare, one of the largest national health plans in the United States. They examine patterns of voluntary HRA uptake and then address whether those who complete an HRA (“HRA-takers”) change their health care utilization patterns differentially relative to a comparison cohort. The researchers' analyses suggest that there are discernable patterns of self-selection among HRA-takers. In particular, women, enrollees of consumer-directed health plans and PPOs, and healthier people are more likely to complete an HRA. Individuals who completed an HRA were less likely however to have received recommended preventive or chronic care in the previous year, despite equal numbers of applicable care recommendations. They also found evidence of changes in health care utilization and quality for HRA-takers, including increases in cervical cancer screening, office visits, and participation in asthma and diabetes disease management.

1 Poll conducted by Research! America, released October 30, 2008. Also see www.researchamerica.org/release_08oct30_election.
2 Remarks of President-Elect Barack Obama, December 11, 2008. To view, click here.  
3 Organisation for Economic Co-Operation and Development, "OECD Health Data 2008: Statistics and Indicators for 30 Countries," December 2008. To view, click here. 
4 MacDorman, M.F. and T.J. Matthews. “Recent Trends in Infant Mortality in the United States,” Centers for Disease Control and Prevention, 2008.
5 Flegal, K.M., et al. "Excess Deaths Associated with Underweight, Overweight, and Obesity," Journal of the American Medical Association, Vol. 293, No. 15, 2005, pp. 1861-67.
6 Thorpe, K.E., Florence, C.S., Howard, D.H., and P. Joski. “Trends: The Impact of Obesity on Rising Medical Spending,” Health Affairs, Web Exclusive, October 20, 2004.
7 Paez, K.A., Zhao, L., and W. Hwang. “Rising Out-of-Pocket Spending for Chronic Conditions: A Ten-Year Trend,” Health Affairs, Vol. 28, No. 1, January/February 2009, pp. 15-25.
8 Russell, L.R. “Preventing Chronic Disease: An Important Investment, But Don't Count on Cost Savings,” Health Affairs, Vol. No. 28, No. 1, January/February 2009, pp 42-45.
9 Trust for America 's Health, “Prevention for a Healthier America: Investments in Disease Prevention Yield Significant Savings, Stronger Communities,” July 2008. To view, click here; and The National Coalition on Health Care, “Prevention's Potential for Slowing the Growth of Medical Spending,” October 2007. Available at www.nchc.org/documents/nchc_report.pdf
10 This issue was addressed during “Comprehensive Health Reform: The Role of State and Local Health Departments,” a public health breakfast conducted in conjunction with AcademyHealth's 2009 National Health Policy Conference. Speakers included Cara McNulty from Minnesota and Hugh Tilson from the University of North Carolina. The informal dialogue included discussion of factors traditionally siloing public health from the health care system, the potential to implement evidence-based interventions in state and local health departments, and suggestions for building inter- and intra-agency partnerships in support of an integrated health system. To view slides, click here.
11 Goetzel, R.Z. “Do Prevention or Treatment Services Save Money? The Wrong Debate,” Health Affairs, Vol. 28, No. 1, January/February 2009, pp. 37-41.
12 Ibid.
13 “The Role of Prevention in Health Reform,” a panel conducted during the 2009 National Health Policy Conference, addressed this topic. Speakers included Ray Baxter from Kaiser Permanente, Craig Jones from Vermont, and Marsha Lillie-Blanton from George Washington University. The panelists suggested that large-scale reform should include strategies for actively strengthening environments that promote health. They supported the notion that health system funding needs to reflect value, not in health care costs, but in the alleviation of disease burden. The moderator, Ken Thorpe, suggested that successful state and community models of secondary prevention should be scaled and replicated. Slides are available at www.academyhealth.org/nhpc/agenda.htm.
14 Iowa Health Care Reform Bill HF2539. Signed by Governor May 13, 2008. To view, click here.
15 Presentation by Cara McNulty, Minnesota State Health Improvement Director, “Health Reform in Minnesota : The Role of Public Health Improvement.” From AcademyHealth's Public Health Breakfast. February 3, 2009. To view, click here.
16 Vermont Blueprint for Health, Also see  http://healthvermont.gov/blueprint.aspx.
17 In October 2008, the State Coverage Initiative Program conducted key informant interviews with state leaders in public health and in health care delivery and financing. These interviews investigated cultural differences, organizational structures, state and federal statutory and constitutional authority supportive of integration, state-level political and economic drivers behind delivery and financing initiatives, and priorities for state health reform. Results from these interviews, as well as a small, invitation-only meeting which engaged seven states in addressing this complex issue, will be released this winter at www.statecoverage.org.