Population health improvement strategies are collective action problems that require targeted infrastructure, incentives, and information to succeed. Research on collective action problems and solutions in public health and other spheres of practice offer insight for the successful scale and spread of population health innovations

Mays, Glen P.

English

University of Kentucky

University of KentuckyUKnowledgeHealth Management and Policy Presentations Health Management and Policy5-9-2014Producing Population Health: Collective ActionRequires Infrastructure, Incentives & EvidenceGlen P. MaysUniversity of Kentucky, glen.mays@cuanschutz.eduRight click to open a feedback form in a new tab to let us know how this document benefits you.Follow this and additional works at: https://uknowledge.uky.edu/hsm_presentPart of the Health and Medical Administration Commons, Health Economics Commons, andthe Health Services Research CommonsThis Presentation is brought to you for free and open access by the Health Management and Policy at UKnowledge. It has been accepted for inclusionin Health Management and Policy Presentations by an authorized administrator of UKnowledge. For more information, please contactUKnowledge@lsv.uky.edu.Repository CitationMays, Glen P., "Producing Population Health: Collective Action Requires Infrastructure, Incentives & Evidence" (2014). HealthManagement and Policy Presentations. 67.https://uknowledge.uky.edu/hsm_present/67Producing Population Health:  Collective Action Requires Infrastructure, Incentives & Evidence  Glen Mays, PhD, MPH  University of Kentucky  glen.mays@uky.edu Nat iona l  Coordinat ing  Center  Delta Omega Induction Ceremony  •  Lexington KY  •  9 May 2014 WHO 2010 Failures in population health   Failures in population health Preventable Deaths per 100,000 population Failures in population health Commonwealth Fund 2012 Premature Deaths per 100,000 Residents Drivers of population health failures Schroeder SA. N Engl J Med 2007;357:1221-1228 Drivers of population health failures >75% of US health spending is attributable to conditions that are largely preventable – Cardiovascular disease – Diabetes – Lung diseases – Cancer – Injuries – Vaccine-preventable diseases and sexually transmitted infections <5% of US health spending is allocated to prevention and public health CDC 2008 and CMS 2011 Failing to connect Medical Care Public Health • Fragmentation • Duplication • Variability in practice • Limited accessibility • Episodic and reactive care • Insensitivity to consumer values & preferences • Limited targeting of resources to community needs • Fragmentation • Variability in practice • Resource constrained • Limited reach • Insufficient scale • Limited public visibility & understanding • Limited evidence base • Slow to innovate & adapt  Inefficient delivery Inequitable outcomes Limited population health impact Social  Supports What are Population Health Strategies? Designed to achieve large-scale health improvement: neighborhood, city/county, region Target fundamental and often multiple  determinants of health Mobilize the collective actions of multiple stakeholders in government & private sector   - Usual and unusual suspects New incentives & infrastructure are in play Next Generation Population Health Improvement What Makes Population Health  Strategies So Hard? Incentive compatibility → public goods Concentrated costs & diffuse benefits Time lags: costs vs. improvements Uncertainties about what works Asymmetry in information Difficulties measuring progress Weak and variable institutions & infrastructure Imbalance: resources vs. needs Stability & sustainability of funding Courtesy Omaha Community Playhouse Can Public Health Infrastructure Help? Organized programs, policies, and laws to prevent disease and injury and promote health on a population-wide basis   – Epidemiologic surveillance & investigation – Community health assessment & planning – Communicable disease control – Chronic disease and injury prevention – Health education and communication – Environmental health monitoring and assessment – Enforcement of health laws and regulations – Inspection and licensing – Inform, advise, and assist school-based, worksite-based, and community-based health programming …and roles in linking people to medical care & social supports  U.S. Delivery of Recommended  Public Health Activities 0%10%20%30%40%50%60%70%80%90%100%1998 2006 2012Assurance Policy Assessment% of activities ↑ 10% ↓ 5% National Longitudinal Survey of Public Health Systems, 2012 Variation in Scope of Public Health Delivery Delivery of recommended public health activities, 2012 National Longitudinal Survey of Public Health Systems, 2012 % of activities 0 5% 10& Percent of U.S. communities 20% 40% 60% 80% 100%   Percent of activities performed National Longitudinal Survey of Public Health Systems, 2012 Complexity in population health  delivery systems Organizations engaged in local public health delivery -50% -30% -10% 10% 30% 50%Local health agency  Other local government  State health agency  Other state government  Hospitals  Physician practices  Community health centers  Health insurers  Employers/business  Schools   CBOs% Change 2006-2012 Scope of Delivery 2012 National Longitudinal Survey of Public Health Systems, 2012 Seven types of population health delivery systems Scope                High       High         High          Mod           Mod         Low          Low        Centralization Mod        Low         High          High           Low         High         Low Integration       High       High         Low          Mod           Mod         Low          Mod Source: Mays et al. 2010; 2012 0%5%10%15%20%25%30%35%40%45%50%1 2 3 4 5 6 7Comprehensive Conventional Limited 1998 2006 2012 % of communities Health Consequences of Delivery System Change Fixed-effects models control for population size, density, age composition, poverty status, racial composition, and physician supply Infant Deaths/1000 Live Births -6.0-4.0-2.00.02.04.06.08.0Cluster 3 Clusters 4-5 Cluster 6 Cluster 70.02.04.06.08.010.0Cluster 3 Clusters 4-5 Cluster 6 Cluster 7-2.0-1.00.01.02.0Cluster 3 Clusters 4-5 Cluster 6 Cluster 70.01.02.03.04.0Cluster 3 Clusters 4-5 Cluster 6 Cluster 7-0.10.00.10.20.30.4Cluster 3 Clusters 4-5 Cluster 6 Cluster 7Cancer deaths/100,000 population Heart Disease Deaths/100,000 Influenza Deaths/100,000 Infectious Disease Deaths/100,000 Infant Deaths/1000 Births Cluster  1-  Cluster  1-  Clusters 1-3 Clusters 1-  Clusters 1-  Relative Change in Preventable Mortality Rates Associated with Changes in Delivery System Type, 1998-2012  Systems 1-3    Systems 4-5  System 6      System   Systems 1-3    Systems 4-5  System 6      System 7  Systems 1-3    Sy t ms 4-5  System 6      System 7  Systems 1-3    Sy t ms 4-5  System 6      System 7  Systems 1-3    Systems 4-5  System 6      System 7 Mortality reductions attributable to investments in public health delivery, 1993-2008 -9-8-7-6-5-4-3-2-1012InfantmortalityHeartdisease Diabetes Cancer Influenza All-cause Alzheimers InjuryPercent change Hierarchical regression estimates with instrumental variables to correct for selection and unmeasured confounding Mays et al. 2011 58006000620064006600680070007200020406080100120Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5Medical spending/person ($)    .      Public health spending/capita ($)    .Quintiles of public health spending/capitaPublic health spending/capitaMedicare spending per recipientMays et al. 2009, 2013 Medical cost offsets attributable to investments in public health delivery, 1993-2008 For every $10 of public health spending, ≈$9 are recovered  in lower medical care spending over 15 years Some Promising Examples Hennepin Health ACO Partnership of county health department,  community hospital, and FQHC Accepts full risk payment for all medical care, public health, and social service needs for Medicaid enrollees Fully integrated electronic health information exchange Heavy investment in care coordinators  and community health workers Savings from avoided medical care reinvested in public health initiatives Nutrition/food environment Physical activity Some Promising Examples Massachusetts Prevention & Wellness Trust Fund $60 million invested from nonprofit insurers and hospital systems  Funds community coalitions of health systems,  municipalities, businesses and schools  Invests in community-wide, evidence-based prevention strategies with a focus on reducing health disparities Savings from avoided medical care are reinvested in Trust Fund Some Promising Examples Arkansas Community Connector Program Use community health workers & public health infrastructure to identify people with unmet social support needs Connect people to home and community-based  services & supports Link to hospitals and nursing homes for transition planning Use Medicaid and SIM financing, savings  reinvestment ROI $2.92 Source: Felix, Mays et al. Health Affairs 2011 www.visionproject.org  Roles for Scholarship & Leadership Identify common interests, incentives & problems Mitigate asymmetries in power & information Use theory, evidence & experience to design strategies  with high probability of success Use policies, payment systems, & resource sharing  models to incentivize collective action Measure progress & provide feedback  - Fail fast  - Continuously improve Evaluate health & economic impact Common questions of interest Rigorous research methods Data exchange Analysis & interpretation Translation & application PBRNs as Mechanisms for Community-Engaged Scholarship & Learning Engaged  practice settings Research partner Identify Apply Finding the connections Act on aligned incentives Exploit the disruptive policy environment Innovate, prototype, study – then scale Pay careful attention to shared governance,  decision-making, and financing structures Demonstrate value and accountability  to the public Green SM et al. Ann Intern Med. 2012;157(3):207-210 Toward a “rapid-learning system”  in population health More Information Glen P. Mays, Ph.D., M.P.H. glen.mays@uky.edu University of Kentucky College of Public Health Lexington, KY Supported by The Robert Wood Johnson Foundation Email:  publichealthPBRN@uky.edu Web:    www.publichealthsystems.org Journal:  www.FrontiersinPHSSR.org Archive:  works.bepress.com/glen_mays Blog:  publichealtheconomics.org    Nat iona l  Coordinat ing  Center  

Producing Population Health: Collective Action Requires Infrastructure, Incentives & Evidence

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Producing Population Health: Collective Action Requires Infrastructure, Incentives & Evidence

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