Health Care Reform and the practicing Public Health Epidemiologist

1. Health Care Reform and the practicing Public Health Epidemiologist CSTE June 23, 2014 David Fleming, MD Director and Health officer

3. Health care system • Setting broken bones • Chemotherapy • Mammograms • Smoking cessation services Clinical & medical services

4. Health system • Setting broken bones • Chemotherapy • Mammograms • Smoking cessation services Clinical & medical services • Housing • Chemical dependency management • Mental health services • Employment Human & social services • Media campaigns to prevent smoking • Policy change to reduce chronic disease • Restaurant inspections Community health services

5. Current state Health care delivery system Clinical & medical services Human & social services Public health system Community Health services

6. Future state Clinical & medical services Health care delivery partners Public health partners Human & social services Community Health services

9. Provision of clinical & medical services Public health/health care delivery partnerships Epidemiology and population access to quality, affordable care • Considerations: • Historically, not a major competency of “public health partners” • Limited availability of community wide information on access, quality and cost of clinical services • Potential vested interests of health care delivery partners • Until recently, insolvable financial access issues dwarfed other concerns

11. Provision of clinical & medical services Public health/health care delivery partnerships Example: Public health and ACA enrollment • New financial coverage created new opportunity • Catalyzed community-wide enrollment effort • Used existing partnership networks to bring many organizations to the table • Engaged political and business leadership • Developed a data-based epidemiologic approach

12. Provision of clinical & medical services Public health/health care delivery partnerships

13. Provision of clinical & medical services Public health/health care delivery partnerships

14. Provision of clinical & medical services Public health/health care delivery partnerships

15. Provision of clinical & medical services Public health/health care delivery partnerships Examples of other opportunities for public health epidemiologic expertise • Analyzing access Median wait time for routine adult checkup Percent of primary care providers accepting adult Medicaid patients • Analyzing quality and cost (all payer database) • Analyzing community access and health disparities 15

16. Access to care won’t cure all ills Spending on Health Care Life Expectancy . 16

17. Ratio of social to health services spending by country Source: BMJ Quality & Safety. Health and social services expenditures: associations with health outcomes, EH Bradley, BR Elkins, J Herrin, B Elbel, March 2011

18. Human & social services Public health/health care delivery partnerships Epidemiology and access to integrated health and human services • Considerations: • Historically, not a major competency of either public health or health care delivery partners • Siloed, service oriented nature of human service partners not a good match with data-based approaches • Outcomes difficult to measure and assess on population basis • Somebody else’s job 18

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20. Human & social services Public health/health care delivery partnerships Needs of complex patients Health services alone will not lead to big health improvements 10% of the Los Angeles homeless population accounts for 55% of public costs 20

21. Human & social services Public health/health care delivery partnerships Risk factors for jail recidivism Considerations: • Presence of a serious and persistent mental illness and/or substance abuse issue increases the odds of re-arrest for a new criminal charge • Comorbid conditions compounded the odds ratio further 21

22. Human & social services Public health/health care delivery partnerships Example: Global to Local • Public Private Partnerships using global health strategies to improve health in low-resourced neighborhoods • Capitalized by healthcare and business sectors • Global health expertise provided by Seattle-based global health organizations • One strategy – link patients seeking health care with provider – identified services to address underlying determinants 22

23. Community health Public health/health care delivery partnerships • Epidemiology and Community Health Services • Considerations: • Historically, not a major competency (or interest) of health care delivery partners • Needs outstrip resources of most public health partners • Ambiguous political environment not always supportive of governmental public health intervention • Public Health often siloed from other natural partners (community development, education)

25. Community health Public health/health care delivery partnerships Top countries Average 81.8 US, 78.2 16 years

26. Community health Public health/health care delivery partnerships Life expectancy, by county, compared to the world’s 10 best countries Murray, C JL and Ezzati, M. “Falling behind: life expectancy in US counties from 2000 to 2007 in an international context,” Population Health Metrics, June 2011

28. Community health Public health/health care delivery partnerships Life expectancy in King County

29. Community health Public health/health care delivery partnerships Life Expectancy Frequent Mental Distress Adverse Childhood Experiences Tobacco Use Obesity Preventable Hospitalization Lack of Physical Activity Diabetes

30. Community health Public health/health care delivery partnerships Time for “local global burden of disease” • IHME global burden of disease work www.healthdata.org • Common metric (DALY) allows for all-cause mortality and morbidity assessments • Sophisticated methodology for handling missing data • Rapid, on-line, state-of-the-art data query and visualization system • If it can be done for Nigeria, it can be done for Nebraska (or Nashville)

31. Community health Public health/health care delivery partnerships Community traits and health effects

33. Community health Public health/health care delivery partnerships Measure at the unit of intervention: Create a neighborhood health record • Systematic, ongoing compilation of health information at the neighborhood level • Should include aggregated information about individuals • Could include information about community attributes and interventions • Ideally would leverage “big data” and real time information

34. Community health • Public health/health care delivery partnerships $$$ Working with our health care partners to help pay for all this • Expand permissible use of current $ • Shared savings • Pay for success • New dedicated trusts/funds • Hospital community benefit

35. Community health Public health/health care delivery partnerships Risk factors today predict cause of death in the future, for example diabetes Obesity Diabetes Diabetes deaths Little physical activity

36. “The best time to plant a tree was twenty years ago. The second best time is today.” Chinese proverb

37. Health Care Reform and the practicing Public Health Epidemiologist • Health care reform has the potential to redefine the partnership between public health and clinical care. • Epidemiologic opportunities abound across the clinical, social and community health service domains of a new health system. Clinical & medical services Human & social services Community health services

38. Health Care Reform and the practicing Public Health Epidemiologist • Clinical services could benefit from a population approach to access, quality and cost issues. • Social services would benefit from an epidemiologic approach, period. • Health care partners may be better engaged in community health if we can better provide timely, comparable, and more granular (neighborhood level) information. • Seize the day. Clinical & medical services Human & social services Community health services