In early December, the New York State Health Foundation and the New York State Department of Health cosponsored a summit focused on improving population health, with the title, “Making New York the Healthiest State: Achieving the Triple Aim.” We had hoped to convince a critical mass of health sector leaders to come together for a day to begin to understand a simple but difficult task: how can we get to be as good at keeping New Yorkers healthy as we are at getting them better after they experience significant medical problems?
We had thought this goal of getting a critical mass of participants might be difficult, given that so many people struggle with what is meant by population health (some actually think it is about birth control!), and so many people are focused these days on health care and the implementation of insurance coverage through the Affordable Care Act (ACA).
To our surprise, within two weeks of our announcement of the conference, we had 250 people filling the allocated slots and another 300 people on a waiting list hoping to attend the meeting. It turns out that the issue of keeping people healthy has taken hold. Also, to our surprise, there were as many people who were health care providers interested in attending as there were public health leaders.
What explains the interest? The presentations at the conference brought at least two answers. First, health care providers know that they are going to benefit financially from keeping people healthy and out of hospitals as capitated payment systems become more important in medical care financing.
Second, our city and state are getting refocused on the challenge of dealing with inequities, as a new mayor in New York City has struck a popular chord in saying that we are “two cities”—one challenged by low incomes, poor education access, and substantial chronic health problems and the other enjoying an exciting, vibrant economy and culture. Leaders in public health and health care want to address these inequities; population health as a field comprises a broad set of initiatives that can help do this. These initiatives address health behaviors, the built environment that can support healthy behavior, and social determinants of health (such as access to good schools, good jobs, and viable social services).
At the end of the day, I was asked to sum up the discussions and find some themes that we could take away from a rich day of interaction among a group of engaged, smart people finding common purpose.
Here are the six themes I heard:
(1) Population health might be the “sleeper” aspect of the ACA. From the time the ACA was passed until a few months ago, many critics argued that the law lacks sufficient focus on—and funding for—public health and disease prevention approaches that keep people healthy. Today, even though the coverage expansion provisions remain front and center, the energy and attention driving the population health and health care delivery reform aspects of the law are working better than the enrollment piece. The public health and health care fields are focusing on promoting health, preventing disease, improving health outcomes, and tackling health care costs because there are incentives and at least some resources to experiment with new ideas and approaches. Our fears that these elements would be left unattended may be misplaced!
(2) Evidence matters. To make good policy decisions, we need to know what works to prevent disease and keep people healthy. Understanding the financial return on investment is also critical, given relentless pressures to contain costs in a time of shrinking budgets.
Nirav Shah, commissioner of the New York State Department of Health, noted in his remarks at the summit that every dollar invested in community water fluoridation saves Medicaid $14 in children’s dental expenses. Another example: it cost approximately half a trillion dollars over twenty years to implement and comply with the Clean Air Act of 1970, but those changes ultimately saved an estimated $22 trillion in health care costs and prevented 184,000 premature deaths in the same time period. For these two population health interventions, we see both clear health benefits and a clear business case.
At the same time, Tom Farley, commissioner of the New York City Department of Health and Mental Hygiene, pointed out at the summit that not all preventive services save money, and we need to be honest and mindful of that reality. I agree: we need to develop good evidence about which preventive services and population health interventions are effective, understand the associated costs, and make policy decisions based on the best available evidence. Sometimes the health benefits of an intervention will be so clear that it will be worth pursuing regardless of whether it saves money—and sometimes not. But we should not fall prey to the magical thinking that all preventive services are effective or that all of them save money.
(3) Collaboration and partnerships matter. As we move toward new models of health care delivery (such as health homes) that emphasize keeping people healthy, we can expect to see much more collaboration between the health care sector and the public health sector. That much is suddenly becoming more obvious, which is why we saw as much interest in last week’s Population Health Summit among medical providers as we did among public health practitioners. What is especially encouraging, though, and what will be needed to make lasting, meaningful changes in population health is the engagement of employers, social service organizations, and groups focused on agriculture, transportation, education, and housing. We have long known that improving health will require bringing together a range of players representing the broad set of factors outside of medical care that affect health, but we are finally beginning to see that collaboration in practice.
(4) Communities are key. The energy to promote a culture of health takes place at the local level. Here in the state of New York, each county is responsible for developing a Community Health Improvement Plan. I see the county health commissioners leading those plans as the quarterbacks at the community level. Last week’s summit featured two case studies of New York State communities working to improve population health at the local level: the Near Westside Initiative in Syracuse and the CATCH (Collective Action to Transform Community Health) initiative in the Bronx. These programs engaged not just public health professionals but community members, from professors to grocery store owners, who volunteer because they care about the health of their neighbors and about their communities.
(5) Financial incentives are essential. Moving the needle on population health will require not just evidence, collaboration, and community support, but also dollars to drive attention and action (it is America, after all!). At the macro level, accountable care organizations and bundled payment approaches are causing hospitals and other health care providers to rethink their roles and approaches to keeping patients healthy. During last week’s summit, Daniel Sisto (the retired president of the Healthcare Association of New York State, or HANYS) noted that incentives need to be aligned so that hospitals not only are in a position to close beds and reduce utilization, but also to share in cost savings so they will not go bankrupt. In addition, Sisto called for a close look at which hospitals are needed and which are not and the courage to close hospitals that are not needed. In an era in New York State when the trend is to nurse hospitals along rather than to create the right incentives for some hospitals to close, this type of thinking is unusual and very welcome!
At the micro level, we probably also need better incentives to motivate individuals’ behaviors related to healthy eating and physical activities. In his presentation, Andy Stern, former president of SEIU (Service Employees International Union), cautioned employers and health plans to tread carefully in this area, however, and reinforced the importance of evidence. It is rare that a workplace wellness program, for example, has airtight evidence supporting its positive impact on health and on health care costs; Stern pointed out that we are practicing “more evidence-based medicine, but more faith-based wellness.” Given the uncertainty of the impact of many wellness interventions, Stern urged businesses not to penalize employees (through surcharges or higher premiums) who fail to meet workplace wellness program goals.
Finally, incentives are also important at the community level. For interventions such as the Diabetes Prevention Program that see a financial return on investment relatively quickly, health insurers are probably the right players to reimburse for such services. For those interventions that see a financial return only after ten or twenty years and spread across a large population, government should be the engine pushing population health activities.
(6) “Health in all policies” should be the mantra. This idea dovetails with the earlier point about collaboration across sectors. We know that issues like income distribution, discrimination, access to education, social isolation, and environmental factors (from air pollution to the accessibility of parks and sidewalks) have a big impact on how healthy or sick a population is. Across the entire social sector, not just in health care and public health, we need to recognize and address the health impacts of policy decisions.
These themes and ideas are perhaps not groundbreaking. We have known for decades that factors outside of health care have a disproportionate impact on our health status; that collaboration is essential; that community leadership and financial incentives matter when it comes to making meaningful, lasting changes to improve health.
What felt different about last week’s population health summit, though, was the sense that the leaders in that room are the ones who can take those ideas and turn them into actual initiatives that can make a difference in the health of the people of New York State. I am eager to see how they—and we—will rise to the challenge to take big and small steps to create a culture of health and a state full of healthy communities.
Summit agenda, slides, and related resources: http://www.health.ny.gov/events/population_health_summit/
Webcast archive: http://www.totalwebcasting.com/view/?id=nysdoh (From this page, click the image above “Making New York the Healthiest State: Achieving the Triple Aim Population Health Summit, December 3, 2013.”)