Blog post by Brian Castrucci
Brian Castrucci is the Chief Program and Strategy Officer at the de Beaumont Foundation. Prior to joining the Foundation, Brian spent a decade working in state and local health departments. Brian is pursuing his doctorate in public health leadership at the University of North Carolina at Chapel Hill Gillings School of Global Public Health. The opinions expressed are those of the author and the de Beaumont Foundation.
Our traditional model of healthcare delivery doesn’t work like any of us wants it to.
It is not for a lack of spending. While the US spends more than any other country on healthcare ($3.15 trillion in 2014), dozens of other countries outperform the US in basic measures of health. For example, US life expectancy is lower than 26 other developed countries.
It is not for attempts to increase access to and quality of healthcare. US health policy has focused on the expansion of access to and quality of health care; in fact, most significant health legislation (e.g., the enactment of the Child Health Insurance Program and the Affordable Care Act) has expanded insurance coverage.
The problem with our traditional model of healthcare is that it was designed to address biological, physiological, and microbial origins of disease – and today, diseases are most often caused by social and community conditions. TB and cholera aren’t the pressing issues that they were a century ago. It’s dealing with chronic diabetes, asthma, and cardiovascular diseases that is straining our health care system and limiting the length and quality of people’s lives.
Nearly all healthcare spending is invested in those who are already sick, with major investments into a small group of super-users. About 1% of Americans account for 20% of all healthcare spending, and 5% of them account for about half of all healthcare spending.
This is a result of our “sick care” system with a payment structure that rewards procedures – questionable or necessary – while disincentivizing prevention. It has resulted in communities with better access to MRIs than to fresh fruits and vegetables and neighborhoods with more emergency departments and dialysis centers than venues for free or low cost exercise.
No amount of reform focusing on healthcare financing and organizational inefficiencies can fix the community-level drivers of the chronic disease that plague population health and are responsible for much of the healthcare spending in the US – how people manage their health, live their lives, and regulate their diets and physical activity in the context of where they live, work, pray, and play.
We cannot afford to perpetuate a system that pressures clinicians to chase outcomes for problems that originate far beyond their reach. We must pursue transformation that aligns public health and primary care. Neither healthcare nor public health can fix this problem alone. We are in this together and only together can we fix it.
Two sides of the coin: Healing individuals and communities
Primary care providers – which include physicians, nurse practitioners, and physician assistants – play a crucial role in achieving and maintaining health. They are on the front lines of interacting with patients. They see the effects of community conditions playing out in individual health every day. They are the trusted dispensers of health knowledge for most individuals. However, with the growing complexity of intertwined medical and socioeconomic factors, providers often voice concern about how difficult it is to advance the health of people in their communities and positively impact their lives.
While their medical bags are full of extraordinary tools and techniques, “stabilizing a condition” is different from addressing its root causes, let alone preventing similar problems from occurring in the future. There is no pill or procedure that can effectively treat or cure the limited access to healthy eating options, limited access to exercise opportunities, exposure to environmental toxins, or the disproportionate distribution of alcohol and tobacco outlets. These are the community-level drivers of disease that plague population health and are responsible for much of the healthcare spending in the US.
Improved collaboration with public health is a powerful strategy to complement individual healthcare – enabling trained professionals to prevent disease before it occurs and create healthy, supportive environments for those already sick.
Public health practitioners are responsible for understanding, attending to, and having an impact on the community’s health as a whole, regardless of insurance status or access to medical care. Public health practitioners – when adequately supported – have the knowledge and ability to respond when patient needs are grounded in conditions far outside of the reach of a clinician’s toolset. For example, they can initiate housing inspections for asthma sufferers living in substandard conditions. They can implement community-wide tobacco cessation programs. They can develop policies to incentivize greater access to healthy and fresh foods in convenience stores and through mobile markets.
Many public health departments have staff with a deep understanding of data and the skill to analyze and deploy it to the benefit of communities, patients, and providers. When patient concerns are related to lifestyle choices or the environment in which they live, work, and play, public health practitioners can help shape the community to make health the default choice by working across sectors (housing, education, criminal justice, etc.) to elevate and address these issues.
While public health practitioners may have the knowledge and skills to address the social determinants of a disease, a term that is well defined by Bernadette Keefe in her recent Healthcare Leadership blog post, we still struggle to get ahead of the curve in detecting and addressing chronic illnesses. Primary care can provide access to real-time information on emerging disease clusters, and public health can use those data to more accurately target interventions to promote wellness.
By joining forces to share and analyze data, public health and primary care can develop stronger, better strategies to improve neighborhoods and the individuals who live there.
Moving beyond medical whack-a-mole
If we are to improve population health, from clinic to community, public health practitioners and primary care providers must see their work as components of a collaborative health system that acts upon the undeniable link between the individual and the community.
Primary care’s commitment to individual health offers a depth of understanding about patient needs from a clinical perspective. When combined with public health’s understanding about health needs from a community context, we can effect real and positive change on a systems level. Otherwise, we’re just playing whack-a-mole: waiting for sick individuals to cross the threshold one by one and sending them back home again with a quick fix. Not only is this method frustrating to both patients and clinicians, but it’s expensive – for individuals, for insurers, and for health care as a whole.
Fortunately, there are resources and initiatives that can help. The Practical Playbook: Public Health & Primary Care Together (open access at www.practicalplaybook.org and for purchase through Amazon) has catalogued success stories from across the country documenting exactly how projects to improve population health were executed through primary care and public health partnerships. The Practical Playbook also provides guidance on developing, leading, and evaluating an integrated project. The American Academy of Family Physicians’ 2014 policy statement, Integration of Primary Care and Public Health, identifies 14 activities in which public health and primary care can work together. These can be grouped into three broad collaborative activities: data and analytics; policy and environmental changes; and aligned health messaging. Innovators and disruptors have already given us great examples of each.
Initiatives like the BUILD Health Challenge, HICCup’s Way to Wellville, the Institute for Healthcare Improvement’s 100 Million Healthier Lives campaign, the American Public Health Association’s Healthiest Nation in One Generation project, the Centers for Disease Control and Prevention’s Community Health Improvement Navigator tool, and the National Committee on Quality Assurance’s Population Health Framework Action Guide are all working toward systems-level partnerships and community-based solutions that promote an upstream focus for downstream health gains.
Localized efforts can have outsized results. The New York City Department of Health and Mental Hygiene’s Primary Care Information Project has worked with clinical practices throughout NYC to analyze clinical information to improve provider adherence to clinical guidelines that reduce preventable death. As a result of this work, there was a 33% increase in the management of high cholesterol and a 15% increase in blood pressure control.
On the August 11, 2015, there was a lively #hcldr chat on the topic of population health. There was consensus on the “what” and the “why” of focusing on population health and addressing the social determinants of health but less on the “how.” On September 29, 2015 at 8:30 Eastern (for your local time click here), join #hcldr for a Twitter “brainstorm” to share the “how” from your experience and identify paths for integration going forward. We will consider the following four questions:
- T1 How do you/can you work more closely with public health agencies and programs?
- T2 What do you need from public health officials that you are not getting? What are some examples of public health supporting the clinical provider?
- T3 How do you/can you specifically help patients address the social determinants of health?
- T4 What is one idea, practice, or policy that could further your efforts to work more closely with public health practitioners to address the social determinants of health?
Resources
“Health Sector Economic Indicators”, Altarum Institute, February 12 2014, http://altarum.org/sites/default/files/uploaded-related-files/CSHS-Spending-Brief_February_2015.pdf, accessed September 22 2015
“The Case For More Active Policy Attention To Health Promotion”, J Michael McGinnis, Pamela Williams-Russo and James R Knickman, Health Affairs, March 2002, http://content.healthaffairs.org/content/21/2/78.long#ref-1, accessed September 22 2015
“5% of Americans Made Up 50% of U.S. Health Care Spending”, Jordan Weissmann, The Atlantic, January 12 2012, http://www.theatlantic.com/business/archive/2012/01/5-of-americans-made-up-50-of-us-health-care-spending/251402/, accessed September 22 2015
“Integration of Primary Care and Public Health (Position Paper)”, AAFP, December 2014, http://www.aafp.org/about/policies/all/integprimarycareandpublichealth.html, accessed September 22 2015
hcldr 
One of the best blogs I have read. Unfortunately I will be on an airplane during the next scheduled chat. Viridian supports a national clinically integrated network of lower-cost community resources in partnership with public health to address chronic disease prevention and control through health plan contracts. I look forward to more!
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[…] love that Karen suggested that both these communities come together because this weeks #HCLDR twitter chat was about the issue of (#sdoh) social determinants of health (things like wealth and access to healthcare). What a great collaboration! Bringing social workers […]