Health Care Reform and the practicing Public Health Epidemiologist

Health Care Reform and the practicing Public Health Epidemiologist

CSTEJune 23, 2014

David Fleming, MDDirector and Health officer

Health care system

Clinical & medical services

• Setting broken bones

• Chemotherapy

• Mammograms

• Smoking cessation services

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Health system


Human & social services

Community health services

• Setting broken bones• Chemotherapy • Mammograms• Smoking cessation services

• Housing • Chemical dependency

management• Mental health services• Employment

• Media campaigns to prevent smoking

• Policy change to reduce chronic disease

• Restaurant inspections

Current state


Human &social services

Community Health services

Health care delivery system

Public health system

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Community Health services

Future state

Public health partners

Health care delivery partners

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

Provision of clinical & medical servicesPublic health/health care delivery partnerships

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Epidemiology and population access to quality, affordable care

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



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10/1/2013 1/1/2014 4/1/20140

50,000

100,000

150,000

200,000King County enrollment: 10/13 – 6/14

Medicaid previously eligibleMedicaid newly eligibleExchange

PHSKC, APDE, 6/3/2014 Sources: WA Health Benefit Exchange and WA Health Care Authority. Historical estimates by APDE.

40,021

90,294

48,344

Total: 178,659



Dec 2013

Apr 2014

45%

50%

Examples of other opportunities for public health epidemiologic expertise

Percent of primary care providers accepting adult Medicaid patients

7 days

7 days

Median wait time for routine adult checkup

• Analyzing quality and cost (all payer database)• Analyzing community access and health disparities

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• Analyzing access

Access to care won’t cure all ills

Spending on Health Care Life Expectancy

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Source: BMJ Quality & Safety. Health and social services expenditures: associations with health outcomes, EH Bradley, BR Elkins, J Herrin, B Elbel, March 2011

Ratio of social to health services spending by country

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Human & social servicesPublic health/health care delivery partnerships

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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

Epidemiology and access to integrated health and human services

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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

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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


Risk factors for jail recidivism

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Referral by type of service requested

Housing Assistance 191

Utilities Assistance 127

Nutrition/Cooking 114

Food assistance 109

Employment training 103

Computer classes 98

Clothing assistance 97

Legal assistance 90

Transportation service 85

Job application assistance 68

English language learner class 64

Childcare 53

Parenting class 29

• 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

Example: Global to Local


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Epidemiology and Community Health ServicesConsiderations:• 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)

Community healthPublic health/health care delivery partnerships

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Top countriesAverage 81.8

US, 78.2

AustraliaCanadaFinlandFranceHong Kong IcelandIsraelItalyJapanMacao NorwaySpainSwedenSwitzerland

16 years

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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 26


S eattle

K ent

B e llevue

A uburn

K irkland

F ederal W a y

S am m a m is h

B urien

S hore line

S eaTa c

Tukw ila

Iss aqua h

B o the llK enm ore

C o vington

D es M o ines

S noqua lm ie

W ood inville

M aple Va lley

B lack D ia m ond

E num claw

M ercer Is land

N ew cas tle

N orth B end

D uva ll

P acific

M edina

L ake F ores t

P a rk

A lgona

N orm a ndy P ark

R edm ond

C a rna tion

M ilton

R enton

L ife E xp ec tan c y C o m p ared toth e Ten L o n g es t-L ived C o u n triesb y C en s u s T rac t2005-2009, K in g C o u n ty W A

D a te : 1 0/11/2011

L eg en dC IT Y

C ale n d a r Y ears A h ead

S m all popu la tio n

C a le n d a r Y ears B eh in d

Y ea rs be hind or ahea d a re fro m 2007 .D ata S o urc es : In te rna tiona l life expe c tancies : Ins titute fo r H e a lth M etrics a nd E va lua tion , U nive rs ity o f W a sh ingto nL o ca l life e xpec ta nc y: W a sh ingto n S ta te D epartme nt o f H ea lth,C en ter fo r H ea lth S tatis tic s D ea th F ilesA na lys is and p re pa ration : A ss es s m ent, P o licy D e ve lo pm e nt & E va lua tion ,P ub lic H e a lth – S ea ttle & K ing C ounty, 10/2011

P rep are d by: A ss es s m e nt, P o licy D e ve lo pm e nt & E va lua tion

P ro v is io n a l: S u b jec t to R ev is io n

24 to 5710 to 23Zero to 9

1 to 1 415 to 3031 to 42

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Life expectancy in King County

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Preventable HospitalizationLack of Physical Activity DiabetesObesity

Life Expectancy Tobacco Use Frequent Mental Distress Adverse Childhood Experiences


Time for “local global burden of disease”

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• 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)

Community traits and health effectsCommunity attribute Health effectSubstandard housing Asthma, respiratory problems, lead

poisoning

Lack of fresh produce, healthy groceries

Obesity, diabetes, heart disease, cancer

Lack of health care services A host of preventable health problems

Lack of sidewalks, bike lanes, parks

Obesity, diabetes, heart disease, high stress

Density of alcohol and tobacco retail

Liver disease, motor vehicle death, injury; lung and heart disease

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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


• Expand permissible use of current $• Shared savings • Pay for success• New dedicated trusts/funds • Hospital community benefit

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$$$ Working with our health care partners to help pay for all this

Risk factors today predict cause of death in the future, for example diabetes

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Little physical activity Obesity Diabetes Diabetes deaths


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

Chinese proverb


• 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.

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• 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.

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Health Care Reform and the practicing Public Health Epidemiologist