Category Archives: Q&A
Ending Healthcare Waste, Improving Healthy Lives: Q&A with the L.A. Department of Public Health’s Jonathan Fielding
In a report released last year, the Institute of Medicine found that the United States wastes billions of dollars each year on such unnecessary spending as inefficiently delivered services, excess administrative costs, fraud and missed prevention opportunities. In response, a group of senior public health scholars at the UCLA Fielding School of Public Health, led by Jonathan Fielding, MD, MPH, a professor at the school and the director of the Los Angeles Department of Public Health, published an article in the American Journal of Preventive Medicine on the improvements to population health the country might realize if only the wasted money was devoted instead to the social and environmental determinants of health. If the government could reap 45 percent of the wasted medical care costs, argues Fielding and his co-authors, and invested those resources in sectors such as education, jobs, healthier foods and transportation infrastructure, the health of millions could be markedly improved and society would see additional social benefits.
Jim Marks, Senior Vice President and Director, Health Group at the Robert Wood Johnson Foundation echoed this approach at the recent American Public Health Association (APHA) annual meeting in Boston.
"We know lots about the cost of illness, but very little about the value of health,” he said.
Marks also said that focusing on health as the ultimate goal tends to eclipse some of the social determinants that can have enormous impact on people’s lives. “Most people don’t want good health as their outcome, they want a quality life. They want to travel, take care of grandkids, have a rich family and social life—you can only do that if you’re healthy,” said Marks. “It’s unrelated to good quality medical care. It’s related to education, safe neighborhoods, [and other social factors].”
According to Marks, improving public health isn’t about curing individual diseases or fixing specific injuries. Rather, it’s about everything; the diseases are the end result of the system we live in. And with all the data we have available, we know it’s a system that needs fixing, said Marks.
Marks’ thoughts came at an APHA panel Fielding moderated in a closing day session about the health impact of investment in major social and environmental policies and interventions; information gaps and how they can be filled; and how the discussion of health spending can be re-framed so that U.S. resources can be invested most productively.
NewPublicHealth spoke with Fielding about better uses for the wasted health care spending just before the start of the APHA meeting.
Tobacco featured prominently as a public health issue at the American Public Health Association (APHA) meeting this week, including a regulatory update from Mitch Zeller, JD, who became director of the U.S. Food and Drug Administration’s (FDA) Center for Tobacco Products earlier this year. Zeller previously worked on tobacco issues in government as associate commissioner and director of FDA’s first Office of Tobacco Programs, and also as a U.S. delegate to the World Health Organization (WHO) Working Group for the Framework Convention on Tobacco Control.
NewPublicHealth spoke with Zeller ahead of the APHA meeting.
Mitch Zeller: I think most broadly my goals are to help give the center and the agency the greatest chance of fulfilling the public health mission behind the law passed in 2009 giving the Food and Drug Administration authority over tobacco. This really is an important piece of legislation. It’s really stunning that in 2013—with everything that we know about the harms associated with tobacco use—that it remains the leading cause of preventable death and disease both in this country and globally.
There are some very powerful tools that Congress has given FDA to use wisely and supported by evidence. That’s where I think, the greatest opportunity lies: to use the tools relying on regulatory science to try to protect consumers and reduce the death and disease toll from tobacco.
There are two areas where I think these tools can make a profound positive impact on public health. The first is something called product standards, which is basically the power to ban, restrict or limit the allowable levels of ingredients in tobacco or tobacco smoke. We are exploring potential product standards in three areas: toxicity, addiction and appeal. And we are funding research in all three areas and working very hard behind the scenes to find out what our options are for potential product standards in those three areas.
Stakeholder Health, formerly known as the Health Systems Learning Group, is a learning collaborative made up of 43 organizations, including 36 nonprofit health systems, that have met for close to two years to share innovative practices aimed at improving health and economic viability of communities.
The idea for the learning collaborative came from a series of meetings at the White House Office and U.S. Department of Health & Human Services Centers for Faith-Based & Neighborhood Partnerships. The Stakeholder Health administrative team is based at Methodist Le Bonheur Healthcare Center for Excellence in Faith and Health in Memphis, Tenn., and at Wake Forest Baptist Health System in Winston-Salem, N.C. The Robert Wood Johnson Foundation provided a grant to share the group’s findings and lessons learned.
Earlier this year, Stakeholder Health released a monograph to help identify proven community health practices and partnerships. Kimberlydawn Wisdom, MD, MS, Senior Vice President of Community Health & Equity and Chief Wellness Officer at the Henry Ford Health System was a key contributor to the monograph.
NewPublicHealth recently spoke to Wisdom about Stakeholder Health’s objectives, goals and emerging successes, which she also presented on at the American Public Health Association’s annual meeting in Boston.
NewPublicHealth: What are examples of implementation of the Stakeholder Health recommendations at the Henry Ford Health System?
Kimberlydawn Wisdom: There are several. Stakeholder Health talks quite a bit about transformative partnerships and the importance of those transformative partnerships. And we have some stellar examples here in southeast Michigan of transformative partnerships, and one that I’d like to point to in particular is an effort we established called Sew Up the Safety Net, which addresses decreasing the infant mortality rate in our region, which is appallingly high.
We’ve developed a partnership with three other competing health systems within the Detroit region. So while on one level we are very strong competitors, on another level, we’ve actually joined our strategies and resources together in order to address the infant mortality challenge that we have in our communities. We also have private partners and public partners that are involved with us at various levels, but I think having that unprecedented partnership with competing health systems and getting real work done is something that we’re very proud of and work very hard to maintain.
New research presented at the American Public Health Association (APHA) annual meeting in Boston today finds that when public health funding increases in a community, its rates of infant mortality and deaths due to preventable diseases decrease over time, with low-income communities experiencing the largest health and economic gains.
According to the research, conducted by Glen Mays, PhD, MPH, director of the University of Kentucky’s National Coordinating Center for Public Health Services and Systems Research, each ten percent increase in public health spending over 17 years led to a 4.3 percent reduction in infant mortality, as well as reductions of 0.5 to 3.9 percent in non-infant deaths from cardiovascular disease, diabetes, cancer and influenza.
However, these health gains were 20-44 percent larger when funding was targeted to lower-income communities. Increases in public health spending also correlated with lower medical care costs per person, especially in low-income areas. The study, which analyzed data compiled by the National Association of County and City Health Officials from 3,000 local public health agencies over a 17-year period, also found that lower death rates and health care costs were seen especially in communities that allocated their public health funding across a broader mix of preventive services.
“The results clearly show that better health and lower health care costs are possible if we simply change how and where we allocate public health funding, even if new money isn’t available, said Mays. “And it also shows that new resources, such as funding from the Affordable Care Act’s Prevention Fund, can have a larger impact if targeted to lower-resource, higher-need communities and if spread across a range of prevention strategies.”
>>NewPublicHealth will be on the ground throughout the APHA conference speaking to public health leaders and presenters, hearing from attendees on the ground and providing updates from sessions, with a focus on how we can build a culture of health. Follow the coverage here.
NewPublicHealth spoke with Mays about the new study just before the APHA annual meeting began.
NewPublicHealth: What are the key findings of the study?
Glen Mays: We’ve done prior studies that show communities that invest more on public health realize gains in health status and, over time, those communities see slower growth in medical care costs. So the goal of the study is to look at who benefits most from investments in public health.
What we found was that, not all that surprisingly, communities that are more economically constrained, that have lower income communities with higher poverty rates and lower socioeconomic status, tend to benefit the most from investments in public health activities over time. These low-resource communities see larger reductions in their preventable mortality, and they also see larger reductions in their medical care costs over time from investments in public health spending compared to more affluent communities. We expected to find that, but this is the first time we’ve been able to document the size of that effect. Those communities see about twenty percent higher rates of health and economic gain from their spending compared to more affluent communities.
Since 2008, local health departments have cut nearly 44,000 jobs, according to a recent survey conducted by the National Association of County and City Health Officials. Although workforce losses and gains were roughly equal in 2012, 41 percent of local health departments nationwide experienced some type of reduction in workforce capacity and 48 percent of all local health departments reduced or eliminated services in at least one program area. Currently, local health departments reporting cuts still exceed the percentage of local health departments reporting budget increases.
California’s Napa County has dealt with its budget cuts by revamping its health department in order to continue to stay on mission.
“I think we've come out the other end of all this as a much stronger health department,” said Karen Smith, MD, MPH, Health Officer and Deputy Director for Public Health at Napa County Health and Human Services. “We moved from what I think of as an ‘old style’ [public health agency] to a department that focuses on our role as a convener/partner, providing expertise and leadership, and helping to craft policy.”
NewPublicHealth recently spoke with Smith about the methods Napa Public Health used—and that other departments might follow—to adapt and improve in the face of budget cuts.
NewPublicHealth: How have budget changes impacted your department over the last five to ten years?
Karen Smith: Napa Public Health started out with a lean health division for the size of the county compared to some of our colleagues, and we remain lean. We have not really decreased services, however. We were able to get out ahead when we saw looming budget constraints.
Napa Public Health is part of the County’s Health and Human Service Agency, which includes social services, as well as mental health, drug and alcohol, child welfare services, comprehensive services for older adults and public health, and our administrative divisions. The previous director had a distinctive approach to budgeting: that the agency has a bottom-line budget and within that we have very detailed division budgets. So I have excruciatingly detailed budgets for every single program within public health, and that was crucial to our being able to respond to the budget shortfalls in creative ways that had limited impact on services.
More than 10,000 public health officials, academics and students will gather in Boston next week for the 2013 American Public Health Association Meeting in Boston. This year’s theme is “Think Global, Act Local,” drawing critical attention to the increasingly global world of health where events across the globe—from food safety, to infectious disease outbreaks, to innovative public health solutions—can impact every local neighborhood.
>>NewPublicHealth will be on the ground at the APHA Annual Meeting, with speaker and thought-leader interviews, video perspective pieces and updates from sessions, with a focus on what it takes to build a culture of health. Follow our coverage here.
Ahead of the annual meeting, NewPublicHealth spoke with Georges Benjamin MD, APHA executive director.
NewPublicHealth: Why is the theme “Think Global, Act Local” so important?
Georges Benjamin: We’re in a world in which everything is global. There are no boundaries anymore. Rapid transit through planes, the fact that our borders are so porous...public health has always been a global enterprise, but even more so today. Our food comes no longer from a single farm but from multiple farms and sometimes multiple countries, so foodborne risks for disease and illness are global. We’ve seen that terrorism disasters are global. We’ve seen that obesity, particularly with corporations that sell certain products globally, is a big issue, and tobacco has always been a global issue. So, public health is global, and the idea is that if we can learn from people around the world and then utilize those learnings within our local communities, we’ll be stronger
NPH: What are some of the meeting sessions you’d highlight?
Benjamin: Our opening session will feature Professor Sir Michael Marmot, Director of the International Institute for Society and Health and Research Professor of Epidemiology and Public Health at University College, London, who spoke at our meeting five years ago on the social determinants of health and is going to give us an update. In the closing session, we’ll hear from actor/physician/public health doctor, Evan Adams, MD, the deputy provincial health officer for British Columbia, who will speak about improving the health of native people. So in both our opening and closing sessions we’re looking globally, as well as emphasizing what happens locally. We’ll also hear from the minister of health of Taiwan, who will talk about universal health care as well as violence prevention. And we’ll also be holding sessions that track the many public crises that we’ve already had this year.
At the recent 2nd Annual National Heath Impact Assessment Meeting held in Washington, D.C.,Paul Anderson, MD, MPH, manager of the HIA Program at the Alaska Department of Health, spoke about his state’s HIA efforts and successes. NewPublicHealth caught up with Anderson following the meeting to ask about lessons learned that can benefit other public health officials considering and conducting health impact assessments.
NewPublicHealth: Tell us about the HIA program in Alaska and how the health department has made HIA a routine part of decision making.
Paul Anderson: HIA in Alaska started with a couple of health impact assessments done in conjunction with natural resource development permitting and environmental impact statements (EISs) in the north of the state. These studies generated increased interest in the human health concerns that arise during project permitting. The Department of Natural Resources (DNR) contacted the Alaska Division of Public Health, asking us if we could get involved with this new idea—called health impact assessment—as it related to natural resource development permitting.
After some deliberation, we realized the importance of being involved with this work, and so we developed an HIA working group. That working group met for about three years and developed an HIA Toolkit, which is our guidance document for performing HIA in Alaska. Out of that working group came a realization that Alaska needed an institutionalized HIA program in order to lead this process forward effectively. So the group eventually decided to create an HIA Program in the Division of Public Health under the Section of Epidemiology.
NPH: Have you worked collaboratively in Alaska on HIAs?
Anderson: When our program was new, we wanted to conduct field work because we needed additional health information regarding a specific region of rural Alaska. This field work involved utilizing surveys, which can be very tiring for rural communities because they are surveyed frequently. There are several agencies in Alaska that already do surveys as a routine part of their work, and one of those is the Alaska Department of Fish and Game. They go house-to-house and community-to-community and use a very well-designed survey tool to learn about subsistence foods. They worked with us to integrate some important questions about food consumption onto their survey form. This turned out to be an effective cooperative relationship that benefitted both agencies and reduced the strain on rural communities.
A key session at the Second National Health Impact Assessment Annual Meeting held recently in Washington, D.C., was a panel discussion on several evaluations of the value and benefits of health impact assessments (HIAs). Andrew Dannenberg, MD, MPH, an affiliate professor at the University Of Washington School of Public Health, was a consultant on a recent evaluation of HIAs funded by the Robert Wood Johnson Foundation and a member of the evaluation panel at the HIA meeting. NewPublicHealth spoke with Professor Dannenberg about some recent findings.
NewPublicHealth: What have the recent evaluations of HIA as a tool told us about the value conducting health impact assessments?
Andrew Dannenberg: Essentially, HIA works. The tool does seem to promote health, and does have influence in some cases but not others. HIAs can influence the health component of [policy] decisions.
There are also indirect HIA benefits: by getting public health professionals talking with decision makers in other sectors—such as transportation and housing—HIAs create partnerships and collaborations for longer-term value. So a transportation department building a highway may then always realize that there are health implications of what gets constructed.
We also came away with a list of factors that influence HIAs to make them successful. The list includes:
- Timeliness is often a factor when doing an HIA (in that the HIA must be completed and recommendations made in time to support or influence the policy decision).
- Involving stakeholders and decision makers gives a better chance that the recommendations will be considered.
- It is important to have community engagement and feedback, or, particularly when it is an HIA being done rapidly, it is critical to have a well-informed health leader at the helm.
- It is critical to screen the topic to be sure it is appropriate for an HIA.
- Dissemination to stakeholders, decision makers and media is very important, using methods, length and language appropriately customized for those audiences.
- HIA recommendations need to be clear and actionable.
- The Australian evaluation found that a key to successful HIAs was getting the right people at the right time to work together.
NPH: Do you have an example of an HIA that showed that using the tool leads to better decision making?
Dannenberg: An HIA conducted in San Francisco several years ago is one of our clearest examples. A developer wanted to tear down some low-income housing to build more expensive apartments that would have displaced the low-income people living at the site. The Department of Health conducted an HIA, which made it clear that it is bad for health to take low income people in an expensive city and throw them out in the street with no housing.
“[Health Impact Assessments have] taught people how to think and speak differently, clearly, objectively,” according to Cleveland Councilman Joe Cimperman. “Suddenly we are saying those words we don’t say often enough in government: Are you comfortable with the environmental and health impacts of this decision?”
NewPublicHealth caught up with Cimperman soon after his plenary address at the second annual National Health Impact Assessment meeting held in Washington, D.C., this week. He is an HIA supporter and enthusiast who is already engaged in health impact assessments for the city of Cleveland.
NewPublicHealth: What was your impression of the HIA meeting?
Joe Cimperman: I was blown away by so many different things—the geographic diversity of the people attending, and the many ideas they presented in questions and in private conversations after I spoke.
NPH: In your opinion, what is the intrinsic value of health impact assessments?
Cimperman: HIA has been a model for how to get things done right. But the tool also allows us to get closer to people and their specific needs by going through the process—which is such an important component—to find out how we help individuals when we make policy-level decisions. If we want to restore our cities, we need to ask what problems we’re solving.
NPH: What’s a strong example of an HIA in your community that was innovative and beneficial?
Cimperman: We have completed an HIA on the health implications of proposed legislation to expand agriculture into urban areas. Cities like ours have enough land that we can think about the different and best ways to use some of it—and urban agriculture is a means of helping people use the land themselves, and use it for something other than home and industrial construction. I think we’ve been able to do so much good by applying an HIA because we’re answering questions right up front. The Urban Agriculture overlay district is a proposed piece of legislation that would introduce intense farm uses in an urbanized environment, including livestock, community gardens and commercial gardens. While the uses are thought to have positive impacts on human health—such as access to fresh fruits and vegetables, community cohesion through the establishment of gardens, potential economic opportunities and a productive reuse of vacant land—unintended adverse impacts to human health include increased animal waste, potential exposure to carcinogens created by insecticides, and increases in noise and odor levels.