Nov 11 2013
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Ending Healthcare Waste, Improving Healthy Lives: Q&A with the L.A. Department of Public Health’s Jonathan Fielding

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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.

NPH: What were your key goals in releasing the research article?

Jonathan Fielding: To stimulate thinking about a different paradigm. Also to get other sectors involved in arguing and discussing priorities in terms of how we spend money at the federal and state levels, as well as to be additional voices toward moderation in how much we’re spending on healthcare in this country.

NPH: What are some strong examples of ways to use that excess healthcare spending to help improve health?

Fielding: One example is taking 24 million students in elementary school and lowering class size from an average of 22-25 students to 13-17 students. That change could lead to between 70,000 and 140,000 additional high school graduates. And if you graduate from high school compared to not, you gain an average of 1.7 quality adjusted life years, and society reaps the economic benefits because the high school graduate pays more in taxes from a higher paying job.

Another example would be to increase funding for the anti-tobacco campaign to try to stop teens from starting to smoke. That could save millions of life years.

NPH: What is needed going forward?

Fielding: We need a set of careful analyses on a wide range of social investments and changes to our physical environment to see how that helps us. For the physical infrastructure, that would be items such as more bikeable, walkable communities and increases to mass transit.

And we also need to have active convenings of leaders in other sectors who can be advocates for their programs and speak eloquently to Congress and state legislatures to show that there are alternative uses that might, in fact, bring better results and reduce the terrible health disparities our country currently faces.

NPH: Do you have models in Los Angeles for absorbing/reducing healthcare spending waste and redirecting it to help improve population health?

Fielding: Unfortunately we don’t control the use of those funds for public health. But what we have done we’ve done with money from the Affordable Care Act’s Prevention and Public Health Fund, through the Community Transformation Grants. We’ve used some of that money to the city to focus on health in their general plan, so that now all major decisions are going to come through the planning department and they will have to consider the health consequences. Other cities have done that, as well.

NPH: How would communities begin if they were able to redirect health care funds toward improving population health?

Fielding: The first thing you need is a broad coalition that involves the various sectors. Second, you need reasonably good metrics, so that you have the information in ways that people can understand it, and what the tradeoffs are. Third, I would suggest starting by looking at policy opportunities, because in many cases the governmental costs are zero or low.

>>NewPublicHealth was 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. Find the complete coverage here.

Tags: Public health system and finance, Health promotion and disease prevention, APHA, Q&A