A better thermometer

For years, public health officials have said the U.S. spends more money on healthcare than other countries but lags far behind in global health rankings. But a report from the Institute of Medicine last week delivered even more disturbing news: as a nation, we don't know how to solve this problem.

That's because the U.S. doesn't have a clear strategy or the right measurement tools to evaluate the social and environmental factors that make Americans healthy or sick, according to the report, For the Public's Health: The Role of Measurement in Action and Accountability, which was sponsored by the Robert Wood Johnson Foundation.

To help the nation change course, the IOM report makes seven primary recommendations, some of which concern collaboration between medical-care organizations and governmental agencies to share information taken from clinical data. The idea is to collect and manage health data more completely and efficiently, and then make that data meaningful to improve the quality of life.

Separately, last week, a presidential committee recommended ways to standardize and protect electronic health information data.

Should HHS follow the IOM's recommendations, this could mean hospitals and physicians might again have to bolster their data-collection efforts for the federal government.

“This is a public good and, therefore, I would not expect that it's reliant on hospital contributions,” Nancy Foster, vice president of quality and patient safety at the American Hospital Association, said about the financial resources required to achieve the report's objectives. “It should be resourced through public means.”

More collaboration

For hospitals, the fifth recommendation is likely to be the most important, Foster said. That recommendation calls for state and local public health agencies to collaborate with clinical-care delivery systems so the public has greater awareness of the appropriateness, quality, safety and efficiency of clinical-care services in their states and communities. It also suggests that performance reports on overuse, underuse and misuse—on things such as preventive and diagnostic tests, procedures and treatments—be made available for certain interventions.

“I think hospitals have to be a part of this, but they're not the primary group,” Foster said of the report's findings and suggestions. “Given state budgets and local county budgets, it's a pretty daunting task unless they start with what they have,” Foster said, adding that existing data could be used as a fulcrum to leverage further activity.

The report is the first of three on public health from the IOM. An 18-member committee—which convened in October 2009—will release the second study, on law, in the first half of 2011. The third and final report, on financing, is expected in the second half of next year.

For this first study, which amounted to 170 pages, the committee was asked to review population-health strategies, related metrics and interventions within the context of a reformed healthcare system. It also was tasked with reviewing the role of score cards and other measures, and summarizing how they could be used to hold government and other stakeholders accountable. The report included a statistic published this fall in the journal Health Affairs that said the U.S. spends more than 17% of its gross domestic product on healthcare, but ranks 49th globally in life expectancy.

And the report emphasized an important note about this year's Patient Protection and Affordable Care Act. It said the monumental health-reform law is only part of the answer to the nation's healthcare problem, because improving medical care alone will not have a major effect on health outcomes.

“Most people in our population have no interaction with the healthcare delivery system—it's a minority of people who do,” committee member Martin Sepulveda, vice president for integrated health services at IBM, said in a Dec. 8 teleconference with reporters. “The ones who do, need help because they are experiencing the adverse consequences of decisions they've made. And they made those in family behaviors, social networks, conditions that are present or not in their workplaces,” he added. “Attacking aggressively the crisis we're experiencing at the end of the line requires attacking those environments that created the problem.”

Marthe Gold, the committee's chairwoman, said the group discussed the report's priorities and determined there are existing measures that are disconnected, and there also are missing pieces of information. So the committee suggested there be an organization that has the capacity to oversee this effort, and that it would be best to build on an already-established structure. That led to the group's first of seven recommendations, in which it suggests that the HHS secretary change the mission of the National Center for Health Statistics to “provide leadership to a renewed population-health information system through enhanced coordination, new capacities and better integration of the determinants of health.”

The report also recommended the nation adopt a single indicator to serve as a GDP equivalent in the health sector. “We're asking that the GDP of health really look at the experience of life expectancy combined with the health-related quality of life that we achieve,” Gold said, adding that this means asking the question: How much of our life is spent in a healthful life?

Linking the data

Georges Benjamin, executive director of the American Public Health Association, praised the report's findings and its call to focus on tracking social determinants and linking those to health. “A lot of data systems don't talk to one another,” Benjamin said. “So our infrastructure to make these kinds of data-driven decisions is very weak,” he added. “And obviously you want to capture the data in a consistent manner to make comparisons. How do you hold people accountable when you don't have the information?”

And after establishing a need to gather the right information and share that information properly, the question remains: Who will pay for this effort? “I think part of it would be federal funds; some of it could be done locally,” said James Marks, senior vice president and director of the Robert Wood Johnson Foundation's health group. “Some of it might be through the CDC, some of it might be in the Affordable Care Act—there is support for prevention and public health, so some of it could come from that,” he added. “It is not specific where it could come from.” The committee will focus on this in the third and final report, according to committee Chairwoman Gold.

Marks also said the public health segment, more and more, has been asked to oversee a wide range of activities—emergency preparedness, the obesity epidemic, chronic disease, to name a few—despite lacking a core funding source. “Without it, they have lost ground over the past couple of decades,” Marks said. “Thousands of public health workers have been laid off. And because the public doesn't understand what they do, they don't have a voice. People think of health as medical care, but medical care is about fixing a problem you have,” Marks said. “Initially becoming ill or injured is really related to where and how they live, learn, work and play.”

Lisa Harris, CEO and medical director of Wishard Health Services in Indianapolis, said there is a great incentive for the public hospital system she oversees to strengthen this connection between medical care and the social and environmental influences that largely determine health outcomes. About 20% of Wishard's payer mix comes from Medicare; 20% is from Medicaid; 10% is from commercial insurance; and the medically indigent make up the remaining half, according to Harris.

“Under the current payment system, our incentives aren't aligned,” Harris said of the nation's healthcare system. “But it's different for public hospitals and health systems because we operate with relatively fixed resources to deal with increasing uninsured and underinsured patients, so it aligns our interests for keeping costs low with our community's interest for better health,” she said. Wishard now offers green spaces and a farmer's market to supply locally grown produce at the hospital, and it expects to have a “sky farm” on the top floor of a clinic that will open as part of the system's expansion in 2013.

Comprehensive measurement

Having access to things such as fresh fruit and fresh air in the community is “absolutely critical” to overall health, according to Janet Corrigan, president and CEO of the National Quality Forum. And Corrigan said it is essential there be a comprehensive measurement in place so communities can see what services they are not providing. “It's important to know not only the health of your population, but where your community is at in terms of already taking action to encourage healthy lifestyles and allow health to thrive,” Corrigan said.

That relates to the observation in the report that the nation lacks a cohesive strategy for tracking these kinds of social determinants. But Carolyn Clancy, director of HHS' Agency for Healthcare Research and Quality, suggested the agency has already begun to make improvements in this area. “I would argue the Healthy People goals, which were released last week, represent a terrific starting point,” Clancy said.

On Dec. 2, HHS announced its Healthy People 2020 initiative, which outlines the nation's goals for health promotion and disease prevention in the next 10 years. The agency said it considered more than 8,000 comments before drafting its objectives, which focus on a wide range of public-health issues, including adolescent health, blood disorders and blood safety, global health, healthcare-associated infections, sleep health and social determinants of health.

And the federal government also is making progress in terms of accountability, an area the IOM report said needs improvement. Starting next year, public health agencies will be accredited for the first time.

“We have developed our standards and measures, and we just finished the field testing at 30 sites,” said Kaye Bender, a nurse who is the president and CEO of the Public Health Accreditation Board in Alexandria, Va., which is funded by the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation.

“Then we'll launch in late summer 2011,” Bender said, adding that public health departments are the only health-related entities that have not been accredited.

Bender said the new Public Health Accreditation Board's mission is closely aligned with the suggestions in the report, especially with the IOM's sixth recommendation, which calls for coordinating the development and evaluation of system-based simulation models to understand the health consequences of underlying determinants of health. “With everybody being worried about the economy and the impact on healthcare, governments need to be able to have a mechanism by which they set really good priorities for the work they do,” Bender said, adding that the health departments in the current test sites said the board's standards gave them an opportunity to see where to focus their efforts.

Gold said the study does mention the potential for public health accreditation to develop some of the capacity needed to help with accountability. Overall, though, she said the report centers on how measurement informs people and galvanizes both action and accountability.

“Unless you measure things, unless you understand what's going on, you don't know what to do,” Gold said. “Measurement isn't sufficient to generate useful action, but it's certainly necessary.”