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Health Care Reform and the practicing Public Health Epidemiologist. CSTE June 23, 2014. David Fleming, MD Director and Health officer. Health care system. Setting broken bones Chemotherapy Mammograms Smoking cessation services. Clinical & medical services. Health system. - PowerPoint PPT Presentation
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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
Clinical & medical services
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
Clinical & medical services
Human &social services
Community Health services
Health care delivery system
Public health system
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6
Clinical & medical services
Human &social services
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
Provision of clinical & medical servicesPublic health/health care delivery partnerships
Provision of clinical & medical servicesPublic health/health care delivery partnerships
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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
Provision of clinical & medical servicesPublic health/health care delivery partnerships
Provision of clinical & medical servicesPublic health/health care delivery partnerships
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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Provision of clinical & medical servicesPublic health/health care delivery partnerships
• 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
17
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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Human & social servicesPublic health/health care delivery partnerships
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
Human & social servicesPublic health/health care delivery partnerships
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
Human & social servicesPublic health/health care delivery partnerships
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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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24
Top countriesAverage 81.8
US, 78.2
AustraliaCanadaFinlandFranceHong Kong IcelandIsraelItalyJapanMacao NorwaySpainSwedenSwitzerland
16 years
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Community healthPublic health/health care delivery partnerships
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
Community healthPublic health/health care delivery partnerships
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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Community healthPublic health/health care delivery partnerships
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Preventable HospitalizationLack of Physical Activity DiabetesObesity
Life Expectancy Tobacco Use Frequent Mental Distress Adverse Childhood Experiences
Community healthPublic health/health care delivery partnerships
Time for “local global burden of disease”
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Community healthPublic health/health care delivery partnerships
• 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
31
Community healthPublic health/health care delivery partnerships
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
Community healthPublic health/health care delivery partnerships
• Expand permissible use of current $• Shared savings • Pay for success• New dedicated trusts/funds • Hospital community benefit
34
Community healthPublic health/health care delivery partnerships
$$$ 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
Community healthPublic health/health care delivery partnerships
36
“The best time to plant a tree was twenty years ago. The second best time is today.”
Chinese proverb
Health Care Reform and the practicing Public Health Epidemiologist
• 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.
37
Clinical & medical services
Human &social services
Community health services
Health Care Reform and the practicing Public Health Epidemiologist
• 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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Clinical & medical services
Human &social services
Community health services