To: President Obama From: Harold Wise, MD, RPSM Founder

To: President Obama

From: Harold Wise, MD,

RPSM Founder

Re: Beyond Health Care Reform

Second Annual Harold Wise Memorial Lecture

January 20, 2009

David Kindig MD, PhD

University of Wisconsin-Madison

School of Medicine and Public Health

SocialEnvironment

PhysicalEnvironment

GeneticEndowment

IndividualBehavior Health

&Function

Well-Being Prosperity

DiseaseHealthCare

EVANS AND STODART 1990

“a society that spends so much on health care that it cannot or will not spend adequately on other health enhancing activities may actually be reducing the health of the population”

New York Times Says……

SOCIOECONOMIC STATUS AND RISK BEHAVIORS• Paula Lantz et al Univ of Mich 2001• Longitudinal Study 1986-1994…. Americans’

Changing Lives Survey• Four risk behaviors (smoking, BMI, etc) only

have modest impact in predicting functional status and self-rated health in low income populations

• “risk behaviors are not the dominating mediating mechanism for SES health differences”

THE “FANTASY EQUATION” “at present we but vaguely

understand the relative magnitude of the coefficients on the independent variables that would inform specific policies rather than broad directions, even if we are beginning to see the variables themselves more clearly”.

G.Stoddart, 1995

Rigorous causal relationships

Policies based on anecdotes and

opinions

Evidence-based

and

Evidence-informed policies

Applied research for policy

Health of Wisconsin Report Card

100 200 300 400 500 600 700

Wisconsin Working-Age Adult Mortality Rates

(Ages 25-64, rates per 100,000 population)

ABCDF

Some college (212)

College graduates (188)

Whites (279)

Women (225)

Suburban (247)

Non-urban(275)

Rural (319)

Men (367)

Milwaukee County (424)

High school or less (459)

Native Americans (592)

African Americans (624)

Worst state Mississippi (519)

Wisconsin (296)

Best state Minnesota (257)

Asians (170)

100 200 300 400 500 600 700

Wisconsin Working-Age Adult Mortality Rates

(Ages 25-64, rates per 100,000 population)

ABCDF

Some college (212)

College graduates (188)

Whites (279)

Women (225)

Suburban (247)

Non-urban(275)

Rural (319)

Men (367)

Milwaukee County (424)

High school or less (459)

Worst state Mississippi (519)

Wisconsin (296)

Best state Minnesota (257)

Asians (170)

African Americans (624)

Native Americans (592)(279)

(279)

(277)

100 200 300 400 500 600 700

Wisconsin Working-Age Adult Mortality Rates

(Ages 25-64, rates per 100,000 population)

ABCDF

Some college (212)

College graduates (188)

Whites (279)

Women (225)

Suburban (247)

Non-urban(275)

Rural (319)

Men (367)

Milwaukee County (424)

High school or less (459)

Native Americans (592)

African Americans (624)

Worst state Mississippi (519)

Wisconsin (296)

Best state Minnesota (257)

Asians (170)

100 200 300 400 500 600 700

Wisconsin Working-Age Adult Mortality Rates

(Ages 25-64, rates per 100,000 population)

ABCDF

Some college (212)

College graduates (188)

Whites (279)

Women (225)

Suburban (247)

Non-urban(275)

Rural (319)

Milwaukee County (424)

High school or less (459)

Native Americans (592)

African Americans (624)

Worst state Mississippi (519)

Best state Minnesota (257)

Asians (170)

Men (367)(225)

Wisconsin (296)(225)

100 200 300 400 500 600 700

Wisconsin Working-Age Adult Mortality Rates

(Ages 25-64, rates per 100,000 population)

ABCDF

Some college (212)

College graduates (188)

Whites (279)

Women (225)

Suburban (247)

Non-urban(275)

Rural (319)

Men (367)

Milwaukee County (424)

High school or less (459)

Native Americans (592)

African Americans (624)

Worst state Mississippi (519)

Wisconsin (296)

Best state Minnesota (257)

Asians (170)

100 200 300 400 500 600 700

Wisconsin Working-Age Adult Mortality Rates

(Ages 25-64, rates per 100,000 population)

ABCDF

Some college (212)

College graduates (188)

Whites (279)

Women (225)

Suburban (247)

Non-urban(275)

Rural (319)

Men (367)

Milwaukee County (424)

Native Americans (592)

African Americans (624)

Worst state Mississippi (519)

Best state Minnesota (257)

Asians (170)

High school or less (459)(212)

Wisconsin (296)(206)

“The fundamental assertion of this book is that population

health improvement will not be achieved until appropriate

financial incentives are designed for this outcome.”

Kindig 1997

Phases of Population Health Improvement

Phase 1 Debate, acceptance (1997-2000) and research

Phase 2 Outcome based payment (2001-10) for integrated health

delivery systems

Phase 3 Incorporating the (2011-20) non medical determinants

and sectors

• “Now is the time to explore possibilities that go beyond medical care determinants and fund demonstration programs…in which community leaders from a variety of sectors can experiment with promising ideas”

BEYOND HEALTHY COMMUNITIES: STRONG MEASURES, REAL RESOURCES

“What is required is a coordinated effort across determinants between the public and private sectors, as well as financial resources and incentives to make it work”.

Public Health System

Schools

Community Centers

Employers

Transit

Elected Officials

Doctors

EMS

Law Enforcement

Nursing Homes

Fire

Corrections

Mental Health

Faith Instit.

Civic GroupsCivic Groups

Non-Profit

Organizations

Neighborhd.

Orgs.

Laboratories

Home Health

CHCs

Hospitals

Tribal Health

Drug Treatment

Public Health Agency

Evans and Stoddart, 2003

“Redirecting resources means redirecting someone’s income…most students of population health cannot confidently answer the question… Well, where would you put the money?”

IF I WERE CZAR, AND HAD TO WORK WITH EXISTING RESOURCES

• I would take the 25% of health care expenditures that are thought to be ineffective ($500Billion), and reallocate

$100 Billion

$100 Billion$300 Billion

Uninsured

PreventionEducation

TO THE NYT EDITOR

“It is encouraging and refreshing that Secretary designate Daschle is considering replacing Medicare fee for service payments with a system that rewards “healthy outcomes” (NYT Jan 9). However, if he means broad health outcomes like life expectancy and infant mortality, his colleagues with responsibility for education, economic development and the environment have as much responsibility as he does.

Social policy is also health policy, and these determinants are as important as health care. Once universal coverage for health care is achieved, perhaps he can become the first Secretary to focus on strong multi-sectoral efforts for real population health improvement.”

Economic Stimulus Package

• Prevention block grant: $296 million; Chronic disease programs in general: $545 million; HIV/STD/TB/HBV: $335 million; Environmental health: $60 million; Public health workforce: $30 million; Injury prevention: $50 million; Immunizations: $945 million; Occupational research: $40 million; National Center for Health Statistics: $40 million; Health care associated infections: $150 million; Healthy communities: $500 million; Pandemic preparedness and advanced research and development: $900 million.