Tuesday, March 12, 2013

Bending the Cost Curve--The Role for Public Health

As I think about the Mid-Michigan District Health Department, one question I ask myself is, “What is the single most important thing the Health Department should be doing?” The answer I give to that question is not one I often hear in public health circles: Helping to reduce the cost of health care.

Before I explain why I answer in that way, let me tell you why I didn’t name two other answers I could have given.  I didn’t name “provide basic public health services” like WIC, Family Planning, Children’s Special Health Care Services, etc. The reason is that we are not the only source of these services. If we disappeared, people would still be cared for, although it would be more cumbersome and fewer people would be served. But the truth is, if WIC disappeared, moms would get food from food pantries; if our Vision program were not available, kids would get glasses from the Lions Club. So those services, while important, aren’t the MOST important.  Another program I didn’t name was the On-Site Sewage program in Environmental Health. There is a great argument for naming it the most important, and that is how poor surface water quality was before modern septic regulations. Before our sanitarians could enforce modern regulations many of the beautiful lakes and rivers of Mid-Michigan were essentially open sewers. The only reason I didn’t pick On-Site is because I think what I did pick—reducing the cost of health care—is where we will find the money to continue to work on improving environmental quality.
I think everyone knows the cost of health care in the United States is out of control. It costs nearly twice what it costs in most other countries to deliver comparable health care services. But because so many Americans are uninsured (which is not true is other, similar counties), lack of access to care means we actually have worse health outcomes than other places with similar economies (Click here for more information http://www.pbs.org/newshour/rundown/2012/10/health-costs-how-the-us-compares-with-other-countries.html).  The cost of health care hurts us in other ways, too.  For example, employers have to spend more on health insurance for their employees, or else they drop it altogether.  It is well known that workers without health insurance are less productive.  Either way, it makes their businesses less competitive than similar businesses abroad.  Poor competitiveness cuts employment and reduces profits. The cost of health care also makes government expensive. Medicare and Medicaid cost too much, bloating the national budget. The cost of providing health insurance to government workers means we are faced with a choice between cutting programs or raising taxes.
I think there is a crazy feedback loop in there, too. It’s pretty easy to show that one of the strongest drivers of health is the economy. The most affluent communities are the healthiest, and vice-versa. By dragging down the economy, the cost of health care is probably making us sicker.

That’s huge: if we could control the cost of health care, we’d be healthier and wealthier. But is there a role for public health in controlling healthcare costs? Is there are role for a local health department?
Obviously there is.  For example, because WIC supplemental nutrition programs are available for moms, more babies are born full term and neonatal intensive care costs are avoided. Food and water programs prevent the spread of gastrointestinal illness and prevent emergency room costs. It’s easy to show that wherever bans on smoking in public places, bars or restaurants went into effect, emergency room utilization dropped the next day (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm).
However, the cost of healthcare is still going up! So however great public health’s contributions have been, we haven’t done enough to get the outcome we want.
Many people in public health think that we are going to reduce the cost of health care by explaining this situation to our neighbors and elected officials. When they get the bad news people will clamor for tax increases to fund an expansion of public health services. Look, if we did that, it would work; and it would cost a lot less than what we are going to do, but the public won’t there. Sadly, our polity seems content to inadequately fund law enforcement, schools, mental health, other critical services and public health, too.
The place in the system where there are still resources for innovation is healthcare. Public health needs to accept this state of affairs, and to figure out how to partner with the healthcare system to improve outcomes and reduce costs. The tools we need to reduce costs are being developed in the healthcare system and that’s where we need to go.
In fact, thoughtful people have already anticipated this and have laid out a road map for us. The Affordable Care Act, for example, contains specific incentives to connect the provision of health care services to community-based preventive services. Under the ACA the Centers for Medicaid and Medicare Services are encouraging states to stimulate collaboration between prevention providers and care systems through State Innovation grants.

In the State of Michigan, Governor Snyder and the Director of the Michigan Department of Community Health, Jim Haveman, have landed a State Innovation planning grant and have funding to support three pilot sites in Ingham County, Saginaw and Muskegon. They are interested in promoting a model of collaboration developed by Mark and Sarah Redding of Ohio called Community HUBs. The HUB model is local, connecting human service providers, mental health and public health to local physicians and hospitals. Under the model, prevention providers demonstrate the return on investment of the services they provide and market these services to health plans, health care providers and hospitals. It is said that the HUB model is already working in two dozen sites across the country.

I’m very excited by the HUB model, because it promises to reduce the cost of health care locally, and use part of the savings to sustain existing public health services and even expand them, not just in health departments, but in other community agencies. I know the HUB concept is not self-explanatory and I’ll write more about it in a subsequent post.