Sunday, July 13, 2014

Public Health and the Health Endowment Fund

I want to muse publicly about the Michigan Health Endowment Fund (MHEF). This is the fund created by the Michigan Legislature which will spend 1.5 billion dollars of Blue Cross Blue Shield of Michigan’s money to improve health over the next decade and a half.  The fund endeavors to serve children and seniors in areas such as infant mortality reduction, wellness, access to healthy food, health technology, health-related transportation and food borne illness reduction. How much will the fund give away in this fiscal year? Several tens of millions of dollars, probably.

The creation of the fund is not occurring in a vacuum.  Michigan’s leadership is also driving the creation of the State Innovation Model (SIM) with funding from CMS.  The SIM aims to control healthcare costs and drive improvements in health outcomes through payment reform, and by strengthening connections between providers and the prevention community in sustainable Community Health Improvement Regions (CHIRs). MHEF is explicitly seen as supporting the SIM.  The selection of Rob Fowler as Chair of MHEF signals this, since Fowler was deeply involved in the development of the SIM and also championed Healthy Michigan.

Let me ask and tentatively answer two questions:  1. What should MHEF pay for with its money? 2. Can local public health play a role in MHEF-funded projects, and if so how?

It is good that MHEF has a broad mandate because there are lots of things that need attention across the State.  However, if there is one thing MHEF should focus on it is childhood obesity; and it almost certainly will address childhood obesity. To make a substantial, long term difference in the cost of health care we must prevent the current young generation from being sicker than their parents. And if we don’t do that, obviously, we will continue to get worsening health outcomes.  The MHEF Board knows this. Reducing childhood obesity will be a holy grail of their efforts. (By the way: I don’t think the much ballyhooed leveling off in childhood obesity rates is a sign of impending victory.  I think it is just really hard to make kids any heavier than they are.)

A great deal is known about how to reduce childhood obesity. There are best practices related to physical activity, the consumption of healthy food, breast feeding and non-motorized transportation, etc. But to really move the dial, experts agree, the one best practice is to create and implement a comprehensive state plan that integrates work in all of these sectors and more. Fortunately, Michigan has a state plan called the Michigan Healthy Eating and Physical Activity Strategic Plan: 2010-2020. To learn more about it click here  and here. In short, the Michigan Department of Community Health with support from the CDC established the Michigan Nutrition, Physical Activity and Obesity Program (MNPAO) to write the state plan.  MNPAO, in turn, reached out to others and convened the Healthy Weight Partnership to implement the state plan with funding through Building Healthy Communities grants.  Of course when the State’s economic fortunes went south, so did support for Building Healthy Communities.  But the plan is still a good one.

So there it sits, a plan rife with best practices, championed by a who’s who of prevention experts in all sectors of health and health care.  We don’t need to scratch our heads wondering what to do, we just need to pick up the plan and run with it.

Can local public health play a role in MHEF-funded efforts to fight childhood obesity? First, let’s give credit to local public health for what it is already doing by providing WIC services, including nutrition education and breast feeding promotion, to half the young families in this state.  In recent years, WIC has focused on integrating comprehensive health education aimed at obesity reduction into its program, and the USDA says this seems to have had a positive effect on childhood obesity levels.

But as I just mentioned, really making progress against childhood obesity over the long term must involve implementation of a comprehensive plan involving the entire community of prevention providers. And this is where local public health can really shine.  Local public health helped to create Michigan’s state plan and implemented important pieces of it while Building Healthy Communities was funded. But more importantly, local public health has a special relationship with the rest of the prevention community that gives it a unique role.

Local public health doesn't need to provide the lion’s share of preventive services in the communities it serves.  Indeed, its proper role is to understand and support the entire fabric of preventive services, to make sure gaps in services are identified and assure the gaps are filled.  This concept is elaborated in the model called the Ten Essential Public Health Services.  There is a name for this process of convening the community to enhance preventive services and that is Community Health Assessment and Improvement (CHAI). The State of Michigan has engaged in this process and so have many, although not all, local health departments. Here is an example of a local CHAI from the Capitol Area.  And by the way, this is exactly the kind of work the SIM imagines will be done in the Community Health Improvement Regions.

Bringing all this together, then, local public health ought to advocate to MHEF that the best way to address childhood obesity in Michigan is to implement the state plan in conjunction with the SIM.  We ought to advocate that all the members of the Healthy Weight Partnership should be supported to play their part in the plan, while putting ourselves forward as the natural conveners and evaluators of local efforts.  To get ready for a conversation with MHEF, we need to identify what it will take to do a good job of convening and evaluation and that is what we should ask for.

We also need to talk frankly with MHEF about two threats to the success of this effort. One threat is the concept of innovation embedded in MHEF’s definition of what it wants to fund.  The CDC does not say we need a new round of innovation.  Millions have already been spent to identify best practices that can be shown to be effective.  The CDC says that what we need to do is comprehensively implement these best practices via state plans.  The worst thing we could do is to turn our attention away from what we know works and start over again in the dark.

The second threat is episodic funding.  MHEF grants are anticipated to sunset after three years.  But we already tried tackling childhood obesity through a series of short term innovation grants under Building Healthy Communities! We know this won’t create long term change.

Here I am not arguing that we should turn MHEF into a permanent funder of public health prevention—that is the role of the State, and the State’s plan for long term funding of prevention is the SIM.  But this thinking does help to clarify where MHEF funding should be targeted, and that is on answering the question “How can local communities leverage the State Innovation Model to develop more sustainable funding for local prevention efforts?”

MHEF grants for reducing childhood obesity—which must be short term and aimed at innovation—should focus on identifying how the work of local teams of Healthy Weight Partnership members can be integrated into the Community Health Improvement Regions (CHIRs) envisioned in the SIM. The SIM explicitly says that, in the future, these CHIRs should be the locus of sustainable preventive services in Michigan communities.  They will be sustainable because state and other funds will flow to them, but also because payment reform will mean payors will reimburse prevention providers for activities with a proven return on investment. This last piece is critical. To make long term change we must not waste time implementing one-off projects.  MHEF and local public health ought to work together to ensure that CHIRs focus on nurturing sustainable childhood obesity reduction efforts, and to accomplish this, these efforts must generate real, measurable ROI that is visible to providers and payors. The state plan tells us who and what will accomplish this. Local public health should be spreading the word.