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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
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SocialEnvironment
PhysicalEnvironment
GeneticEndowment
IndividualBehavior Health
&Function
Well-Being Prosperity
DiseaseHealthCare
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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”
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New York Times Says……
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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”
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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
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Rigorous causal relationships
Policies based on anecdotes and
opinions
Evidence-based
and
Evidence-informed policies
Applied research for policy
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Health of Wisconsin Report Card
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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)
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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)
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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)
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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)
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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)
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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)
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“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
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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
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• “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”
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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”.
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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
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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?”
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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
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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.
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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.”
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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.
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