Perspective
Opportunity in Austerity — A Common Agenda for Medicine and Public Health
N Engl J Med 2012; 366:395-397February 2, 2012
- Article
Faced with the growing pressure to reduce the federal budget deficit, government leaders have increasingly turned their attention to reducing health expenditures. In this atmosphere of austerity, public health programs are likely to be hit particularly hard as they compete for funds against the health care delivery juggernaut and as state and local governments, which carry out the bulk of public health activities, are forced to make further cuts.
The political vulnerability of public health financing was clearly illustrated in 2011 by Congress's attempt to repeal the Prevention and Public Health Fund created by the Affordable Care Act (ACA), with House Republicans labeling it a $15 billion “slush fund.” The Obama administration, though it initially threatened to veto a repeal bill, ultimately mounted a more tepid defense, proposing to cut $3.5 billion from the fund as part of the President's deficit-reduction plan. Many public health leaders believe this move is shortsighted and will hamper efforts to improve population health and reduce medical spending.
Taking a longer view, disease-prevention advocates assert that skyrocketing health care costs must not crowd out investments in public health; they point to what should be common goals in both fields and an arguably disproportionate allocation of resources to the health care delivery system. Indeed, whereas inadequate medical care accounts for 10% of premature deaths in the United States, behavioral patterns, social circumstances, and environmental exposures have a far greater effect, accounting for roughly 60% of deaths.1 Yet despite these compelling data, public health programs receive less than 5% of U.S. health spending, an amount that does not even reflect the latest budgetary squeeze.2
This seemingly imbalanced approach to health investment reflects a long-standing schism between medicine and public health, which remain professionally and institutionally distinct despite past calls for a closer bond.3 Ideally, population health would benefit from the integrated, complementary activities of a cooperative health sector. Often, however, the predominant interaction between a clinic or hospital and the local public health department is mandatory reporting of communicable diseases. Meanwhile, physicians and health care systems seeking to promote population health generally do so at their own expense, which leads to missed opportunities for both collaboration across health disciplines and potential cost savings.
Perhaps paradoxically, the current push for austerity could bring together clinical medicine and public health in unprecedented, mutually beneficial ways that could improve population health and reduce spending. One example is found in the Internal Revenue Service (IRS) community-benefit requirement for nonprofit hospitals, recently revised in accordance with the ACA. To qualify for tax-exempt status, hospitals must provide community benefit, a historically vague term referring to uncompensated care, professional training, research, and community engagement. Under the new requirement, each hospital must perform a community health needs assessment (CHNA) every 3 years, adopt a strategy to address identified needs, and report its progress to the IRS (or incur a $50,000 tax penalty and jeopardize its tax-exempt status for failing to do so).4
A health care system responsible for meeting CHNA requirements could conceivably partner in such an endeavor with a public health institution that is already engaged in similar activities but that might lack the funds necessary to fully assess and address identified needs. A partnership built on the financial and technological resources of hospitals and the broader perspective and population-management expertise of the public health sector could serve as a blueprint for future community collaborations on other common goals, such as reducing hospital readmissions.
Another significant opportunity for strengthening ties between medicine and public health lies in the emerging consensus that metrics that track health outcomes and per capita costs over time must replace metrics that track services delivered. The final regulations recently promulgated by the federal government for Medicare accountable care organizations (ACOs) provide a framework that holds provider networks responsible for their patient groups and outlines a shared savings program and performance metrics based on cost and quality, including domains of patient experience, care coordination, patient safety, preventive health, and the health of at-risk and frail elderly populations.5
The ACO framework represents an important new approach to measuring value in health care. Yet to fully capitalize on the potential for improving population health, ACOs will need to push the boundaries further toward metrics that really matter for patients and communities. For example, current pay-for-performance programs often focus on what is easy to measure (such as whether physicians check glycated hemoglobin levels) rather than what will be more likely to improve health outcomes (such as population-level control of glycated hemoglobin levels).
Moreover, ACOs are held accountable only for patients already in a particular health care system. If the overarching goal is to improve outcomes for people in a community, the focus must be not only on patients already receiving care, but also on patients who are lost to follow-up, patients who have the most fragmented care, and high-risk persons who are not engaged in care. Although health systems already face a host of challenges in organizing as nascent ACOs, extending providers' accountability to include marginalized groups is critical to the long-term success of health care reform.
If stronger indicators of population health were built into pay-for-performance or value-based purchasing schemes, cost controls could prompt a stronger alliance between clinical medicine and public health. A more robust primary care system could serve as the nexus for clinical and community interventions by combining personal and population-based approaches to address fundamental health problems. For example, to battle the obesity epidemic, clinical interventions such as weight-loss counseling could be reinforced by community interventions to eliminate “food deserts,” promote safe and usable recreational space, and develop smarter nutrition-labeling requirements. Meanwhile, local public health departments could serve as clearinghouses for networks of primary care practices, initially for data-sharing purposes and ultimately for structuring effective interventions across practices (see precedents in the table
Examples of Effective Collaboration between Health Systems and Public Health Departments.).A new function of public health departments could be creating the information infrastructure for such an integrated approach to managing population health. Patients could be organized into panels by primary care providers that would be aggregated into registries at the health-center or health-system level, then further aggregated through health information exchanges at the health-department level. Work on building such information systems is ongoing, spurred by the federal Health Information Technology for Economic and Clinical Health (HITECH) Act. Although there remain substantial privacy and system-integration issues to resolve, connecting clinicians, provider organizations, and health departments would advance public health beyond what any one health system could accomplish. Potential applications include tracking radiation risk associated with frequent computed tomographic scans, augmenting prescription-drug–monitoring programs to identify problematic opioid prescribing, and developing a citywide antibiogram that provides clinicians and hospitals with cumulative data on antibiotic resistance.
The opportunity to reinforce a common agenda for medicine and public health is perhaps the greatest promise of health care reform. Although the political spotlight is currently on spending cuts, the grim economic outlook could motivate public health officials and health care practitioners to cross their institutional boundaries in search of new, cost-effective interventions. In this way, the confluence of austerity measures and shifting payment priorities may herald a new era of collaboration toward improving the health of all Americans.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
Source Information
From Brigham and Women's Hospital and Harvard Medical School — both in Boston.
- References
References
1
McGinnis JM ,Williams-Russo P ,Knickman JR . The case for more active policy attention to health promotion. Health Aff (Millwood) 2002;21:78-93
CrossRef | Web of Science | Medline2
National Health Expenditure Accounts by type of service and source of funds, calendar years 1960-2009. Baltimore: Centers for Medicare and Medicaid Services (https://www.cms.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp).
3
Brandt AM ,Gardner M . Antagonism and accommodation: interpreting the relationship between public health and medicine in the United States during the 20th century. Am J Public Health 2000;90:707-715
CrossRef | Web of Science | Medline4
Internal revenue bulletin: 2011-30, Notice 2011-52. Washington, DC: Internal Revenue Service, July 25, 2011 (http://www.irs.gov/irb/2011-30_IRB/ar08.html).
5
Proposed rule RIN 0938-AQ22; 42 CFR Part 425. Baltimore: Centers for Medicare and Medicaid Services, Department of Health and Human Services, March 31, 2011.
