Towards a Value-Based Public Health.

Before beginning today’s note, an acknowledgment of recent events. By passing the American Health Care Act (AHCA) last week, Congress has advanced a bill that would challenge Medicaid expansion, open the door to denying coverage to people with preexisting conditions, and likely cause millions of Americans to lose health care. The progress of this legislation is troubling. The potential that it could become law suggests, yet again, the importance of public health as a voice in the public conversation, now more than ever. It is fundamentally our role to prevent disease, and to challenge any social or political forces that threaten health. The AHCA is one such force that runs entirely counter to the health needs of populations, and should be called out as such.

On to today’s note. Health care systems worldwide, particularly in the United States, face the challenge of rising costs, inefficiency, and lackluster health outcomes. This is in part due to the prioritization of the profitability of health services over the quality of patient care. In their book, Redefining Health Care, Michael Porter and Elizabeth Teisberg propose a solution to this problem: a “value agenda,” which would shift the focus of market competition away from health providers and towards prioritizing patients and the prevention and treatment of disease. This notion of value-based healthcare delivery is centered around three core concepts: choice and competition, value, and positive-sum competition. Choice is fostered through the creation of integrated practice units (IPUs), which organize medical care around specific conditions, procedures, and patient demographics. This allows patients to select from a range of care options, each designed to address specific needs. Bundled pricing for these services can incentivize value, laying the groundwork for positive-sum competition among providers that is motivated by a drive to deliver the best health outcomes at the lowest possible cost.

In reflecting on this concept, I found myself wondering whether this has applicability to the goals of public health. Public health also works towards ever-greater efficiency in its efforts. Our goal, however, is not treating and curing patients, but, rather, stopping disease from occurring at all. Our interventions aspire to shape the social, economic, and environmental conditions that determine the health of populations.

Could applying a value-based approach to the work of public health sharpen the effectiveness of our efforts, guided by the key principles of choice and competition, value, and positive-sum competition?

How might we apply the principles of choice and competition to public health? In clinical care, the introduction of IPUs allows providers to target their expertise toward specific areas of focus. Rather than diffuse energy and resources, clinicians can identify the area where they can make the most difference, and build their functions around that area. Public health could be guided by a similar strategy. Instead of taking a generalist approach, our efforts should be informed by a key question: what matters most to the production of population health? We can then direct our energies accordingly, investing in the fundamental causes of health. Consider obesity. Obesity has long strained our health system, and is estimated to cost the US between $147 billion and $210 billion in annual health care spending. A focus on what matters most in the fight against obesity means eschewing broad-brush, largely ineffective “lifestyle” modifications, and focusing, instead, on mitigating the primary drivers of this epidemic: namely, poverty and the proliferation of sugar-sweetened beverages. A targeted obesity intervention could maximize efficiency by addressing these factors at the political level, reducing poverty through measures like more progressive taxation, and curbing the effects of sugary drinks through taxation and portion control policies.

In health care, the provision of value is closely tied to the integration of health systems. This integration is achieved by defining the overall scope of services where a provider seeks to maximize value, then using an IPU structure as a basis for linking services across units, providing a network of care. Moving to a network-based approach can also add value to the work of public health. It is rare that disease is the product of a single cause; rather, our well-being is shaped by a complex web of factors. This reality has increasingly moved public health towards a systems science approach. Systems science, as applied to health, is the study of the interplay of factors that leads to particular outcomes. Applying a systems perspective to public health means engaging with the complete picture of what makes us sick—how our environment interacts with economic, political, and social factors to shape well-being. An earlier example of this approach is the successful public health campaign to minimize traffic deaths over the course of the last century. By addressing interconnected factors like seat belts, traffic laws, and the construction of roads—which, if neglected, create the conditions for unsafe driving—public health was able to significantly reduce hazard, maximizing the value of its interventions.

Choice and value both point towards perhaps the key objective of value-based care delivery: encouraging positive-sum competition, where providers are empowered to pursue a model that measures success by care quality and health outcomes, rather than by profitability alone. Here, public health can set the example. The success of initiatives designed to improve the health of populations is measured by how efficiently they are able to facilitate positive health indicators. Public health should therefore take a consequential approach to all it does, as we ask ourselves: Are doing all we can to safeguard and promote the well-being of populations? This clarity of focus can help sharpen public health’s engagement across sectors and can incentivize buy-in from the partners—from the corporate the political spheres—that public health must have to improve the health of populations.

I often struggle with the links between public health and clinical medicine. Reflecting on this, though, it seems to me that public health can indeed learn from value-based approaches that might work well for individual care to improve the health of whole populations. Such a framework can help introduce accountability and establish best practices at all levels that are relentlessly focused on producing the best possible health indicators locally and nationally.

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Robert A. Knox Professor
Boston University School of Public Health
Twitter: @sandrogalea

Acknowledgement: I am grateful to Eric DelGizzo for his contributions to this Dean’s Note.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/tag/deans-note/