5

Population Health Research Priorities: Perspectives from Users of Research

In the second panel discussion, speakers representing different categories of users of research, such as local public health practice, consumers, the federal government, and the private sector, provided their perspectives on research priorities. LaMar Hasbrouck, executive director of the National Association of County & City Health Officials (NACCHO), provided his perspective from working with the local health officials NACCHO represents. The consumer perspective was provided by Ron Pollack, executive director of Families USA. A federal perspective was shared by Linda Elam, deputy assistant secretary for Disability, Aging, and Long-Term Care Policy in the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in the U.S. Department of Health and Human Services (HHS). Jenelle Krishnamoorthy, executive director for U.S. Policy and Government Relations at Merck & Co., Inc., shared her perspective based on her experience both in the pharmaceutical industry and as a congressional staffer. Following the panel presentations, an open discussion was moderated by Jeffrey Levi of Trust for America’s Health and George Washington University. (Highlights are presented in Box 5-1.)

LOCAL HEALTH DEPARTMENT PERSPECTIVE¹

NACCHO represents about 3,000 local health departments across the country, assisting them in their work through public health advocacy, capacity-building assistance, development of tools, professional development, and other activities. Hasbrouck said that local health officials, administrators, and subject-matter experts need better access to research so they can make use of it in their work. He urged researchers to partner with local health departments in a meaningful way (i.e., not just ask for access to data). As the experts on the health of the local population, the local health department can be an asset to researchers. Local public health regularly interfaces with and convenes community members around community health needs assessments, community health improvement plans, and other activities.

NACCHO uses research to understand the needs of its members and maintains a state-of-the-art national database of all local health departments, Hasbrouck said. For example, NACCHO releases a National Profile of Local Health Departments, as well as a survey, called Forces of Change, of the trends and factors that affect local public health (e.g., workforce composition, implementation of the Patient Protection and Affordable Care Act [ACA]).² These data and surveys are used to inform the development of policy positions and guidance by workgroups of subject-matter experts and NACCHO members. In response to a question, Hasbrouck noted that the data from the various surveys are accessible to researchers, and he encouraged researchers to contact NACCHO.

NACCHO members use a broad spectrum of research (e.g., science, management, marketing, organizational strategy, psychology, economics) for surveillance and epidemiology, to identify root causes of poor health outcomes, to inform public health practice, and to shape policy. Research is also needed to assert the value proposition for local public health, as funding and support for their work has been eroding, he noted. Hasbrouck highlighted three main research priorities from the perspective of local public health:

1. Upstream interventions—More empirical evidence is needed to support the idea that population-level interventions and policies have a positive effect on the broad factors that influence health, and that these interventions and policies provide a real return on investment for population health. Hasbrouck emphasized the role

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¹ This section is based on the presentation by LaMar Hasbrouck, executive director, National Association of County & City Health Officials, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

² See http://nacchoprofilestudy.org (accessed May 30, 2017).

2. of collaborative efforts among public health, population health experts, and the health care delivery system, and cited the State Innovation Models Initiative as a step in that direction.

3. Drivers of health—Research is also needed to identify the drivers of health and the best practices for public health and health care delivery to improve the health outcomes of populations beyond the walls of the health care facility. Areas for research include social determinants of health, workforce development, and information sharing and interoperability of informatics systems (e.g., tracking patients across care systems).
4. Financing—New research is needed in the area of public health financing, Hasbrouck said. This includes sustainability research on innovative and alternative models of funding for public health. In this regard, Hasbrouck referred participants to the Foundation for the Public’s Health,³ a philanthropic foundation launched by NACCHO to support community public health through public–private collaboration.

CONSUMER PERSPECTIVE⁴

Families USA is committed to achieving affordable, high-quality health care for all Americans, and is deeply concerned about those who are least advantaged, Pollack said. He emphasized the need for more attention to safety net programs, noting that the single largest provider of health coverage today is the Medicaid program. Pollack highlighted six key areas around access to care where he said it would be very helpful to have a better understanding:

1. The uninsured—The Congressional Budget Office (CBO) estimated that, even with the implementation of the ACA, about 35 million people would remain uninsured.⁵ Although there has been significant progress made in enrollment, Pollack suggested that the original CBO estimate likely was low. Families USA has been very involved in enrollment-related efforts. There is a lot of information about the demographics of the uninsured. Some are undocumented immigrants who are not helped by the ACA. However, there are many others who are eligible for significant assistance under the

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³ See https://tfph.org (accessed May 30, 2017).

⁴ This section is based on the presentation by Ron Pollack, executive director, Families USA, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

⁵ See, for example, CBO, 2015.

2. ACA, who are not receiving it. Decision makers need to better ascertain the strongest impediments to getting this remaining population covered.

3. Insurance literacy—Among people who do get enrolled (many of whom were uninsured for a lengthy period of time), many do not understand even basic definitions (e.g., deductibles, copayments), or other key aspects of accessing care. An assessment is needed of the insurance literacy of newly enrolled individuals, and what is needed to improve their ability to convert an insurance card into actual health care.
4. Navigators and assistors—The ACA calls for insurance marketplaces to have navigators to guide consumers through enrollment. A related function is assistors, who have a similar role. These functions are a vital link to getting people enrolled in health care, Pollack said; however, there are concerns about sustained funding of such services in the future. He cited the need for an apolitical analysis of the significance of the role of navigators and assistors and offered as an example the HHS call for navigators to be active not only during the 3 months of the open enrollment period but also year-round to help people who get coverage to access care.
5. Employer-sponsored insurance—Employer-sponsored insurance is still the predominant way people obtain their coverage; however, Pollack predicted that the coming years would bring significant transformation in employer-sponsored insurance. Small and medium-sized businesses may consider dropping out and referring employees to the marketplace, he said, particularly as premiums rise and enrollees experience significant increases in deductibles and copayments. Analytical data will be needed to explain what happens to the approximately 150 million people who now get their coverage through employer-sponsored plans (e.g., insurance status, quality of coverage obtained).
6. Medicaid—Together, Medicaid and the Children’s Health Insurance Program (CHIP) cover almost 72 million people, or more than one out of every five people in the country. Pollack predicted that, with the expansion, Medicaid would cover between 80 and 90 million people in the near future. Research is needed on the experiences of people with Medicaid, especially the differences from state to state in terms of traditional Medicaid versus premium support options. It will be important to understand how those different systems are serving low-income populations (e.g., affordability, employment requirements, time limits on coverage).

6. Premiums, deductibles, and copays—Pollack cited a recent Kaiser Family Foundation report that found that while premiums are increasing modestly (about 4 percent), deductibles and copays are rising significantly.⁶ As these trends continue, data are needed on how many people will continue to maintain coverage, and the extent to which those with coverage can realistically access care in the face of increasing personal cost for that care.

FEDERAL PERSPECTIVE⁷

ASPE at HHS is the principal policy advisor to the Secretary on issues of health, disability, human services, science and data, and economics. Elam explained that ASPE coordinates the evaluation work, research and demonstration activities, legislative planning, strategic planning, and other activities on behalf of the secretary of HHS. ASPE also conducts and contracts research and evaluation activities, policy analysis, and cost–benefit estimates of policy alternatives that are under consideration by HHS or Congress. This cross-cutting role affords ASPE the ability to see overlaps and gaps, she said, to highlight opportunities to better streamline and coordinate work, and to set a research agenda.

Setting and coordinating research priorities for an enterprise as large as HHS can be a challenge, Elam said. The process seeks to balance the tension between identified needs and the estimated impact that department efforts could make in that space. Needs include both immediate health needs and political imperatives. As an example, Elam said that ASPE has responsibility for updating and maintaining the National Plan to Address Alzheimer’s Disease, and facilitates the federal Advisory Council on Alzheimer’s Research, Care, and Services. Despite the current efforts, there are concerns that Alzheimer’s disease and related dementias are not receiving the appropriate level of support. Certain stakeholders in the community of organizations working on dementia have expressed concerns that responses such as that to Ebola in Sierra Leone are taking precedence over the response to Americans suffering with Alzheimer’s disease, which is the sixth leading cause of death and affects both individuals and their caregivers. Similarly, there are calls for a response to Alzheimer’s disease on the level of attention given to developing drugs

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⁶ See http://kff.org/report-section/ehbs-2015-summary-of-findings (accessed May 30, 2017).

⁷ This section is based on the presentation by Linda Elam, deputy assistant secretary, Disability, Aging, and Long-Term Care Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

for HIV. Elam pointed out that there are fundamental differences between HIV and Alzheimer’s disease, in particular, the etiology, potential treatments, and threats of an infectious disease versus those for a disease with multiple complex etiologies. These are difficult conversations to have, but they are part of the exercise of balancing need and impact, she said.

Another aspect of the federal portfolio is the many public programs that have a tremendous influence on the health of the nation, and which also serve as vast repositories of data. Research is needed on how to leverage those data resources effectively. Elam relayed that the secretary of HHS has announced initiatives on health care delivery system reform, including alternative payment models for Medicare based on value and quality. Research areas include identifying effective incentives, mitigating unintended consequences of delivery system reform, the outcomes of reform on vulnerable populations, and coordinating programs to serve vulnerable populations and the dually eligible. There are also opportunities to better use and coordinate disparate governmental programs to promote health. Elam cited the housing example discussed by Brennan and noted that ASPE is also studying supportive housing [including the financing aspect] for the chronically mentally ill and for seniors.

Elam highlighted several other research priorities for ASPE. The U.S. Departments of Justice and Labor and HHS are considering how to address the health needs of those reintegrating into the community after incarceration. Although getting them enrolled in health care is a primary concern, there are also significant needs for employment and training, and other aspects of living in a community successfully.

There are many opportunities for research on the implementation and effectiveness of the ACA. For example, research is needed on how best to help people make decisions in the face of volumes of new information in areas they have not dealt with before (e.g., the roles and effectiveness of facilitators, navigators, assistors). There is also much to be learned about insurance coverage, including elements that limit usefulness of coverage (e.g., availability/distribution of providers, realities of accessing care).

PRIVATE-SECTOR PERSPECTIVE⁸

Krishnamoorthy highlighted some of the work of Merck & Co., Inc., in the area of population health. Merck has long had a strong focus on vaccine development. The Merck for Mothers program is a 10-year, $500 million initiative to reduce maternal mortality around the world. Merck

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⁸ This section is based on the presentation by Jenelle Krishnamoorthy, executive director, U.S. Policy and Government Relations, Merck & Co., Inc., and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

is also focused on antibiotic resistance, in particular, addressing the dwindling pipeline of antibiotics, and developing policies for the stewardship of new antibiotics. The company also conducts research and development of products in other areas of unmet need, including diabetes, oncology, hepatitis C, and Alzheimer’s disease.

Drawing on her experience in the private sector and as a congressional staffer, Krishnamoorthy said that congressional members and staff often do not understand community prevention and population health, and she noted the ongoing challenges of funding the Prevention and Public Health Fund established under the ACA. Population health can be very politicized, and she asked if a different vocabulary might be needed to get the message across.

An area for research suggested by Krishnamoorthy was the possibility of incorporating population health into the health system so it is part of the reimbursement system in the way that clinical prevention is. Research is also needed to understand the integrated person. When developing interventions, it is imperative to understand the entire community, and the factors that affect use of the interventions. Research on medication adherence and vaccination practice also inform product development. It is important to understand the beliefs and barriers related to someone adhering to the intervention or receiving the vaccine. She also emphasized the need to assess health systems relative to their effects on population health. There is currently a focus on quality and value measures for reimbursement, but it is also important to assess whether the population is actually becoming healthier.

Another area for research is the potential economic effects of improved population health. How do better health and longer life affect entitlement programs (e.g., increased Medicare costs)? This is a multifaceted issue, and unbiased facts are needed to inform budget discussions. Another aspect of population health is cost containment and the extent to which preventive interventions result in reduced health care costs (e.g., smoking cessation, diabetes prevention). Economic analysis is needed to bolster the case that increasing the health of the population would save money overall, she said, and such analysis would help to support the passage and funding of more health policies by the federal government. Krishnamoorthy agreed with Pollack about the need to better understand the effect of Medicaid expansion programs. She noted that several states are including health risk assessments or a commitment to healthy behaviors in the Medicaid enrollment process. It would be interesting to study the effect of this approach on population health, she said, including whether it actually creates a barrier to people accessing the Medicaid program.

In closing, Krishnamoorthy encouraged participants to reach out to policy makers and advocate for population health. Members of Congress

have health advisors on their staff, and this information is vitally important to them, she said. Population health is not just “the nice thing to do,” she said. It is the future of where the health system needs to go, and it is important that this topic be part of the dialogue on value, quality, and an accessible health system.

DISCUSSION: FRAMING THE MESSAGE TO ENGAGE POLICY MAKERS

Participants discussed further the need to frame the messages around population health such that the messages more effectively engage policy makers and others outside the health care system. Nancy Krieger of Harvard University relayed a comment from a conference she attended; the speaker had said that, in the context of urban planning, reframing the message as one of livable cities and sustainability helped to get the attention of policy makers outside of the health care system. The language of population health is necessarily different from that of individually oriented clinical care, Krieger noted, and both languages are needed. To seriously start discussing societal determination of health, what are the terms that would be relevant and useful?

Pollack said that, although terms such as population health and social determinants of health are used regularly in population health research, few outside the field really understand what they mean. The population health research community also needs to conduct research on how best to communicate its findings and connect with people outside the field. A better understanding is needed of what communication approaches work for which audiences. Krishnamoorthy encouraged participants to reach out beyond the usual partners on population health to let others know what is going on in the community and in population health, and engage them in helping to spread the message.

Hasbrouck agreed that nomenclature and lexicon are very important. He suggested that one of the unintended consequences of the ACA in introducing population health was that there was no formal definition of population health in the law. Exactly what it means remains an open question, and it means different things to different people. For a clinician, it might mean the patient population. For a local health commissioner, it might mean the catchment area. For a critical access hospital, it might mean the people they serve.

Hasbrouck highlighted the concept of a “culture of health.” Cultures are very local and intimate, he said. He suggested talking about the health expectancy of a community, rather than life expectancy. A reasonable expectation of health in a community requires more than access, literacy, and appropriate use of care. These are the downstream (i.e., at the patient

level, in the clinical setting) elements for when care is needed, he said. A culture of health incorporates elements that reinforce, enable, drive, and determine a person’s ability to be healthy. These include systems, structures, policies, health department, schools, places of worship, segregation or desegregation, and other elements.

Pamela Russo of the Robert Wood Johnson Foundation noted that building a culture of health is the stated vision of the foundation. She asked whether, regardless of terminology used, there is a growing awareness in federal, state, and local government that actions taken in other sectors (e.g., transportation, housing) have an effect on health? She also asked whether there are examples of where a politicized issue benefited from being reframed around a health outcome. Krishnamoorthy said there is some awareness. She cited a highway bill where a senator attempted to add an amendment to consider sidewalks in the plan. She also mentioned changes to cases not made in active living programs, supported by the Robert Wood Johnson Foundation, to promote healthy communities. There are competing concerns, she noted. The asphalt lobby, for example, might be concerned about funding being diverted from building roads. A challenge when discussing population health with members of Congress, she observed, is that issues fall in different silos, and there are different staff supporting health, education, transportation, agriculture, and other issue areas. It helps to have the scientific community coming together and making an integrated case, and to engage and influence the staff from the different sectors.

Brent Ewig of the Association of Maternal and Child Health Programs commented that his association has found using concrete examples to be effective in engaging congressional staffers and lawmakers on population health. They show, for example, that, although there are fewer uninsured children than ever before because of Medicaid and CHIP, this has not resulted in a reduction in the childhood obesity epidemic. Similarly, injury is the leading cause of death for children, and coverage is essential to be able to treat them when they are injured, but there is not enough investment upstream in preventing injuries. Such examples open the door for conversations about strategies, he said. The challenge, he continued, is defining and supporting funding requests. He shared his experience in lobbying for maternal and child health funding in the Labor HHS (refers to the U.S. Departments of Labor, Health and Human Services, Education, and related agencies) appropriations bill, requesting a modest $2 million increase to the $635 million program. When asked what that $2 million would buy, his response was that each state that has deployed evidence-based strategies with accountable performance measures would be able to extend those interventions. This is not nearly as satisfying an answer, he said, as being able to say that the money will

buy a certain number of clinics, perhaps in that member’s district, and provide a specific number of people with free comprehensive primary care, and other specific cost details. What is needed is more economic analysis of what effective population health strategies and interventions cost. Estimates are suitable, he said, and exact costs are not needed. Without cost information, population health is competing against much more politically appealing messages (e.g., how many more constituents will be served, versus some benefit to a population that may or may not be voting for that member).

Pollack added that it is not sufficient to analyze how effective an intervention is, it is also important to analyze how cost-effective it is. He noted that the Patient-Centered Outcomes Research Institute is constrained in this area by the ACA. Families USA, in partnership with the Institute for Clinical and Economic Review, is analyzing half a dozen clinical problems to consider both the clinically effective options and the cost-effective options people have. This is the type of analysis that must be done if population health wants to encourage interventions that are nonmedical but which have a real effect on health care. For example, for a child with asthma, how cost-effective is mold removal in the home for avoiding an asthma attack? This type of analysis can be done for a variety of different chronic health conditions, he said.

Hasbrouck pointed out the need to consider the political cycle. Often there will be buy-in from an elected official, but upstream strategies and approaches take time, and that official cannot wait 4 or 5 years for a return on the investment and to get credit for supporting it. The culture needs to change to prioritize value, and people need to be advocates for these sustained changes.

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