Authors argue for a coming-together of healthcare and public health
By Mark Thill
The U.S. healthcare system has often been described as a “sick care system,” because it emphasizes treatment rather than prevention, point out the authors of an article in “The Health of Americans” series in this summer’s The Lancet. The low proportion of state and federal government health spending that is devoted to public health activities – only 2.7 percent in 2012 – speaks to how low a priority public health is, they say in the article, “The Patient Protection and Affordable Care Act: Opportunities for prevention and public health.”
Do you think this might explain why we spend so much on healthcare in this country, but fail to gain the good health that many other countries do – at lower cost?
Traditionally, hospitals and public health agencies operate like two ships passing in the night. “The healthcare system mostly provides individual care,” write the authors. “The public health system focuses on the detection of, and response to, disease threats through epidemiology, disease surveillance, community-wide preventive interventions, and clinical services that are necessary for population health.”
This division of labor costs lives and money. Effective clinical preventive services can reduce premature disease and deaths, but tens of millions of people in the United States are not using these services, the authors write. For example, fewer than half of patients with diagnosed ischemic vascular disease were prescribed aspirin or other antiplatelet agents, according to a 2012 analysis. “Increased uptake of these services could save thousands of lives every year.”
Changing our traditional, deeply rooted model of healthcare delivery – in which inpatient care is inpatient care, and public health is public health – will be difficult. First, people have to buy in to the idea that the two sectors should, in fact, work with each other. Second, we have to figure out who is responsible for what, and how each should be compensated for its services.
Through the Affordable Care Act, the Obama administration is trying to push the process along, point out the Lancet authors. For example, the law mandates that new private insurance plans and states with expanded Medicaid programs provide, without cost-sharing, a set of clinical preventive services that have been recommended by the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices. The law establishes a Prevention and Public Health Fund to “provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public health sector health care costs.”
Accountable care organizations and patient-centered medical homes prompt healthcare providers to broaden their focus from individual patients to entire panels of patients or to the whole population, the authors write. The Affordable Care Act also encourages healthcare and public health entities to pursue better ways of organizing care, use data to understand the health of patients and communities, and link clinical care to non-traditional resources. “Ultimately, this new collaboration could bring more focus to the prevention of disease,” they say.
Journal of Healthcare Contracting readers may already be feeling the effects of these changes, particularly those of you whose IDNs have acquired physician practices or formed an accountable care organization with an insurer or physician group. Given continuing concerns about the high cost of healthcare, it’s likely we’ll see more calls for a melding of healthcare and public health.