Do You Have New Evidence on Aligning Health and Social Systems? Submit Your Paper to AJPH by December 15

What Are We Learning about Systems Alignment?

A large and growing body of evidence demonstrates how social determinants shape health across the lifespan and inter-generationally, including factors such as poverty, discrimination, lack of access to good jobs with fair pay, poor educational opportunities, food insecurity, exposure to household and community violence, and involvement with the criminal justice system. Unfortunately, the services and supports designed to intervene on these determinants – such as housing, transportation, educational reforms, and legal services and supports – are often disconnected from the medical services and public health programs tasked with improving health. As a result, medical and public health interventions often fall short in improving health and health equity because they fail to adequately address underlying social, economic and environmental conditions.

Over the past several years, there has been an explosion of pilots, demos, and trials of multi-sector initiatives designed to build stronger connections among medical, social, and public health systems. This rapid innovation is impressive and encouraging, but unfortunately the research community has not kept pace, raising concerns about sustainability and unintended consequences. How will we know what works, and do we need to wait for years to find out?

Our research program, Systems for Action (S4A) , has been working hard to put strong research designs around these initiatives so that we can produce strong evidence about what works, where, for whom and why. As a signature research program of the Robert Wood Johnson Foundation (RWJF), the S4A program builds a Culture of Health by rigorously testing new ways of connecting the nation’s fragmented medical, social, and public health systems. Studies conducted through the S4A program test innovative mechanisms for aligning delivery and financing systems for medical, social, and public health services, with a focus on estimating the effects of these mechanisms on health and health equity.

The system alignment mechanisms we study take many forms, including shared governance models, platforms for data exchange and integration, bundled and blended payment models, and cross-cutting workforce components such as navigators and integrators. Over the past 4 years, more than 25 studies have been implemented through S4A to identify which alignment mechanisms work best for which populations and in what community circumstances. And we are in good company, as other federal and philanthropic initiatives have begun to sponsor research on multi-sector approaches to population health improvement.

Special AJPH Supplement Issue: Aligning Systems

To synthesize and spread the emerging evidence from this growing area of research, we are collaborating with the American Journal of Public Health to produce a special supplement issue on health and social system alignment. This issue will feature the latest findings from studies of system alignment models tested in communities across the U.S.–including a careful examination of both successes and failures—along with discussions of the policies and practices needed to spread and sustain promising models. This issue will prioritize empirical research articles that offer evidence about the implementation and impact of system alignment strategies, but we will also consider other types of AJPH manuscripts such as analytic essays, and field reports on innovations in practice. This issue will appear in print and online in summer 2020.

Submissions for this issue must be received by December 15, 2019 through the AJPH submission website. Importantly, submissions must include a cover letter formatted as requested in the AJPH Instructions for Authors, and should specify that the submission is for the special supplement issue on “Aligning Health and Social Systems.” Please visit the AJPH website to review instructions for authors and specific guidelines for manuscript submission.

Larger & Longer Research Awards Enable More Powerful Studies of Medical, Social & Public Health System Alignment

The year 2019 continues to be an exciting period for those of us interested in nudging public health systems toward more productive forms of interaction with medical and social systems. A growing number of health care providers, social service organizations, and government agencies throughout the U.S. are taking steps to address social determinants of health by building stronger connections across the medical, social, and public health sectors. Hospitals and health systems are forging new relationships with public health agencies, housing authorities, food banks, transportation councils, schools, and a host of other community-based organizations. These approaches to system alignment are extremely diverse, including new ways of sharing health and social services data, new financing models and payment methods, new organizational and governance structures, and new staffing models.

As with any newly emerging area of practice, the pace of innovation far exceeds the supply of evidence right now. This means that system leaders have very few research-tested models, tools and guidelines they can use to inform their work in multisector systems alignment. And the organizations currently engaged in systems alignment work are often too busy to rigorously evaluate the impact of their work.

The danger of this situation –where innovation outpaces evaluation–is that communities are prone to repeating the same mistakes and failing to learn from them rapidly. Scarce resources may be wasted. Successes may be difficult to distinguish and detect. Experience may fall short of expectations. This dynamic ultimately can dampen enthusiasm for multi-sector work and lead to attrition from collective actions.

With support from the Robert Wood Johnson Foundation, our Systems for Action Research Program seeks to counteract this dynamic by building rigorous research designs around some of the most innovative approaches to system alignment. We recently announced the fourth round of funding available for studies that carefully evaluate the implementation and impact of new mechanisms for aligning medical, social, and public health systems. This year’s awards will support studies of up to 3 years in duration and up to $500,000 in total costs per award.

This year our call for proposals focuses on a specific subset of system alignment strategies that have not been explored fully by previous Systems for Action studies, including:

  • Alignment mechanisms that are designed and implemented in the social services or public health sector, rather than the medical sector;
  • Studies that include a focus on financing systems and/or incentives for system alignment;
  • Studies that examine system-level change and impact, as opposed to only person-level or patient-level impact; and
  • Studies that include explicit methods for evaluating impact on health equity.

Research proposals must be submitted by the deadline of November 6, 2019. Make sure to read the Call for Proposals brochure,  view our virtual workshop on developing a successful research proposal, review the portfolio of currently funded studies, watch a recording of our informational webinar on this funding opportunity, review our updated research agenda, and check out our list of frequently asked questions.

Addressing Social Determinants by Aligning Systems: the Time is Now for New Research

The Robert Wood Johnson Foundation-supported Systems for Action research program is again soliciting proposals for new research studies that test novel strategies for aligning medical and social systems. The deadline of October 10 is fast approaching. So why do we need your new research ideas?

The fact is that our toolbox of research-tested strategies for addressing social determinants of health remains alarmingly sparse. Research has produced a large body of knowledge about how social, economic, and environmental circumstances influence health and health equity. We understand the problem better than ever before. Additionally, research has given us valid ways of identifying the populations and individual patients who experience unmet social needs that, if left unchecked, will contribute to adverse health outcomes. We understand who is at risk better than ever before, and we understand that all of us are adversely affected by social conditions that morph into health inequities. Most recently, research has begun to identify actions and interventions that appear effective in connecting patients to services and supports that can help address unmet social needs, such as the Health Leads program and its extensions, and the CMS Accountable Health Communities model. Increasingly, we understand that solutions are possible.

Unfortunately, individual interventions implemented in isolation have yet to achieve the scale and spread necessary to improve health and health equity for large segments of the U.S. population. Our existing systems are not configured to support these interventions. Delivery and financing systems for medical, social, and public health services operate largely in isolation from each other, despite pursuing many common goals and serving overlapping populations. These systems interact in complex and often poorly understood ways through fragmented funding vehicles; information systems; governance and decision-making structures; implementation rules and strategies; and professional practices. Fragmented and poorly coordinated health and social systems can easily blunt, overwhelm and undo even the very best social determinant interventions.

New research is needed that can help untangle the complex interactions of health and social systems and expose novel ways of coordinating systems to improve health and health equity. Very few research-tested models currently exist that describe how to align and coordinate the delivery and financing systems for medical, social, and public health services. We urgently need new studies that can help to fill up our toolbox of models that work.

I invite you to download our Call for Proposals brochure, review the studies we’ve funded to date, and submit your research proposal by October 10.

Just Making Sure? Laboratory Testing and National Health Security

It doesn’t require deep thinking to appreciate the importance of public health laboratories to national health security. Labs detect disease outbreaks as early and quickly as possible. Labs accurately identify pathogens in air, water, soil, food, humans and other animals. Labs rapidly convey test results to public health responders who can close restaurants and schools, quarantine infectious people, evacuate neighborhoods, issue public warnings and otherwise interrupt the cascade of exposure and transmission. In sum, labs are the central nervous system of the health security enterprise.

So, can you identify the most heavily questioned and hotly contested element of the National Health Security Preparedness Index? Believe it or not, it is the set of measures that indicate what public health laboratories do.

Heterogeneity and Controversy in Lab Testing

The controversy stems from the concept of assurance. And it flows from the many different ways that public health responsibilities get divvied up across state governments.

In most states, multiple laboratories exist, operated by different state agencies. Public health laboratories are often organized within state health agencies, but sometimes they are organized as independent state institutions or as part of state university systems. Environmental laboratories are often located within state environmental protection agencies, which may or may not fall under the umbrella of a health-related super agency. Agricultural laboratories are found within state agriculture agencies. And of course there are clinical labs located within state hospitals, crime labs located within state law enforcement agencies, and medical examiner’s labs located somewhere in this mix. Which lab is responsible for testing food samples for pathogens? Which lab tests air, soil or other environmental samples for harmful substances like lead? Which lab tests public drinking water sources, private wells, or recreational bodies of water? Which lab tests the white powder found in an office building?

Political dynamics add to the controversies surrounding heterogeneity in laboratory structure. Environmental and agricultural labs conduct testing largely in support of the regulatory enforcement duties carried out by their parent agencies. Some of the tests performed by public health labs also fulfill regulatory purposes, but these labs typically have a broader surveillance mission and a wider scope of responsibilities. Concerns about industry capture and political interference in testing exist, and examples that fuel these concerns are not hard to find.

Figure 1: State public health laboratory roles in testing for hazards in air, 2016

Source: Association of Public Health Laboratories, 2016

The Solution: Assurance

Long ago, laboratory experts at CDC and at state public health laboratories recognized the problems that can arise when testing capabilities exist in one agency but interpretation and response capabilities reside in other corners of state government. Information does not always flow seamlessly through government bureaucracies. The legal authority to act and the scientific knowledge about what to do are distributed unevenly across agencies. This situation can cause delays in responding effectively to hazards detected through laboratory testing. And delays can have serious human and economic consequences.

The solution devised by CDC and its state laboratory partners at APHL involves two key ingredients:

1. Recognize that public health testing and reporting capabilities are carried out by a multi-agency system of laboratories in most states.

2. Recommend that a state’s designated public health laboratory take responsibility for ensuring that all necessary health-related testing and reporting capabilities exist somewhere within the state’s laboratory system and are implemented effectively. The laboratory can carry out this assurance function either by directly providing necessary testing and reporting activities itself OR by confirming that another laboratory somewhere within the state system provides these activities effectively.

This “provide or assure” recommendation for state public health laboratories forms the basis of CDC’s and APHL’s Comprehensive Public Health Laboratory System definition and its Core Functions and Capabilities of State Public Health Laboratories framework. Moreover, this recommendation is formalized in the federal Healthy People 2020 health objectives for the nation.

How Does the Index Measure Laboratory Capabilities?

The National Health Security Preparedness Index follows the recommendations of CDC and APHL when measuring public health laboratory capabilities. In fact, we use a series of measures constructed from periodic surveys that APHL fields with state public health laboratory administrators. The measures in this series indicate whether or not the state public health laboratory “provides or assures” testing of water, air, soil, and human samples for specific pathogens and hazards. A state receives credit for having a specified capability if the public health laboratory directly performs the test, OR if it assures that another laboratory entity performs the test.

Figure 2: State public health laboratory roles in testing public drinking water systems, 2016

Source: Association of Public Health Laboratories, 2016

The controversy arises in states where a certain type of test is performed by an environmental or agricultural laboratory, but there is no assurance function performed by the public health laboratory. In these cases, the capability to test for a certain hazard exists. But the capability to assure that the testing and reporting function is carried out effectively does not exist within the public health laboratory. Such states do not comply with the CDC/APHL recommendation. By following the CDC/APHL recommendations, the Index measures the assurance capability rather than the testing capability alone.

And as you can imagine, some states don’t agree with this way of measuring laboratory capabilities.

Figure 3: State public health laboratory roles in testing hazardous waste, 2016

Source: Association of Public Health Laboratories, 2016

Testing vs. Assurance: Are We Measuring the Right Stuff?

The CDC/APHL “provide or assure” recommendation for public health laboratory testing reflects the consensus opinion of experts and experienced laboratory professionals at the dawn of the 21st century. As a recommendation based more on experience than on rigorous scientific evidence, it should remain open to continued evaluation, critical analysis, and revisions over time. The Index continues to monitor the scientific and professional literature on this topic, and we stand ready to update our measurement approaches as professional norms and standards evolve.

One issue in need of clarification involves how the assurance function should be defined and carried out by public health laboratories across the U.S. The APHL surveys used in constructing the Index rely on information that is self-reported by individual laboratory administrators. The surveys provide little guidance about what is meant by “assurance” and how laboratories should carry out this function in cases where they do not directly perform the testing. Consequently, it is left up to the interpretation of individual administrators as to whether or not their laboratory carries out the assurance function.

Figure 4: State public health laboratory roles in testing for hazards in soil, 2016

Source: Association of Public Health Laboratories, 2016

Is assurance really all that important? Isn’t it enough to know that testing exists somewhere within the state bureaucracy?

Clearly some people think so. But in the absence of clear scientific evidence, the Index relies upon well-reasoned professional recommendations like those from CDC and APHL.

It is not very difficult to find real-world examples that support the underlying logic of the “provide or assure” recommendation. As one example, Arizona’s environmental laboratory has responsibility for testing the safety of public drinking water systems, but it does not have the legal authority to notify the public of potential hazards. As a consequence, residents of one community waited years to learn that their drinking water supply had seriously elevated levels of uranium contamination from a defunct mine. The Flint water crisis provides another recent example of the problems posed by organizational complexity in lab testing and response. In that case, Michigan’s environmental agency held responsibility for overseeing testing of Flint’s drinking water system, but the state’s public health agency had responsibility for monitoring test results for reportable diseases like Legionnaires’. Delays in connecting the dots between water test results and disease surveillance enabled the hazards in Flint to persist and grow unchecked.

We hope the Index will stimulate further dialogue, discussion, and debate about these important issues in health security. Publicly accessible data, rigorous analysis, and critical thinking lead the way to a clearer understanding of actions that can strengthen health protections for everyone.

The original version of this post by Glen Mays can be found at www.nhspi.org

New Research: Investing in Public Health May Reduce Medicare Spending

Investments in public health programs appear to reduce spending in the Medicare program, providing an economic benefit for seniors and the federal budget as growing numbers of baby boomers join Medicare. Results from a new study published in the December issue of the journal Health Services Research by our research team at the University of Kentucky suggest new directions for containing costs by aligning medical and public health programs.

Public health programs aim to prevent diseases and injuries within the public at large, such as those caused by tobacco smoke, poor nutrition, inadequate physical activity, contaminated food and water, or exposure to infectious diseases like influenza. Logic dictates that these programs, if effective, may reduce the need for costly medical care, particularly as people age and accumulate health problems. But research confirming the existence and the size of this effect, which economists and policy analysts call a medical cost offset, has not been available until now.

Estimating Public Health’s Medical Cost Offsets

The new study tracks hundreds of U.S. communities over the period 1993-2013. We measured the amount of money spent annually by local public health agencies in each community, and linked these data with measures of Medicare spending per beneficiary in the same local areas, along with detailed information on demographic, economic and community characteristics. Using an advanced statistical methodology known as instrumental variables analysis, we estimated how public health spending influenced Medicare spending over time, while controlling for other factors that tend to obscure the true causal relationship between these two types of spending.

The results show that Medicare spending per beneficiary fell by about 1 percent for each 10 percent increase in public health spending per resident, with larger offsets observed in low-income and medically underserved communities. These findings suggest that the federal Medicare program could realize an average of $1.10 in savings for each $1.00 invested in local public health activities over time.

Figure: Estimated Impact of a 10% Increase in Public Health Spending Per Capita

Implications for Policy and Practice

A large body of research examines the causes and consequences geographic variation in Medicare resource use – work led by scholars at Dartmouth and elsewhere. Most of the empirical research has focused on supply-side factors and, to a lesser extent, patient preferences. This study is the first to suggest that public health programs and resources may contribute to this variation in important ways.

Local public health agencies appear to generate important but largely hidden economic benefits for their communities, alongside the more visible health benefits. Consequently, medical providers who participate in Medicare’s value-based payment models like accountable care organizations and shared-savings programs should explore the roles that public health agencies can play in helping to improve outcomes and contain costs.

One challenge highlighted by the study’s findings is the so-called “wrong pocket” problem that can undermine incentives to invest in public health programs. Many public health agencies are funded predominantly by state and local government contributions, but the Medicare savings generated by their work accrues to the federal government. Resolving this problem will require new models for public health financing, such as including public health agencies in Medicare’s shared savings models.

The study cannot rule out the possibility that other factors may contribute to the observed connection between public health spending and Medicare savings in local communities. For example, communities that choose to invest in robust public health programs may support other social and community resources that help to constrain Medicare spending, such as better housing and transportation options for seniors. Nevertheless, the study’s strong research design and analysis make this possibility less likely to affect the results.

For More Information

The study was conducted as part of the Robert Wood Johnson Foundation’s Systems for Action national research program, which studies new models for aligning the work of medical, social, and public health sectors in ways that improve health and wellbeing. The study appears in the December 2017 issue of Health Services Research, in a special theme issue featuring research on the economics of public health services.  For more information, contact me at glen.mays@uky.edu

It’s Hurricane Preparedness Week, How Strong is Health Security Where You Live?

The U.S. has experienced relatively mild hurricane seasons in recent years, and this trend may continue in 2017 according to some models. Hurricane season reminds us of just one of the many types of events that can threaten the health status of large groups of people in the U.S. each year. These events – including storms, fires, floods, infectious disease outbreaks, and infrastructure failures – are uncertain as to their exact location, timing, geographic scale, and intensity. For this reason, health security experts recommend that all states and communities maintain a broad spectrum of health protections that help to keep people safe and healthy regardless of the type of hazard that may occur. Unfortunately, the latest results from a national index of health security indicates that these protections are far from equal in strength across the U.S.

The National Health Security Preparedness Index uses big data and analytics to summarize the strength of health security protections across the U.S. and to track changes over time. The latest results show trends for the period 2013 through 2016 for every U.S. state and the nation as a whole. The comforting news is that health security has trended upward steadily for the nation as a whole. The troubling news is that some people enjoy much stronger protections than others based solely on where they live. For example, the Index shows that residents of the Deep South experience health security levels that fall significantly below the national average, despite their history of exposure to hurricanes and other damaging storms. Across the U.S., states with higher poverty levels, larger rural populations, and lower rates of health insurance coverage tend to fall below the national average on measures of health security.

The Index was created by the U.S. Centers for Disease Control and Prevention, and is now supported by the Robert Wood Johnson Foundation. Last week we shared insights from the latest Index results at the Preparedness Summit 2017 in Atlanta, one of the largest convenings of health security stakeholders in the U.S.

Whether or not you live in a region vulnerable to hurricanes, you have many reasons to care about health and social systems and their ability to protect people when hazardous events occur. For this reason, you will want to visit the Index website and explore its data and measures. And you can join the health security Innovator Challenge by devising a novel way to use the Index in stimulating actions that strengthen health security.

Defragmenting Health and Social Systems: Pitch Your Research Idea Now

The Robert Wood Johnson Foundation’s Systems for Action research program announced our 2nd call for proposals for new research last month. The May 5 deadline for brief proposals is fast approaching, but you still have time to pitch your idea. With this call we will build upon the strong cohort of intramural and extramural studies launched last year through the S4A program, which aim to answer a fundamental and urgent question:

How can we better align delivery and financing systems for medical, social, and public health services in ways that improve health and health equity?

Research shows us with increasing clarity that social, economic, and environmental conditions strongly influence health and health equity for individuals, families, and communities. But we also know that services and supports designed to improve these conditions—such as housing, transportation, education, income and employment assistance, child and family supports, and legal and criminal justice services —are often disconnected from the medical services and public health programs tasked with improving health. As a result, people experiencing adverse social, economic and environmental conditions are more likely to develop costly and preventable health conditions, but they are less likely to benefit from the medical and public health services available to them. We need more scientific evidence about productive and feasible ways to defragment our medical, social, and public health systems in order to solve these coordination problems.

For colleagues who have a special interest in the organization and economics of public health services, the S4A program is a golden opportunity for studying the ways in which public health strategies can help to connect the dots between the medical and social service needs faced by individuals and communities. All of the research supported through S4A pursues an overarching focus on how system alignment strategies can help to achieve health equity by activating key drivers represented in the RWJF Culture of Health Action Framework.

This year we seek research proposals in two different categories: (1) a category for exploratory and developmental studies and (2) a category for full research studies that examine impact and effectiveness.

Submit your research idea today!