Podcast Episode Transcript: Prevention vs. treatment: Investing in the health of communities

With L. Gordon Moore, MD

Gordon Moore: Hello. This is Dr. Gordon Moore the host of the 3M Inside Angle Podcast. Welcome to today’s podcast where our guest is Dr. Nico Pronk, who is the President of the HealthPartners Institute and the Chief Science Officer at HealthPartners. His research areas include Population Health Improvement, The Role of Physical Activity in Health, and The Impact of Multiple Health Behaviors on Health Outcomes. Welcome, Dr. Pronk.

Nico Pronk: Thank you, Gordon. Great to be with you today.

Gordon: Thanks for coming on. We have lots to talk about today. Part of what is interesting to me is the understanding. I came into health care, obviously, as a physician and that’s with the idea that I can help people get better outcomes. But every time I take a class in public health or talk to folks who are steeped in that literature, I realize that the impact of public health on health outcomes is much greater. So there is an interest of mine to think about how we achieve better population health outcomes and wondering, as the co-chair of the Healthy People 2030 Committee, if you can give me some guidance and thoughts about where things are going and how we can understand health and how we can understand health care’s intersection with improving health of people with conditions as well as healthy people. It’s a broad topic, but let’s have at it.

Nico: I think you’re right when you say the impact of public health on the health and wellbeing of the population is perhaps much larger than the impact of health care. We’ve seen, for example, studies that note that the determinants of health—the social determinants of health that are really part of other sectors besides health care, maybe have as much as 90 percent impact on outcomes in the health sphere. That leaves only 10 to 15 percent or so for the medical care part. That sort of perspective is important when you put all the resources that we consider going into the outcomes of health—outcomes in the area of health across the nation, and really think about what’s the value that we generate when you think about medical care alone.

The other observation is that medical care is also a determinant of health. It’s an important determinant of health. And so, it’s not necessarily one element or one component of all of those different areas that impact health at the end of the day. It’s medical care, it’s behavior that people participate in, it’s the social circumstance in which they find themselves, and it’s their genetic makeup. It’s really the interaction of all of those components. So medical health care is certainly a part of it and it should be, but it may well be that a little bit more emphasis on these non-medical care determinants is a very important consideration for the overall health of the population we serve.

Gordon: I think that’s been—there’s a lot of awareness around this now but in terms of social determinant’s health impact on things like chronic condition management in the health delivery side of population outcomes. I hear about initiatives to reduce hospitalization by homeless people by feeding hungry people. I wonder about how health care gets into that public health intervention with maybe an incomplete understanding of what levers they can pull, how to do it, and is this really effective. It makes me a little bit nervous, though, as I look at health systems that are entering into contracts with insurers to say we can manage this population to better outcomes and they start getting into this world.

Are they doing a good thing? Are they pushing public health aside and that’s ill advised? What do you think of that?

Nico: There is a danger, in a sense, that we end up medicalizing interventions that are really public health oriented. That is probably not a good thing. At the same time, health systems—care delivery systems oftentimes are the largest employer in a community. They have an enormous impact on a given community. As a result, they can bring resources to the table that really are needed to make sure that it can make a difference in some of these outcomes. I would say that health care organizations need to be part of that equation. They need to be part of the dialogue that goes on in a given community, but they should not drive their objectives and their reasoning for participating in that onto the community.

It needs to be part of that. And so in that context, I would say you sort of go back again to the interaction of all of these elements at the same time. It’s really a systems perspective across a community or a society that needs to be considered. From my perspective, there are certainly investments that need to be made that have this impact—that really public health is so focused on, which really oftentimes, has to do with prevention more so than treatment. That means you have to be able to care for the urgent needs of a community, meaning if something happens that really demands an acute response, whether it’s a disaster relief or addiction treatments that are oftentimes urgent. Shelter needs for homeless folks, and the need for food assistance.

Those are really urgent needs for people. There needs to be an investment that allows you to respond to those needs, but at the same time, enhancing what I would refer to as vital conditions of a community. So stable housing, healthy food accessibility, clean air, clean water, education—particularly, early childhood education, living wage jobs, and those kinds of examples. Those are really vital conditions in a community that need to be addressed ongoing. It’s that balancing act between how do you invest resources that are available and balance them in a way such that there is a long-term, high-value impact of those resources. Oftentimes, that needs to be balanced against a political will of people.

Gordon: You had mentioned medicalizing. I wonder if you could unpack that a little bit for me and what that means.

Nico: The idea that all of a sudden care delivery organizations find themselves investing their resources into community programs that really go way beyond medical treatments alone. If all of a sudden housing—affordable housing, for example, is dependent on investments that come out of the medical industry—that, in my view, is not a good line of rationale to follow. It medicalizes the challenges in a way that unless this is a treatment oriented approach, it won’t get done versus thinking about this more from a public health perspective, which perhaps, is a little bit more prevention focused. Let’s make sure that people have access to affordable housing such that we can maintain the health that they have rather than treating the health care needs they get once they are homeless.

Gordon: To pursue that a little bit more, the HealthPartners Institute is a large group of researchers looking into things like this. I wonder if you guys have done any research that looks at the medicalization of some of these public health intersection initiatives in terms of population health management and the costs and outcomes of those?

Nico: Well, we do, but I would say that the HealthPartners Institute is actually a research organization embedded inside a health system. A lot of our work is actually focused on issues that deal with treatment in the context of care delivery. That said, because HealthPartners is an integrated not-for-profit and member-governed system that has as it’s mission statement the pursuit of health and wellbeing of the people, patients, and communities that we serve, we end up spending a lot of time in these non-medical determinants of health. That’s where some of the community-based partnerships oriented kind of programs are housed. Despite the fact that we still do a lot of work on the treatment side, we spend a lot of time thinking about what’s the most efficient and effective approach to work with communities around optimizing health and wellbeing for everybody we serve in our area.

That said, we do find ourselves working very closely with communities oftentimes in a way that allows us to actually generate impacts of those projects and then position evaluation or research questions on top of that. For example, we made a ten-year commitment to work in the St. Croix Valley with a whole series of communities—it’s a more rural area—to optimize health and wellbeing for children and youth. We basically communicated our intent with the various communities and stakeholders in those communities. It probably took about two years before that conversation ended up with a clear definition of what the communities wanted us to do. We did not come in with an agenda to say, well, we’re here to help out and maybe focus in on obesity, because that’s a topic that the health system wants to address.

Instead, we went in and asked the community what is it that you want to focus in on? It turned out, the community wanted to focus in on healthy children, which turned into making it focused enough to actually do some work. It turned into active living and healthy eating. This program ended up being called PowerUp. We ended up then hiring a director for this work. The director works closely with the different communities and school systems, in particular, in those communities. This now has been about eight years ago that we started that work. About six years ago, it really became in all earnest a project that was being implemented across those communities. And six years later now, we are starting to see impacts related to health.

It takes a long time to get you to a place where some of those community-type of interventions really start paying off. But in doing that setting up of a longer term agenda, it does allow you to create partnerships that really have a sustainability component to them that otherwise you wouldn’t see if you went into a community and said, we’re going to fund you for two year. And then after two years, the project ends because the funding runs out. Figuring out, I think, those kinds of approaches in these kinds of systems kind of approaches, there isn’t a really strong role that health systems can plan. But it needs to be a role that really is optimized through partnerships and stakeholders that have an equal share and responsibility at the table rather than a medical organization coming in and saying, this is what we want you to do and do things to the community instead of with the community.

Gordon: I know in New York State Medicaid there is—one of the requirements to the entities that are assuming health outcomes for Medicaid recipients is to develop plans to intersect with community agencies to expand their reach and scope of what they do. Is there a template that they can look to—a model? Are there places where they don’t have to reinvent the wheel?

Nico: Yeah. I think there are. Across the country there are really good examples of how that’s done, but it does also depend on sort of the local situation. I think going back to Healthy People 2030, there are really good examples available in some of these places where inventories are being kept. Some of those places include things that the federal government is doing. I think the Healthy People program, which has been in existence since 1980, has great examples of local public health agencies, for example, that work in partnership with other stakeholders to address these issues. And so, the Healthy People website is a very rich source of information. There are also other organizations. I’m thinking of the work that’s coming out of the 100 Million Healthier Lives effort from the Institute for Health Care Improvement.

The Wellbeing In The Nation Initiative that is part of some of that work is really organized around creating partnerships to improve wellbeing. Lots of those partner organizations have these experiences. Doing an assessment of where that work was done is clearly a good use and an efficient use of resources.

Gordon: You mentioned that six years into the initiation of the real interventions in the St. Croix Valley, you are starting to see things. What are you seeing?

Nico: Actually, that program being focused on children with a particular emphasis on healthy diets—particularly, fruits and vegetable intake, and then associated with that, active living. Getting kids to participate in activities with family and what have you. We’ve had over the first couple of years a major focus on participation. How can we get really the school systems, in particular, to participate in this program? That’s been an extremely successful effort because of the notion that everybody at the table has an equal voice. It’s really a community-driven effort. We have over 90 percent of school systems participating. Within each of those schools, more than 95 percent of kids are actually participating.

Over the years, we’ve had this great level of exposure, if you will, to efforts and interventions and activities that start perhaps at the school system but then are moving deeper into the community. Even though the focus is not necessarily on obesity, after six years we are now starting to see the intervention communities with a reduction in BMI versus sort of the control or comparison communities for which we have data that do not show that same impact. This is one of the few interventions at the community level that are starting to generate data that actually has an impact and outcome on such difficult variables as body mass index. That’s pretty encouraging and that’s pretty impactful.

Gordon: Being able to demonstrate reduction of BMI is actually pretty impressive. It makes me wonder about—

Nico: And I would say, Gordon, that is a great success, I think, for that program. But what really is driving it is that continued 90+ percent participation in activities that make sure that families have fruit and vegetable options at the dinner table, and that kids are growing up with those kinds of messages. Really, that’s the driver behind these outcomes of interest. It’s the process part that is so important and doing that in a way that is positive, that is sustainable, and that is scalable. I think those are the real sort of successes that this program is generating.

Gordon: I can imagine that in the early days of BMI improvement, this is sort of setting a tone for a large group of people with a positive trajectory compared to control for a lifetime.

Nico: Exactly, because that’s what you want. Starting at the children level and how can we be sure to set in motion a set of behaviors, attitudes, and values that will last for a lifetime.

Gordon: The challenge that I run into in the U.S. is that the average life span of a person who is enrolled with a health insurance company is about four years. That number may be out of date, so I won’t swear to it. Therefore, the interest in an improvement trajectory is relatively short term and the desire to invest is pretty low if the benefit is going to come five or ten years out. How do your funds work like this and how do you sustain it over ten years? You mentioned that programs and research initiatives may come in and say, we have two years of funding and then we’re going away. How is it you go in with ten years of funding and how is this sustained? And then, ultimately, how do we spread it?

Nico: That’s a commitment. It’s the idea of a long-term view of the leadership that needs to be at the table for these kinds of investments to be made. I’m thinking of, for example, the leadership that comes from business and industry that needs to align with leadership from public health. That leadership conversation is couched in the context of maybe a 10 to 15 year agenda. When you think about business and industry needing the next set of—the next generation of employees, that is really only 10 or 15 years away. If you think about the 3 year old 15 years later being 18 years old, that’s your next employee as a business in a community. Do you want that employee to be healthy coming in or not? Today oftentimes, we see the retirees are in better health than the new hire.

I think that is a conversation that needs to happen at the level of a community. That’s a longer-term view than what we do today oftentimes in business, which is that quarterly earnings report that is driving all the decisions. That’s not a good idea. So health wellbeing is directly linked to productivity and performance of a workforce. That opens up an opportunity for leadership of business and industry sectors to sit down with leadership from public health and figure out how to partner in a positive, reliable, sustainable, and scalable manner such that you can get to benefits that are really benefits to both parties.

This notion of creating shared value is an example of a methodology that would allow business and industry to be much more creative about how it actually supports efforts to improve health and wellbeing at the community level such that it also benefits their own company. The health and wellbeing and the vitality and prosperity of the community is what business needs to be successful. This getting outside of the short-term view to a longer-term view that is really also a systems perspective is what is sorely needed.

Gordon: Have you seen business and industry leaders resonate with this message and actually make moves in this direction?

Nico: Yes. In fact, this has been an agenda of our work over the past couple of years, so probably five to ten years or so. We have partnered with lots of organizations around the country working on, first of all, what’s the evidence. If as a company you take this kind of approach, does it pay off? And it turns out, companies that have this kind of view—a view of a long-term culture of safety and wellbeing at the organization that is investing in their community, and that is actively partnering around these kinds of topics, they actually do better than their counterparts in the marketplace such that they out perform those companies by five to fifteen percent on the S&P 500. That is real profit to an organization. In fact, you can argue as a shareholder you may want to maximize those returns by having this kind of a view.

And so, after those years of working on this evidence with partner organizations, there are now studies available that look at this in the United States, but it’s actually a global phenomena. The South African stock exchange has the same kind of learnings that are coming out, so now you see lots of investment organizations think about if I’m going to invest in this company, then let’s see what the health of that company actually is such that it can actually optimize my investment. And so, health and wellbeing of the workforce is fast becoming a major driver for investment organizations around decisions whether or not to do so in a particular company. This is not something that is sort of stand alone from what I would say is project-oriented work.

It really is starting to become a trend in the market. And now with the recent announcement of the Advisory Board—the business roundtable that they are going to put people before profits. Those are the type of announcements that fit right into this perspective. This notion that this is an industry that needs to realize that actually health and wellbeing is an absolutely necessary component of the way that they manage the company.

Gordon: I want to make the granular connection in my head so I’m going to state it to see if it resonates with your understanding of the evidence. A company invests with a community agency for the health of the community and by so doing is able to hire healthier people who are more productive, show up more often, and accomplish more in their work. Is that what gets the 15 percent ROI for the company?

Nico: That’s one element that you could look at, but you could also look at things like what is it that the company invests in for the community or in the broader marketplace that allows them to create a marketplace that they previously did not have? This can be resources of all kinds. It could be that it’s a technology company that can bring expertise to community solutions that are needed. Let’s say, what’s the expertise on computer programming that a particular company has that could be brought to bear to improve water systems and water cleaning plants that are necessary. I’m thinking, for example, IBM has identified seven or eight cities around the world where they bring their resources around computer systems to problems that are linked to technology in that community. For example, Des Moines, Iowa, is one of those cities.

I’m thinking of Kohler, the water treatment company that is doing major efforts in countries like India where there is major hygiene challenges and helping create more hygienic conditions that have an immediate impact on the health of populations. But in doing so, they create a new marketplace where their product gets implemented. That, to me, is creating shared value. That, to me, is providing social benefit by companies that at the same time see then their products being implemented. As such, they receive a benefit of that themselves. Does that make sense?

Gordon: That makes total sense. I love that there’s a multi-faceted opportunity for enlightened self-interest. I’ll put it that way.

Nico: Yeah. Going back to our earlier conversation about Healthy People 2030, Healthy People 2030 is now starting to move beyond healthy people alone and introducing wellbeing in that context. The introduction of wellbeing besides health allows you to extend beyond health into these determinants of health that are nonmedical. That opens up a bridge, if you will, to the social determinants of health dialogue that’s going on today. All of a sudden now, we have an opportunity to make this truly a multi-sectorial effort and a comprehensive programming in the back of your mind that really is organized around prevention as well as treatment.

It’s not just dealing any more with the prevalence of diabetes or the prevalence of heart disease, but also the incidence of diabetes and the incidence of heart disease. How can we reduce incidence so that the total burden of a population is actually improving over time because you actually stem the influx of new cases rather than treating only those cases that are there and never stopping the flow of new cases in that prevalence pool of people that already have the condition. The focus on incidence through preventive actions is something that we really do need to start thinking about intentionally in order to get out of this, I think, treadmill of continuing to pour way too much resources into treatment alone, particularly compared to other OECD countries around the world.

Their investments in medical care can actually pay off because the social context in which people live their lives outside of the medical setting is actually supportive of health and wellbeing.

Gordon: That is, I think, a beautiful description of the way we could shift dollars to public health, get upstream, think about prevention, and as you so well described, reduce the incidences of chronic conditions that are making new hires sicker than retirees. Thank you very much, Dr. Pronk. This has been a terrific conversation.

Nico: Great. Thank you. I really appreciate it.

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