HSC 4630Understanding U.S. Healthcare

Population Health

Companion to Jonas & Kovner’s Health Care Delivery in the United States, Chapter Five,

“Population Health”

2

Presentation Objectives

• Explain the multiple determinants of health

• Demonstrate reorientation of the U.S.

health system from a medical model to a

population health model

• Explore the County Health Ranking model

of population health

• Examine concepts related to racial and

ethnic health disparities in the U.S.

Source: Jonas & Kovner’s Health Care Delivery in the United States, 10th edition, Kovner and Knickman, Editors. Springer Publishing Company, 11 W. 42nd Street, New York. Page 81.

Multiple Determinant of

Health

County Health Rankings Model

Healthy Tampa Bay

http://assets.thehcn.net/content/sites/tampabay/2011_HEALTHY_1FINAL.PDFhttp://www.healthytampabay.com/index.php

ACA & Community Health

Needs Assessment

Tampa General Hospital: https://www.tgh.org/wp-content/uploads/Community-Health-Needs-Assessment_2013.pdf

Social Determinants of Health

Social and Economic Factors

Pincus, T., Esther, R., DeWalt, D. A., & Callahan, L. F. (1998). Social conditions and self-management are more powerful determinants of

health than access to care. Annals of Internal Medicine, 129(5), 406-411.

Relative Risk for Death from Coronary Heart Disease

Health Behaviors

Chronic Disease Self-Management Programs (CDSMPs)

1. Lorig, K. R., Ritter, P., Stewart, A. L., Sobel, D. S., Brown Jr, B. W., Bandura, A., ... & Holman, H. R. (2001). Chronic disease self-management program: 2-year health status and health care utilization outcomes. Medical care, 39(11), 1217-1223.2. Gifford, A. L., Laurent, D. D., Gonzales, V. M., Chesney, M. A., & Lorig, K. R. (1998). Pilot randomized trial of education to improve self-management skills of men with symptomatic HIV/AIDS. JAIDS Journal of Acquired Immune Deficiency Syndromes, 18(2), 136-144.3. Bodenheimer, T., Lorig, K., Holman, H., & Grumbach, K. (2002). Patient self-management of chronic disease in primary care. JAMA: the journal of the American Medical Association, 288(19), 2469-2475.Meng, Y. Y., Pourat, N., Cosway, R., & Kominski, G. F. (2010). Estimated cost impacts of law to expand coverage for self-management education to children with asthma in California. Journal of Asthma, 47(5), 581-586.

Clinical Care

Dartmouth Atlas data used by Mulley, A. G. (2009). Inconvenient truths about supplier induced demand and unwarranted variation in medical practice. BMJ, 339.Wennberg J, Cooper M, Dartmouth Atlas of Health Care Working Group (1999) The quality of medical care in the united states: A report on the Medicare program. Technical report, American Hospital Association, Chicago, IL.

Cancer: Local Area Variation

http://www.dartmouthatlas.org/downloads/reports/Cancer_report_11_16_10.pdf

Roemer’s Law: a built bed is a filled bed

Physical Environment

Shain M, Roemer MI (1959) Hospital costs relate to the supply of beds. Modern Hospital 92: 71–73.http://www.dartmouthatlas.org/downloads/reports/supply_sensitive.pdf

“More Care is Not Better Care”

Baicker, K. and Chandra, A. Medicare Spending, The Physician Workforce, and Beneficiaries Quality of Care. Health Affairs (Millwood), 2004; Suppl Web Exclusives:W4-184-197

Racial and Ethnic Disparities

• Race and ethnicity are social constructs

• Race and ethnicity are proxy measures

• Disparities are persistent

• Disparities are pervasive

http://www.cdc.gov/nchs/data/databriefs/db74.htmMMWR Supplement, November 22, 2013, Vol. 62, Supplement No. 3, pg. 1-187.

Why Racial and Ethnic

Disparities?

Ashton, C. M., Haidet, P., Paterniti, D. A., Collins, T. C., Gordon, H. S., O'Malley, K., ... & Street, R. L. (2003). Racial and ethnic disparities in the use of health services. Journal of General Internal Medicine, 18(2), 146-152.

Balsa, A. I., & McGuire, T. G. (2001). Statistical discrimination in health care. Journal of health economics, 20(6), 881-907.Van Ryn, M. (2002). Research on the provider contribution to race/ethnicity disparities in medical care. Medical care, 40(1), I-140.

County Health Model

Framework and Disparities

• Social and economic factors

• Physical environment

• Clinical care

• Health behaviors

Williams, D. R. (1999). Race, socioeconomic status, and health the added effects of racism and discrimination. Annals of the New York Academy of Sciences, 896(1), 173-188.Morrison, R. S., Wallenstein, S., Natale, D. K., Senzel, R. S., & Huang, L. L. (2000). “We don't carry that”—failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. New England Journal of Medicine,342(14), 1023-1026.Tamayo-Sarver, J. H., Hinze, S. W., Cydulka, R. K., & Baker, D. W. (2003). Racial and ethnic disparities in emergency department analgesic prescription. Journal Information, 93(12).

August, K. J., & Sorkin, D. H. (2011). Racial/ethnic disparities in exercise and dietary behaviors of middle-aged and older adults. Journal of general internal medicine, 26, 245-250.

Conclusion

• Long way to go to transition from the established

medical model to a population health model

• Health services research is challenging the

medical model with health outcomes-related

evidence

• Unwarranted variation in health care delivery,

and more healthcare is not better

• Ethnic and racial disparities is expressed in our

social environment, physical environment,

clinical care, and health behaviors