FOR THE PUBLIC’S HEALTH

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Committee on Public Health Strategies to Improve Health Board on Population Health and Public Health Practice

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. 65863 between the National Academy of Sciences and the Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommen- dations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data For the public’s health : the role of measurement in action and accountability / Committee on Public Health Strategies to Improve Health, Board on Population Health and Public Health Practice, Institute of Medicine. p. ; cm. Includes bibliographical references and index. ISBN 978-0-309-16127-5 (hardcover : alk. paper) — ISBN 978-0-309-16128-2 (pdf : alk. paper) 1. Public health administration—United States. 2. Health status indicators—United States. I. Institute of Medicine (U.S.). Committee on Public Health Strategies to Improve Health. [DNLM: 1. Public Health Administration—standards—United States. 2. Health Status Indicators—United States. 3. Social Responsibility—United States. WA 540 AA1] RA445.F657 2011 362.1—dc22 2011004593 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2011. For the Public’s Health: The Role of Measurement in Action and Accountability. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and techni- cal matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON PUBLIC HEALTH STRATEGIES TO IMPROVE HEALTH MARTHE R. GOLD (Chair), Professor and Chair, Department of Community Health and Social Medicine, Sophie Davis School of Biomedical Education, City College, New York, NY STEVEN M. TEUTSCH (Vice Chair), Chief Science Officer, Los Angeles County Department of Public Health, Los Angeles, CA LESLIE BEITSCH, Associate Dean for Health Affairs; Director, Center on Medicine and Public Health, Florida State University College of Medicine, Tallahassee, FL JOYCE D. K. ESSIEN, Director, Center for Public Health Practice, Rollins School of Public Health, Emory University; Senior Medical Advisor, Research and Outcomes Branch, Division of Public Health Performance Improvement, Office for State, Tribal, Local and Territorial Support, National Centers for Disease Control and Prevention, Atlanta, GA DAVID W. FLEMING, Director and Health Officer for Public Health, Seattle & King County, Seattle, WA THOMAS E. GETZEN, Professor of Risk, Insurance and Health Management, Fox School of Business, Temple University; Executive Director, International Health Economics Association (iHEA) Philadelphia, PA LAWRENCE O. GOSTIN, Linda and Timothy O’Neill Professor of Global Health Law and the Director of the O’Neill Institute for National and Global Health Law at Georgetown University, Washington, DC MARY MINCER HANSEN, Director of the Masters of Public Health Program; Adjunct Associate Professor, Department of Global Health, Des Moines University, IA GEORGE J. ISHAM, Medical Director and Chief Health Officer, HealthPartners, Bloomington, MN ROBERT M. KAPLAN, Distinguished Professor of Health Services, Distinguished Professor of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA WILFREDO LOPEZ, General Counsel Emeritus, New York City Department of Health and Mental Hygiene, NY GLEN P. MAYS, Professor and Chairman, Department of Health Policy and Management, Fay W. Boozman College of Public Health, University of Arkansas Medical Sciences, Little Rock, AR PHYLLIS D. MEADOWS, Associate Dean for Practice, Office of Public Health Practice; Clinical Professor, Department of Health Management and Policy, University of Michigan, School of Public Health, Ann Arbor, MI POKI STEWART NAMKUNG, Health Officer, Santa Cruz County Health Services Agency, Santa Cruz, CA v

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MARGARET E. O’KANE, President, National Committee for Quality Assurance, Washington, DC DAVID A. ROSS, Director, Public Health Informatics Institute, The Task Force for Global Health, Decatur, GA MARTÍN JOSÉ SEPÚLVEDA, IBM Fellow and Vice President, International Business Machines Corporation, Somers, NY STEVEN H. WOOLF, Professor, Departments of Family Medicine, Epidemiology, and Community Health, Virginia Commonwealth University, Richmond, VA Study Staff ALINA B. BACIU, Study Director AMY GELLER, Program Officer ALEJANDRA MARTÍN, Research Assistant RAINA SHARMA, Senior Program Assistant (through July 2010) ALLISON BERGER, Senior Program Assistant (from June 2010) NORMAN GROSSBLATT, Senior Editor ROSE MARIE MARTINEZ, Board Director, Board on Population Health and Public Health Practice vi

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Edward Baker, University of North Carolina at Chapel Hill Leah Devlin, University of North Carolina at Chapel Hill Paul Erwin, University of Tennessee Russ Glasgow, National Institutes of Health Ron Z. Goetzel, Emory University Anthony Iton, The California Endowment Kenneth W. Kizer, Kizer & Associates, LLC Paula M. Lantz, University of Michigan Elizabeth A. McGlynn, The RAND Corporation David Meltzer, University of Chicago Margaret Potter, University of Pittsburgh Mary Selecky, Washington State Department of Health Burton H. Singer, University of Florida Edward H. Wagner, Group Health Research Institute vii

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viii REVIEWERS Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Lawrence D. Brown, University of Pennsylvania, and Jo Ivey Boufford, New York University. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Acknowledgments The committee wishes to thank colleagues both outside and inside the National Academies who provided valuable information at various points in the study process. These include Connie Citro (National Research Council [NRC]), Gooloo Wunderlich (NRC), Michael Wolfson (University of Ot- tawa, formerly, Statistics Canada), and Jennifer Madans (National Center for Health Statistics, Centers for Disease Control and Prevention). The committee learned a great deal about measurement of health from representatives of federal, state, and local public health agencies and from researchers and many types of practitioners who presented at the com- mittee’s information-gathering meetings pertaining to the present report. The meeting agendas provided in Appendix C include the names of all the speakers. Additional support with one technical area of the report was pro- vided by IBM Research Division colleagues of committee member Martín Sepúlveda. The committee thanks Peter Haas, Paul Maglio, and Pat Selinger for their assistance with report discussions about modeling. Finally, the committee would also like to thank the Institute of Medicine staff members who contributed to the production of this report, includ- ing study staff Alina Baciu, Amy Geller, Alejandra Martín, Raina Sharma, Allison Berger, Rose Marie Martinez, and Hope Hare, as well as other staff on the Board on Population Health who provided occasional support. The project received valuable help from Norman Grossblatt (senior editor), Christine Stencel (Office of News and Public Information), Christie Bell and Amy Przybocki (Office of Financial Administration), and Greta Gorman and colleagues (IOM Office of Review and Communication). ix

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Contents Preface: Introduction to the Series of Reports xiii Summary 1 1 Introduction 13 Charge to the Committee, 17 Key Terms, 19 Two Paradigms, 21 Meeting the Charge, 27 What This Report Does Not Address, 28 References, 29 2 Needed: An Information Enterprise to Drive Knowledge and Population Health Improvement 35 The Need for a Determinants-of-Health Perspective, 38 Responsiveness to the Needs of End Users, 43 Need for Improved Coordination at the National Level (Including Federal Agencies), 49 Concluding Observations, 59 References, 61 3 Measuring Health for Improved Decisions and Performance 67 Improving Coordination at the National Level, 67 Adopting the Determinants of Health Perspective at a Fundamental Level, 87 xi

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xii CONTENTS Responsiveness to the Needs of End Users, 90 Concluding Observations, 103 References, 104 4 Measurement and Accountability 111 A Framework for Accountability, 113 Context and History, 121 Roles of System Stakeholders in Measuring Accountability, 123 Measurement and Accountability in the Future, 132 Types and Examples of Needed Accountability Measures, 134 Concluding Observations, 140 References, 141 APPENDIXES A Acronyms 145 B National and Community Health Data Sets 147 C Meeting Agendas Held by the Committee on Public Health Strategies to Improve Health (November 2009–May 2010) 171 D Committee Biosketches 179

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Preface: Introduction to the Series of Reports In 2009, the Robert Wood Johnson Foundation asked the Institute of Medicine (IOM) to convene a committee to examine three topics in rela- tion to public health: measurement, the law, and funding. The committee’s complete three-part charge is provided in Box P-1. The IOM Committee on Public Health Strategies to Improve Health explored the topics in the context of contemporary opportunities and challenges and with the pros- pect of influencing the work of the health system (broadly defined as in the report summary) in the second decade of the 21st century and beyond. The committee was asked to prepare three reports—one on each topic—that contained actionable recommendations for public health agencies and other stakeholders that have roles in the health of the US population. This report is the first in the series. The committee’s three tasks and the series of reports prepared to re- spond to them are linked by the recognition that measurement, laws, and funding are three major drivers of change in the health system. Measurement (with the data that support it) helps specialists and the public to understand health status in different ways (for example, by determinant or underlying cause where national, local, and comparative evidence is available), to un- derstand the performance of the various stakeholders in the system, and to understand the health-related results of investment. Measurement also helps communities to understand their current status, to determine whether they are making progress in improving health, and to set priorities for their next actions. Although the causal chains between actions of the health system and health outcomes are not always clearly elucidated, measurement is a fundamental requirement for the reasons listed above. xiii

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xiv PREFACE BOX P-1 Charge to the Committee Task 1 (accomplished in this report) The committee will review population health strategies, associated metrics, and interventions in the context of a reformed health care system. The committee will review the role of score cards and other measures or assessments in sum- marizing the impact of the public health system, and how these can be used by policy-makers and the community to hold both government and other stakehold- ers accountable and to inform advocacy for public health policies and practices. Task 2 (to be addressed in a forthcoming report) The committee will review how statutes and regulations prevent injury and dis- ease, save lives, and optimize health outcomes. The committee will systematically discuss legal and regulatory authority; note past efforts to develop model public health legislation; and describe the implications of the changing social and policy context for public health laws and regulations. Task 3 (to be addressed in a forthcoming report) The committee will develop recommendations for funding state and local health systems that support the needs of the public after health care reform. Recom- mendations should be evidence based and implementable. In developing their recommendations the committee will: · Review current funding structures for public health · Assess opportunities for use of funds to improve health outcomes · Review the impact of fluctuations in funding for public health · Assess innovative policies and mechanisms for funding public health ser- vices and community-based interventions and suggest possible options for sustainable funding. Laws transform the underpinnings of the health system and also act at various points in and on the complex environments that generate the conditions for health. Those environments include the widely varied policy context of multiple government agencies, such as education and transpor- tation agencies, and many types of legal or legislative measure intended to reshape the factors that improve or impede health. The measures range from national tobacco policy to local smoking bans and from national agricultural subsidies and school nutrition standards to local school-board decisions about the types of foods and beverages to be sold in school vend- ing machines. Funding that supports the activities of public health agencies is provided primarily by federal, state, and local governments. However, government budgets must balance a variety of needs, programs, and policies, and the

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xv PREFACE budgets draw on different sources (including different types of taxes and fees), depending on jurisdiction. Therefore, the funds allocated to public health depend heavily on how the executive and legislative branches set priorities. Other funding sources support public health activities in the community, including “conversion” foundations formed when nonprofit hospitals and health insurers became privatized (such as the California Wellness Foundation). Additionally, funds for population health and medi- cal care activities may be provided by community-based organizations with substantial resources, not-for-profit clinical care providers, and stakeholders in other sectors. The subjects addressed in the three reports are not independent of each other and often affect one another. For example, measurement of health out- comes and of progress in meeting objectives can provide evidence to guide the development and implementation of public health laws and the alloca- tion of resources for public health activities. Laws and policies often require the collection of data and can circumscribe the uses to which the data are put (for example, prohibiting access to personally identifiable health informa- tion). Similarly, statutes can affect funding for public health through such mechanisms as program-specific taxes or fees. And laws shape the structure of public health agencies, grant them their authority, and influence policy. In the three reports, the committee will make a case for increased ac- countability of all sectors that affect health—including the clinical care delivery system, the business sector, academe, nongovernment organiza- tions, communities, and various government agencies—with coordination by the government public health infrastructure. The present report reflects the committee’s thinking about how accountability would look at local, state, and national levels1 and suggests measurement strategies that would heighten accountability and galvanize broader action by communities and other stakeholders. In later reports, the committee will review legal and regulatory strategies that heighten public and private responsibilities and, in the final report, will consider resource needs and approaches to addressing them in a sustainable manner to ensure a robust population health system. 1 The committee’s discussion about measurement framework for accountability may also apply to territorial and tribal government, although this is not explicitly stated.

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