DEPARTMENT OF HEALTH AND HUMAN SERVICES
Meeting of: Secretary's Council on Health Promotion and Disease Prevention Objectives for
2010
April 23, 1999, Proceedings
DR. LURIE: It sounds like a segue to our discussion on Leading Health Indicators, and I am going to ask members of the panel for this discussion to come up and join me. While they are doing that, let me just refresh your memory, present you with a little bit of background.
About 3 years ago, when the development process for Healthy People 2010 was getting under way, the department conducted a number of focus groups to find out what stakeholders liked about Healthy People 2000 and what things they wanted to see improved. We received, again, a lot of information, but there was really an inherent conflict in what we heard. Health departments told us that they wanted the Healthy People document to grow in size, and this was because they really used Healthy People as a menu or template for developing their State and local plans and want everything in their plans and the national plan for benchmarking purposes to help them benchmark and move along.
However, business and managed care gave us a very different kind of message. Many of them, for example, were not using Healthy People because it was so overwhelming in size and it did not prioritize the objectives in any way.
We recognized that these two groups were both very important for our health improvement activities and, in this version, really strike to seek a balance and accommodate the needs of both perspectives. So what we have done, as you know, is we have allowed Healthy People 2010 to become much more extensive-and it grew from about 300 objectives to over 500 objectives in the thick yellow book-while at the same time we have been really striving to create a smaller set of what we call Leading Health Indicators.
The Leading Health Indicators are really viewed as a way to, I think, extend the reach of Healthy People beyond health professionals to the public, to opinion leaders, to health professionals, and we have had actually a lot of discussion about getting the public to recognize these as they do the leading economic indicators, for example. The set of Leading Health Indicators then would be intended to assess our progress toward our health goals as a nation and to do so in a manner that really prompts public understanding and is actionable by States and the public to achieve that progress.
I think we also view this as a core set of measures for Healthy People. It would be our hope and expectation that all State and local Healthy People plans would adopt this core set of measures in toto, in addition to the other parts of the document they want so that we would have comparable data in this set and at national and State and, hopefully, many local levels.
Let me tell you a little bit about our process for getting there so far. This past fall, as you know, we accepted comments from the public and went through our regional meeting process. I want to particularly commend the work of Linda Bailey, who is sitting here, who has really coordinated our work with Leading Health Indicators in this and has been really organizing and pulling together a lot of the information here. She will share with us in a little while the workgroup's perspective.
We have asked Dr. George Isham, a colleague from Minnesota and Medical Director and Chief Health Officer at Health Partners. He was one of the professionals that we heard from a lot on Leading Health Indicators, and he has agreed to participate today to share the perspective of managed care organizations as they engage in the Healthy People process.
Finally, we have asked Dr. Roger Bulger, who chaired an IOM committee for us on Leading Health Indicators, to come and share that committee's perspective with us. As you know, Roger is also executive director of the Association of Academic Health Centers.
When the Secretary just a bit ago-something like, how did you get in here, from the IOM perspective-I want to make a comment that a couple of weeks ago I went to the University of Maryland and talked to a group of medical students about health policy and public health, and I talked a lot about Healthy People 2010. I stopped partway through, and I asked the audience, "How many of you have ever heard of Healthy People 2000?" Not a single individual raised their hand in a group of first and second year medical students. After my talk, a bunch of students came down to the front of the room, and two of them came up to me and said, "We just want to tell you that we are nursing students, and we have had lots and lots of lectures about Healthy People."
[Laughter.]
So I think our academic health centers, as well as the rest of us, have a lot of challenges with all kinds of health professionals as we help them develop and move forward. Once we get through the Leading Health Indicators, Roger, we will put that back on your plate.
So I have asked the speakers now to limit their presentations to about 10 minutes so that we can have time for discussion or questions. This is a place where I feel like we need an awful lot of feedback and interaction from all of you. So I am going to ask Dr. Bulger to start the presentation and present the summary of the IOM report.
DR. BULGER: Well, good morning. I need to place myself here. In the first place, we have heard, for I guess Phil's benefit, that one of our participants came on rollerblades to work. Another one came on a bicycle, and I walked, and I perspired more than they did, which places me in one age group. The second thing I want to say is, as I look around the room, I am reminded that the vision that sort of came into my mind was Krisch's Ice Cream Parlor on Long Island where I grew up where, every Wednesday night in our high school, if you wanted to see anyone else that you knew or had not seen, you would go there for an ice cream soda and to hang out, which places me right back in the fifties, right? Can you imagine people hanging out in ice cream parlors now? And as I look around the room, I see so many faces of friends from different segments of my life, that it is better than Krisch's to come here.
[Laughter.]
The other thing I want to do is, rather than try to take you through the summary, because I think we can assume you have got it-if I could just ask you to turn to the roman numeral five in the front of it that lists the members. I would like to talk a little bit about the process, rather than to try to discuss many of the details, because I think we will get into details with the questions and that maybe those kinds of comments are more valuable.
If you just look down the members of that committee, those of you who know about the IOM know that the chair is frequently a person who does not know anything and therefore is supposed to not be biased, and I think that to a certain extent those two things were true about me.
But what I learned about all of these people is that we really, in typical IOM fashion, have a very diverse, talented group of experts representing a variety of fronts, and they joined this committee, I think, as we learned by interacting with them, with one purpose, because they were all intrigued by the problem. Every one of us, I think, realized pretty quickly why you asked the IOM to do it, because there are so many different views, to get down to fingers and toes or just numbers of fingers for Leading Health Indicators, there cannot be any perfect, right, or logically compelling set that everyone in the world will agree to.
There really was a judgment call that had to be made, but every one of these people wanted to participate in the intriguing effort of doing what I thought I heard Julie saying we should be doing-to try to see if we could get a surrogate set of measures for following the health status of the population, for addressing the discordance and health status among subpopulations in our citizenry that we could measure and that would affect people's behavior and communities' behavior and that could, in fact, help to go beyond the professionals in the field and get folks to begin to do some of the things now that could make a dent on some of the intransigent problems that we are dealing with.
So we all saw that, and I have to say that as we went through the process, as with many IOM committees, I think the people watching us were worried that we would never find anything out, we would never be able to come to a conclusion. I need to confess that I was worried that we would not be able to do it, and if we were able to do it, would we be able to do it with some conceptual models? Not only that, could we deliver two to the Secretary that would make some sense?
In fact, there are just two other things I will refer you to. On page 3, table E-1, those are criteria that we chose to select Leading Health Indicators, and I just wanted to tell you how we did this. We took all the information that came at us, and we sat down and said let's consider this health indicator; does it meet these criteria or not? This is a simplified list. I think the larger document you all have had nine. We first enlarged it to 14, and then as we thought about it, we felt we needed to go back and make it six.
These were the criteria we used, and we went through one health indicator at a time and decided to keep it in or leave it out. So then we got a list of 35 or 40 such indicators that we thought passed this test by the criteria on E-1, and then, if you just turn the page, you can see on E-2 what the three models were that we finally chose. This will be shown up here on the slide, but it is the same as table E-2.
I think the important thing here is that you will see that some of the indicators in each of these models are common throughout the three models. You will see that a few are unique to one or the other or the third of the models, and you will see that some are in two of them and not in the third.
What we believe is that there is a concept behind each of these models, and let me just tell you a little bit about the models. There was a set of models. We had, oh, 12 or 14 that seemed were candidates, and we sort of winnowed them down, first to five and then to three. What we did with this is, we recognized the complexity of making the final decision about this that you will have to make and how you jiggle with a model or do not jiggle with a model, and that there are a whole set of concerns that will go into your thinking that we as a committee could not know or fully understand. As we talked to each other about this, we said our job is to make believe we are literally up in an ivory tower and to think about this as clearly as we can and see if we can develop and pass on to you some conceptual models that would be useful. These three are the ones that in our judgment passed the test.
It is important to know, anticipating some questions later on, that we did not ask each other which was our favorite. We did not straw poll and rank them. They are not listed in that fashion. We did it like, I suppose, a university president uses the list from a search committee for a dean or something. Give me three names or four names that you think pass the test and let me choose. So that is precisely what we did, and I think my guess is that some of our members would rank different ones of these as number one. I do not think that there would be a unanimous choice of all of our members that any one of these would be number one, just on the basis of the discussions that we had.
So I guess the last point I would make about these things is that we wanted to make-I think we grew as a group in our belief-and I personally was not at that point at the beginning-that it would be wise to choose a model with a concept behind it, and if you changed it, took one indicator out and added another in, that is fine, but keep a concept as we thought about-as we were asked to think about to some extent-the dissemination and the public impact that one could have. One of the conclusions we felt was certain, as we sort of talked through some possibilities, was that it was very important to have a concept and to have a model that you could identify with a concept as we sort of sold it over a decade to our population.
The second thing I think we did is, we felt that the dissemination ought to be-and we are bringing coals to Newcastle, I know that-but we thought about it, and it is a recommendation here that the dissemination of this really needs to be very much thought about, invested in, and be a kind of activity that brings together lots of new people in the enterprise as we go forward. I can tell you that-and I will close with this-I should say also and point out that Mark Smith-as we got closer to trying to say something intelligent in this report against the timeline about dissemination, we realized that what we needed to do to say something more intelligent was to have some focus groups, was to do some experimentation with how to say certain things. Mark Smith came up with some support for some focus groups, and I do not know-I mean, in my experience with the IOM, we were always trying to take money, but here we were ending up supporting something for you to, I think, carry out in the next few months that we could not carry out in the time course of our report. You, of course, have your own resources, I am sure, but at least this expresses, I think, the level of significance, at least to the committee, that we felt about that point.
Finally, I think that as we-you know, we had a great sense of relief, and I expressed this last time we talked. I am so relaxed about this, because we are done with it.
[Laughter.]
Monte, you can say you do not like any of these, and I do not really care.
[Laughter.]
Because we cannot change it. The committee never wants to see each other again.
DR. DUVAL: As somebody said the other day, you got me confused with somebody who gives a damn.
[Laughter.]
DR. BULGER: I do want to say that as we got to the conclusion and realized, thought that maybe we had actually done it and gotten a reasonable report with which you can work, and as we sensed that maybe that is at least partly true, that all of us on the committee as individuals really walked out of that last meeting committed to trying to do what we can do to implement this in our various walks of life. I think, as this happens and gets implemented in some significant way, that the response will be very, very positive, and I think it is, from that point of view-on behalf of the committee members, I would like to just thank you all for the opportunity to do this. So with that, why don't I just stop.
DR. LURIE: Thank you. Great. I want to thank you and the committee again for what I know is an incredibly difficult and challenging task. This committee provided us not one, but two interim reports so that we could check along the way and, in one of them, the indicator sets were 50 and 70 items long. So, hence, the comments about the fingers and toes, and they have come a long, long way. Now we just need to be sure that the fingers are all connected to the same hand and the same body, and I think we are really getting there.
Linda Bailey is going to talk to us now about the workgroup perspective. As you know, there has been an HHS workgroup on these Leading Health Indicators that has worked very hard, and I will turn this over to you.
MS. BAILEY: Thank you.
As Dr. Lurie mentioned, I am Linda Bailey. I coordinate the HHS Workgroup on Leading Health Indicators. This workgroup was set up by Suzanne Stoiber when she was our acting Deputy Assistant Secretary for Health in ODPHP, and Dr. McGinnis came in and chaired us for the first 4 months of our existence.
Last year, we presented to you the red book, which was some ideas on how we should proceed with leading health indicators, and for anyone who is new to the committee and does not have this, please let us know, because we have extra copies. The workgroup really was a working workgroup, and I want to thank all of you around the tables for allowing your staff to spend so much time on this project. It got very intensive at times, and there were contributions from every agency in this department and many of the staff divisions in the Office of the Secretary. So thank you first for that, and also to the IOM for delivering to us a really high quality report, which you will all find at Tab V of your notebooks.
There are two things at Tab V. First is a memo from the working group, and it is a review of IOM's report that goes to the Healthy People Steering Committee and from them to all of you. The second thing there is the full text of IOM's report, which is also up on their Web site, and there is also a connecting node from our Web site to it. So there are many ways to get copies of this report.
I wanted to focus, really, on the topics of the Leading Health Indicators and selection of those health topics today. There are two pieces of followup work that I would propose we set aside and do over the next 6 weeks, and the first is data issues. In terms of what actual measures we select for tracking the Leading Health Indicators, I would propose that that go through data consultation and that today we just focus on what topics of the Leading Health Indicators we want to include in this set.
The second thing that I would propose we put off is how these indicator topics should be phrased? We need to do some focus group work over the next 6 weeks. As Dr. Bulger mentioned, IOM has helped make that focus group work possible for us, and we will be testing not only with the general public but with gender, racial, and ethnic groups and different age groups, how these indicators are perceived, if people understand them to be health and important health topics, and if they see them as things that they can act on and make a difference through.
So those are two things that we would like to do over the next 6 weeks, and I want to bring your attention back again to the topics of the Leading Health Indicators.
I have a couple of overheads I was going to show, and the first one is a screen that the workgroup developed for taking IOM's report, which we knew would be two or more sets of Leading Health Indicators, and working it through and determining which of the sets was most appropriate for Healthy People 2010, the characteristics that we thought were very, very important in a set of Leading Health Indicators. We developed a screen based on what the workgroup originally thought, what our charge was from Suzanne Stoiber, the insights that Michael McGinnis gave us, what we heard in all five of the regional meetings, as well as the Consortium meeting last year, and much that we learned from IOM in the process.
We thought, first of all, we need indicators that drive action, that can help us drive action, that are clear to stakeholders as important to health, that are prevalent enough that we can see changes over time in these indicators. Second, we need indicators where we can track progress. We need to make sure that these are measurable indicators and that we have data systems in place or in development for measuring this progress.
Third, we need to make sure that each of these indicators contributes in an important way to the goals of Healthy People 2010, and by that we meant that they are important areas where we have disparities in health and that they impact in a significant way on either quality of life or years of life.
The fourth characteristic was ensuring diverse representation, and by that we really meant two things. First of all, do the stakeholders who we need to be involved in health over the next 10 years see themselves in this set? Can we pull in managed care in a new way? Can we pull in the business sector? Do mental health, substance abuse, business see themselves in this set of indicators, because those are groups we need to better bring in to the Healthy People family.
Secondly, we wanted to make sure that each of the current focus areas in Healthy People 2010 is represented by the set of indicators, because the structure we are thinking about now and that we are working with has two goals. Below that we have a set of 10 or so indicators, and below that we have the indepth chapters of Healthy People, the 25 to 30 chapters that we will end up with for Healthy People 2010. There needs to be a link from the indicators up to the goals, and there needs to be a link from the indicators down to the focus areas. We need to make sure that everybody who is currently bought into Healthy People 2010 remains bought in and understands how they can impact on the set of Leading Health Indicators.
The last characteristic was being memorable, and that is where we get down to how many indicators we can have. We had hoped for a set when we first started out of 20 or less, and that was something that we agonized over in our workgroup. Then Dr. Lurie and Dr. Satcher said we are not talking about 20; we are talking about 10 or less. It is very difficult to do something meaningful and that is linked in the ways we want with 10. We think we can do it, and we think IOM both under the leadership of Dr. Bulger and Carol Chrvala, who is in the back of the room here, gave us many ideas and ways to do that. The conceptual model is one way that we wanted to think about doing that.
We took the screen and ran the IOM sets through the screening tool that we had developed. What we found was that each of the sets really did fairly well in the screen, and I think it is because, as this whole process was evolving, IOM came to all of the regional meetings. They heard everything that we heard, and so our thinking was pretty much in line.
What we did find, however, was that the first set, the health determinants and health outcomes model, made a whole lot more sense to Healthy People, given the new model that Mark Smolinski just presented to you, that in terms of having a conceptual framework, that the first model really was based-IOM based it on an Evans-Stoddard model. The model that Mark presented was based sort of on the Dutch model, as well as the Evans-Stoddard, but it is a determinants model. So it is very consistent there.
What we also found with this set is that many more of our stakeholders could see themselves in that set. If you look at the third set, the prevention set, it is fairly clinically or health care sector-oriented. We wanted to make sure that we reached out to business and to nonhealth sectors. So the first set, really, the workgroup felt was probably the strongest set for us.
In looking at the indicators inside the set, the workgroup felt that we needed to make a few modifications so that, in addition to having consistency with the model and the framework for Healthy People, we also linked all of the Healthy People chapters into this set of indicators. So what we would propose is that the first five indicators proposed by IOM in the health determinants set remain in the set of leading health indicators-clean air or water, teen smoking, healthy weight, physical activity, and injury deaths as a measure of community safety and environment. We would be looking at violence as well as motor vehicle crashes there.
Then we propose that we modify three of the indicators. The first one was cancer detection, which we thought we might want to replace with immunizations for two reasons. Number one, there is nothing on infectious diseases currently in that set, and we thought, looking at the McGinnis-Foege actual causes of death, the 10 actual causes of death, infectious diseases comes up as one of them. So we wanted to have a place for infectious diseases in the model. Also, when we looked at the different populations that were included in the model, there was not a lot for children, and for immunizations we were thinking child, teen, and adult immunizations. So that would link children back into the model.
The second indicator that we wanted to modify slightly was health care and treatment. IOM had health insurance, and AHCPR had suggested that we might want to look at regular source of primary care there, that over the next 10 years it may not be health insurance that becomes the driver. So we would want maybe to track regular source of primary care and have health insurance as a backup there.
Then for the third one, social environment, IOM included both poverty and high school graduation. We would like to select one of these and ask for your input on whether you think one is more actionable than the other.
The last three changes that we proposed making had to do with topics that within this department had become very important-substance abuse, mental health, and sexual behavior. Those were not included in the IOM set. We think they are important topics and would ask for your input on whether or not they should be included.
The one indicator that we really struggled with was disability. IOM included disability. We think it is an incredibly important topic. We think the goals measure disability better than an indicator set could. We see it more as a bigger thing than an indicator. It is really part of the goals, but we would appreciate your guidance on that. Should we include disability? Certainly it drives action for the business sector, and your thoughts and ideas on whether it should be included would be very helpful.
I just had one last overhead, and this is also in your packet. It is a busy overhead, so you may want to look at Tab V in your packet. One of the things that we did with the measures that we had proposed, the indicator set that we had proposed, was to say, "How does it link to the goals of Healthy People?" This is at Tab V, on about page 10 in Tab V as part of the appendix.
How do these indicators link both to the goals of Healthy People, which is here in the second column, and to the focus areas? If you look through that list, you will see that all of the McGinnis-Foege actual causes of death, those 10 top contributors to death, are included in this set, and also, without having to force-feed any focus area into the set, there was a very natural link between the set and the focus areas of Healthy People 2010.
Thank you.
DR. LURIE: Thanks, Linda. That was very comprehensive and extremely helpful.
Why don't we hear now from George Isham, who will give us, I think, a very useful perspective of managed care organizations and the quality indicator movement as we move forward.
DR. ISHAM: Thank you. I really appreciate this opportunity to give input to this process. I have been very active in doing that along the way, and I suspect that, in a Darwinian sort of fashion, I have survived to give input once again at this point.
[Laughter.]
I appreciate the opportunity to see Dr. Satcher again and to have the opportunity to be in the company of such a distinguished group of former Assistant Secretaries, as well as the heads of the department.
This topic is important. Healthy People 2000 inspired us as a care system in Minnesota to develop our own goals in 1994 and then to focus our programming around achieving improvement in those areas.
I found it hard to use the Healthy People 2000 document because it was such a compendium of targets. Secondly, in a care system like ours, which has a large group practice, a hospital and an insurance carrier, the geographic population statistics are not segmented by insured versus self-insured, Medicare and Medicaid segments. So we had to adjust the Healthy People 2000 targets for our population. Once you do that, most people in an acute care system think you are kind of crazy, because establishing goals is not common and they have not seen anything like that. So we had a lot of trouble getting going.
A number of years later, now almost 5 years later, everybody in our care system acknowledges that the goals are an important focal point for us and that has done a lot toward improving our capability, both in preventing illness, dealing with the detection of illness, and improving the care. We happened to settle on two topics that were acute care-focused, diabetes and heart disease. That is not hard to understand, given our setting. Screening objectives were established for immunization and breast cancer. Birth outcomes was an objective because we address this frequently. Dental care was included because we have a large dental care delivery organization. The issues of childhood injury and domestic violence were included to challenge our system, because we did not have data or programs that addressed these issues, although they were important community issues in our region. So that was an act of leadership on our part and, if you accept the direction that I have heard as both Dr. Lurie's and Dr. Satcher's of keeping this set to a very small number, it would be an act of leadership to establish a small and focused set of leading indicators.
I have been criticized for not including asthma, for not including this, for not including that, for not paying attention to AIDS, for example, and so forth. On the other hand, people have accepted the fact that we do in fact address those issues in our other programming and that it has been important to set a stake in the ground on a focused set of a few objectives.
Our experience has told us that the act of prioritizing and limiting this set is very important to making progress. I therefore underscore strongly the notion that keeping the number of leading indicators to something countable on ten fingers is important.
Secondly, I feel that, if this is carried out the way you are envisioning it and you are listening to the stakeholders and doing your focus groups and these things, health will improve as a result of this. We have some examples of that. I will not go into them, but I believe that, and I think it is important.
The IOM report is right on target. I have followed the development of this report. I was very pleased, along with a number of other public and health professionals, to be convened by a group sponsored by the Centers for Disease Control Assessment Initiative activity in December. That was a group of about 20 Federal, State, local health officials, as well as those from Medicaid and from the private care sector. We came up with some recommendations for the criteria for selecting leading indicators and a list of Leading Health Indicators. We then had an opportunity to give that input to the committee preparing the IOM report. The improvement between that interim edition and the final is tremendous and very responsive to that input.
I think the IOM needs to be complimented, both for refining the criteria, and then, secondly, on the recommended indicator sets. It is a tremendous and powerful report. I think it is also a piece of work that should be disseminated more widely, especially in the acute care private sector. It could be a vehicle for helping to take Leading Health Indicators beyond public health professionals. It could be important in educating them about how acute care and chronic care fit in to achieve larger population health objectives. I will find it useful in that way and I hope others do, as well.
I will comment on one criterion, the multilevel criterion that was emphasized during our workgroup discussion. It is important to me not only that we have something that makes sense at the national level, but that we have something that makes sense at the very local level in terms of the front lines of chronic and acute care delivery. That is a topic that has not been addressed in previous editions of the Healthy People project. I think the recognition here of the importance of the ability to address issues at national as well as local levels is a very important step forward. I would draw your attention to the importance of paying attention to how we can have an integrative and linked set of indicators going from the very broad national level down to the local level and thinking through how that happens.
The IOM choice between the three sets creates a useful context for me. I was very much struck with it. I do not know if you still have your slide of the three sets. The prevention set of indicators is where I live. If I were to vote based only on my acute care experience, that is obviously the one I would vote for.
However, the Evans-Stoddard framework is such an important concept, and actually it is people like me from the acute care sector that need more education and emphasis about that framework. So I think that the recommendation of the working group for the health determinants and health outcomes set makes a lot of sense, even though my inclination would be to settle on the topics in the prevention set.
I think that Evans-Stoddard model is very important. I have read the book out of which it comes. I use that model to orient my thinking about how health care contributes to the overall health of my community. I often use it to educate physicians in our system.
There are a couple of issues that have been raised in Linda's presentation about how the committee has come down that I thought I would comment on specifically. One is the issue of the choice between cancer screening and immunization. To me, that is a hard one. In our system, we have had some of that same kind of conversation and what we have come to is developing composite measures where they make sense. I assume that, when we are talking about Healthy People 2000, we are talking about individual Americans in some way, or however you would title that, whether their services are up to date, which includes both cancer screening and some of the immunization topics.
I have a specific example that I will share that is very specific, but it is a way that one could think about addressing both the important issue of immunization as well as cancer screening. Those two topics will be particularly compelling for the acute care and managed care sector, because we are beginning to realize that we need to build systems that help doctors and other health professionals do the right thing for age, gender, specific visits. There are many things that you have to do right at the one time, for example, in one visit. As our data systems and office visit planning system develops, we are beginning to think that it is not so much an issue of remembering the specific MMR recommendation or the specific Pap smear recommendation, but building those systems that remind health professionals of all specific recommendations they should consider when they see the patients. So that moves us to a concept of what we would call members-up-to-date, or patients-up-to-date, with all specific recommendations at a specific visit or point in time. So I offer you that idea as a way to resolve that particular dilemma. Rather than choose between specific screening for a specific cancer or specific immunization for a specific single disease, consider patients, citizens up to date for age and gender for all cancer screening and immunization and preventive services.
The second is the disability indicator. I have shared a little of this with a couple of our health leaders, and the first thing they say is that this is the top thing on the mind of business. I expect that you will get that feedback, and I expect that, with your process of focus groups, you would have a chance to test that. We are eager to be responsive to the business sector as it looks at capability in terms of people being able to be active at work.
The third is chronic care. This is obviously not in this particular set-the health determinants recommended set. From experience with the Health Employer Data and Information Set [HEDIS], which I co-chair with Helen Darling, and which some of the people here have been on, there was criticism a number of years ago that HEDIS addressed preventive topics but not chronic care topics. I wonder, whether some will level that same criticism at the health determinants set and whether or not you should modify this set to include something for perhaps addressing either heart disease or diabetes.
Lastly, with respect to a regular source of primary care versus access to insurance, I think the more global indicator is access to insurance. I think a regular source of primary care as a concept is too detailed a concept for a leading indicator set. If it were up to me, I would favor access. Access has a profound implication for quality of care. As we have looked at our Medicaid versus our fully insured performance rates, we see tremendous disparities in terms of the rates of immunization and other indicators. That difference allows us to focus attention on how to address those differences, and I still think access is still far and away the more important and more profound issue with respect to quality of care and keeping preventive services up to date, and therefore a more important candidate for a Leading Health Indicator.
So those are my comments. I would just illustrate the one concept of preventive services up-to-date with one overhead. Again, this is very specific. These are the services that we use to do this preventive services
up-to-date indicator in our health system: our tetanus, pneumococcal vaccine, flu vaccine, DPT by age, tetanus booster by age 12, MMR booster by age 13, cholesterol screening, blood pressure, mammography, Pap smear, and colon cancer screening, for example. So it combines both immunization and cancer screening. The concept is up-to-date with all of these services.
So the concept is that one looks at members up-to-date in the orange bars, which you can then measure over time, or services up-to-date, and the methodology is a sampling methodology, a statistically drawn sample. We have a goal, as you see, generated for this, and that focuses the initiative. So that is the concept.
I would again reinforce the notion that it is 10 fingers and 10 goals. I would strongly support the concept of a small, compelling number of health indicators that are based on that Evans-Stoddard model. So thank you very much.
DR. LURIE: Thank you for those very helpful and very real world comments for us.
I know that we were originally scheduled for a break at 10:30. We started late, so I am going to take the prerogative of asking us to stay through this discussion, and then we will take a break. So with that, let's open it up. Julie?
DR. RICHMOND: Well, first, this is a very rich presentation, and I think we certainly appreciate all the work that has gone into this. I cannot help but comment historically on the participation of IOM, having been there at the initiation of our Healthy People effort. I would just recall to everyone's attention the fact that in that first iteration of Healthy People, we had a companion volume to provide the documentation of the sciences for what was in Healthy People and the helpful information that had emerged as a consequence. That effort was carried on-that is, the production of the science base-by IOM, and even though we published it as a companion volume from the department, the acknowledgment was clearly that it was the IOM that did that. So I think it is interesting and important that this continuing relationship has developed.
So I would just like to make a couple of comments and then raise a question directed initially at Roger, but others might want to comment on this. I thought that this was a very significant contribution, and I particularly admire the fact that, as you went through this, you did not oversimplify, because if you could not put an indicator in one category, you were not reluctant to have it appear in another category. So I think that that is a very important thing to pay attention to.
The question that I would raise, Roger, is whether you went through the exercise in looking at what these indicators would produce as a yield in terms of outcome, as we know there are many ways of looking at outcomes, whether it is longevity or feelings of well-being or reduction of chronic disease, or, as I think David may have mentioned early on, years of life lost. I wonder if you tried to sort of look at where we get the biggest bang for the buck in relation to pursuing any of these indicators.
DR. BULGER: Let me say first, thank you Linda for bringing Carol's name up, and I know it is standard procedure to say gee whiz, we could not have done this without the staff. Only as a matter of fact, that is true.
[Laughter.]
Really, she put this together with-we had the meetings is what it amounts to and then read some of the stuff afterwards. It really was an amazing job against a very tight timeframe, and she is to be commended. So I invite her comments to this.
But I think we did do what you suggest, especially when we looked at the large list of Leading Health Indicators that we had. We went through one after the other after the other and asked that question of the group. We queried the science behind it. We had the benefit of the large yellow book, which I think actually made it possible to do this a little bit against this timeframe. Going back into that book, which was the preliminary work that had been amassed, I think that was rich for us as well. But we did do that, or tried to do that, and I think when we got to the end here-I think that as we maybe did not ask that particular question at every point-but it got very difficult.
I kept figuring, maybe if I had an extra toe, we could count toes, but we tried to stay within 10. We had to take 10 out, and it got very-I think we had very good discussions about what we would leave in, what the impact of each was that we put in, but it is not-I think it is fair to say that, as you look at the data that is possible or look at the sense of whichever one of these you choose, if it is the first one, that some of the indicators might be replaced by something else that responds more effectively to qualities or whatever. I think our group would be certainly right on with that.
DR. RICHMOND: Roger, is what you are saying that, in the documents of your committee, one could go back and sort of reconstruct how you did those exercises so that we could look at where you get the biggest bang in terms of areas of-
DR. BULGER: Well, I think you could listen to the tapes, which I would not recommend for anybody, unless you have insomnia.
[Laughter.]
But-Carol, I think maybe you can help me here-but I think you could not go back and look and say, why did they choose this one instead of the other, and here is the data. I think we do not have that detail.
DR. LURIE: I think that is something that, as we look with data consultation at some of the measures, that is something that we really want to do.
Why don't we hear from some other people?
DR. DUVAL: Roger, I want to at least endorse and second one comment of Julie's about the value of this exercise. I think as an exposition, so to speak, of the maturation of this process, this particular contribution is almost in the category of seminal. I really think a first-rate job has been done, and I congratulate all of you who did it.
I would now ask, however, a question that technically in a way contradicts what I just said, in this sense. It is not clear to me whether or not you see this as, shall we say, a taxonomy for organizing ultimately the objectives. Do you see it as a set of priorities, to go back to what Dr. Richmond said, or do you see this as a means of addressing certain target audiences? This part is missing to me in the presentation.
DR. BULGER: I think what we believe we were responding to, the charge, was to see if we could develop, I suppose, the analogy of the leading economic indicators. That was sort of the vision we put out there, where we could have a finite number of surrogate measures that would fit inside a conceptual model that could link to Healthy People 2010. We were not trying to impose a set of priorities on Healthy People 2010 or to affect it. Our charge was to see if we could we develop a set of indicators that would fit inside a conceptual model that could be used in parallel-which was, I think, our understanding-with Healthy People 2010-not supplanting it, not able to address it in all its richness, but able to produce-maybe November would be physical activity month, and that report would come.
You know, as we would spell it out, the conceptual model was, at least in my mind, something that might enlighten a dissemination and communication strategy, rather than try to shape the existing report of 2010. But it needed to link to that, and it needed, when taken together, to be able to measure progress so that it could-that was our understanding, and what we tried to do was not to impose anything else of our own on that mission, as we understood it, and to also think back-the basics we were thinking about were to improve the quality of life and life years and to reduce disparities. Those were the two. You know, that was always up there; could we do this? So that is really what our objectives were.
DR. DUVAL: I think, personally, those last comments are very helpful, at least to me, and I thank you for making them. I think I was hung up on the concept that we had used earlier in two prior iterations of this exercise when we talked, for instance, about the hows. We talked about health promotion, we talked about disease prevention, we talked about health protection. You could take the objectives and you could fit them into those hows. I see this as becoming more like determinants in what I would call the what sense. Each of them is, as you have said in your document, predictive. It is also measurable.
I would now follow with another question and say-this is an unfair question, and I would advise you to back off if you think it is inappropriate-do you see violence done to the integrity of the content by taking some of the recommendations of the workgroup? You made a strong pitch about the fact that each of these three sets of criteria or Leading Health Indicators, if you will, has a sort of integrity because they fit the concept. The workgroup subsequent to that has said, Yes, but, and has made a couple of, quite frankly, responsible, not necessarily persuasive, objectives. That is one of the things we should be talking about today. I would ask you as, shall we say, at least the signatory author of this document, do you think that those suggestions do violence to the premise from which you started?
DR. BULGER: I can only speak for myself. We have not tested this with anybody else, and I just read that. I thought they were terrific, and I think I have no problems with them. They even added one. We got an extra finger.
[Laughter.]
DR. SATCHER: I think George really helped us with that. I was really impressed with his discussion about the health care systems, because I believe if you can have access to quality health care, then that takes care of cancer screening, and it takes care of some other things, too, maybe even immunization. But the issue is how do you assure access? If you can do that, then I think it helps us to reduce.
DR. BULGER: And that is where we would-I mean, if I had to say taking health insurance off or some other surrogate for access, we would be sad about that.
DR. SATCHER: The other thing that George did that I was struck by, because it gets back to Monte's comments earlier about individual behavior versus community, he said the system versus the individual behavior of the physician. I think that is really key. If you have in place a system, you can take care of the behavior of the physician.
DR. ISHAM: I also, responding to your comment, I tried to make my comment so that the overriding comment was the support of the IOM intellectual framework. I think there is tremendous value in preserving the Evans-Stoddard health determinants model. It is a very compelling rationale.
DR. LURIE: There were a couple of things I wanted to see if we could get to consensus here today. One was the 10 or less. I think I have heard that. The other was just to be sure that most of you felt that the recommendation about moving in the direction of the determinants and outcomes kind of set and conceptual framework was the way in which you would advise us to move. If there is strong sentiment for moving in a different direction, we ought to hear it.
DR. DUVAL: Yes, I would speak to that again. I think this could prove to be extremely useful, and I think, ultimately over time, which is why I chose the word seminal before, Roger, with respect to your contribution, over a long period of time-and I am talking now in terms of, if you do this every decade, certainly the next three decades-I think these have tremendous holding power, and we could hear later from Clem Bezold maybe as to whether or not they will meet the criteria of the shifting sands out there. That is the definition, but I think these are superb.
I do, however, have two very specific questions that are a little bit narrower, and they go back in part to what George said. I would ask, do you include-let me start a different way. I was asked not too long ago, do you consider access and availability to be the same thing. I had to pause and stop and say no, they are absolutely not the same thing, that access really, in my judgment, has three elements to it, one of which is geographic. In other words, is it available? Number two, at least in terms of the health care industry and the health care field, do you have a willing point of contact? Number three, do you have a block, such as an absence of insurance? All three can be embraced by the term access.
But I am more interested in something else. This issue of disability is not the least bit unimportant, as has been said, and I would ask in terms of your particular comments, especially when you referred to business, did you include mental health as part of disability?
MS. CHRVALA: Yes.
DR. DUVAL: Thank you. I think that is extremely important, and you can comment about the fact that infectious disease may not be represented until you put it in there, but I would submit the same thing is true today, particularly in mental health and absence from work and all of the spinoffs that come from this, whether they are in Littleton, Colorado, or just an angry-
DR. SATCHER: In fact, depression, I believe, is number one on the disability-adjusted life expectancy.
DR. DUVAL: Thank you.
DR. ISHAM: And I would say that I said that to reflect the interests of the employer sector, and they are obviously not here. It would be a tremendous achievement if this leading indicator idea engaged that public employer sector in some way. If the disability indicator was the vehicle for that, that would be tremendous, and I would hope it would include mental health.
DR. LURIE: That is very helpful. Let me hear from just a couple of other people.
Earl?
DR. FOX: Well, I apologize for not hearing the whole discussion on the indicators, but I just want to say, in thinking about which ones we would choose, part of the idea, when we had looked at the indicators when I was in ODPHP, was the idea that we had some objectives in the last document, and they did not really get used as such.
So part of the intent, I think, is a way of giving both additional visibility to 2010 and prevention, putting it on the national radar screen, and having a nation's report card that we could actually issue that people would pay attention to and that would be brief enough. So I would just argue that whatever objectives we actually pick for this, one, I think, have to be carried out at the State level. I think, if they are not, we are not going to get the State-level attention, and I think the State-level comparison is important.
The second is, they have to be something that we have data for and that we can get with some degree of frequency, not once or twice a decade, and I think ideally at least every year or two. So we issue a report card every year that can be taken down to the local level and we have data from the year before to compare it to, and we can get USA Today and on CNN. That just puts prevention more on the radar screen and gives more visibility to 2010, and I think that is part of what we were hoping to accomplish with this whole idea of having leading indicators.
DR. LURIE: Phil and Ed, I cannot see if you have your hands up. I do not know if you want to make any comments.
DR. BRANDT: No, I am doing fine. I am listening and enjoying all the comments.
DR. LURIE: Good. Martha?
DR. KATZ: Nicole, we think the health indicators are terrific. It is a giant step forward and one that will really help focus on prevention and give people an opportunity to understand where as a country we stand on it.
In answer to your specific question, have you chosen the right framework, yes. I read the report really carefully last night and sort of looked at the different options. I think the IOM gave us a nice set of choices, but I think, in taking this framework, you get closest to the spirit of prevention, which is what is driving all this and which gives us something that we can all look at and hold ourselves accountable for. So they are quite nicely done.
DR. LURIE: Christine, and then Ed, and Julie, and then I think we will have to take our break.
DR. IRVIN: I am Charlene Irvin. I would just like to support the statement that was made regarding a yearly report card brought down to the State level. It strikes me as interesting that there may be significant strides made in certain areas, with significant cost savings, by implementing one of these criteria and finding a good resolution and a good outcome from implementing a certain program, but I think the people that do the best jobs, the States that do the best jobs, need to be commended.
Those techniques that have been shown to be helpful to achieve those indicator levels, or whatever the measure that they are talking about, in the advertisement at the grade level when they give the yearly report card-those measures need to be advertised so that other States can say, oh, well, in Iowa it looks like they gave an incentive to get, you know, everybody in their State to wear a helmet, and their injury death went down significantly. Whatever that is, without having that feedback loop-just giving us Iowa did great and Michigan did poor is not as helpful as saying Iowa did great because this is what they did.
I think there needs to be some feedback loop in the system so that people that do a good job in achieving these indicators are allowed to at least advertise or make it known which techniques they use. Then you can do a cost-benefit analysis and say, well, this one is very cost-effective. They made significant strides in this indicator, and in this one, maybe not.
DR. SONDIK: I just want to compliment, first, all of the reports for their discussion of data. I think it really sets an agenda for the department and maybe, when we discuss data later, we can come back to that. The comment I wanted to make, though, was on social environment. I think this is so important that I wonder whether we should not have 10 indicators and then always mention where we stand as an additional measure, social environment, in terms of poverty and, I think, not just poverty, but something related to education like percent graduated from high school. I think it is that fundamental, and I think, by including it in the set of 10, it almost changes the character of that. That is what I was struck by.
DR. SATCHER: So you think it impacts upon all of them?
DR. SONDIK: I really do, and I think it is so important that I would sort of single it out as part of the foundation. So we could report on the 10, which I think really fit together, and then report on that 11th one or two, if you will. I would not choose one or the other. I would actually have a measure of education and a measure of income.
DR. LURIE: That is a really interesting idea as we move forward.
Okay, I think Julie wanted to make one last comment, and then I think we need to take a break. I am impressed that everyone has been able to sit here. And clearly, if you have other thoughts or feedback throughout the day or after, you know how to find us.
DR. RICHMOND: I think there would be some merit, and coming after David has just-it is interesting that we have somebody who deals with vital statistics as his primary occupation talking about the social environment. I think that is extremely important for us, and there is a linkage as he, I think, is so properly pointing out.
But I think there would be some importance to going back and doing an additional kind of sequential exercise, looking at those 10 categories or whatever-unless as Monte was suggesting we develop polydactylly-like we were talking about, a finite number, and linking those to some kind of overarching goal.
Let me illustrate what I mean. If one looks at the death from violence among teenagers and young adults, the total numbers in terms of mortality are not very great, but I think, when the Surgeon General goes out to talk about this report, if one translates that into years of productive life lost, then that goes to the top. So what is the burden to the nation? So I think we have to have some way of making a very sound, rational case. Cost-benefit analysis was just mentioned and I think, in macro terms, that is some of what we are talking about. So I think that is well worth doing, or it is going to be very difficult publicly to defend why we came up with these particular issues. I think we have to illustrate that these are important indicators in terms of the health record for the nation.
The other point that is interesting-I mentioned that I thought it was a good idea that you did not try to stamp out any repetition in the three categories of indicators. I think the one that appears-and this gets back to the social environment issue-that appears in all three is poverty, a very important issue in relation to the social environment. I would like to suggest that, certainly in talking with the Secretary, that this issue be kept in the forefront as a major policy issue that is so relevant to health.
I know that we tend to fall into the pattern of thinking that these are intractable issues, but if we look at childhood poverty, we have to remember that in the 1950s and the 1960s we had children coming out of poverty in significant numbers, and it is only in recent decades that children have been slipping back into poverty. Children have been slipping back into poverty at about the same rate that the elderly have been coming out of poverty. So we are able as a society to influence poverty rates. I think Dr. Isham indicated, just in looking at their managed care data, the Medicaid data and the utilization rates and all of those issues look different for the insured population that does not fall into the Medicaid category.
So we know that there are many, many kinds of ramifications even in terms of the health care system, and that leads me to just one final comment on access. I think, first, we need entitlements, so that again we have to come back to having everyone insured or a national health program that provides financing for services for everyone, and certainly with children we are further down the road to doing this. Not only do we want that entitlement, but the points that Monte was talking about-utilization. Knowing the children are enrolled is not sufficient information to satisfy me. It is whether they are utilizing the services to which they have entitlement.
DR. LURIE: I think your points are very important, yes, and really helpful, all of you, in moving us along. So thank you all for your comments.
If you have further thoughts or comments, please direct them to Linda Bailey at ODPHP. And thank you again. This has been a very useful discussion. Why don't we take a 15-minute break.
DR. BRANDT: Hi, this is Ed Brandt. I have to leave, because I have to go over to a Safe Kids meeting.
DR. LURIE: Sounds great. Thanks.
We are going to break for about 15 minutes or so.
[Brief recess.]
DR. SATCHER: I just want to emphasize again how really outstanding and important that last panel presentation was, and I think it really, really moves us forward. So we feel very good about that, and even though it took more time than we had planned, I think it was worth it, and as Martha said in her statement, I think it is going to help the focus areas and objectives areas to move even faster than they were going to move, because I think it really helps us in thinking about where we want to go.
I want to take a minute and do something else as we are reassembling, because we have a lot of appreciation for the people who are really making this happen at various levels. I wanted to take an opportunity to recognize the outstanding contributions of one of our very valuable colleagues, Claude Earl Fox. As you know, Dr. Fox-Earl-served as chair of the Healthy People Steering Committee, and for over 3 years he guided the development of Healthy People 2010, even when he was working as acting head of HRSA before his permanent appointment. For a long time he continued to serve in this capacity and continued to help us move forward. So I wanted to say thank you and officially present this certificate of appreciation to Claude Earl Fox, M.D., M.P.H., for your outstanding contributions and commitment in chairing the Healthy People Steering Committee for 1996 through 1999. It is signed by me.
DR. FOX: Thank you.
[Applause.]
MS. KATZ: David, Earl is too shy to tell you that last night he received the distinguished alumnus award from the University of North Carolina.
[Applause.]
DR. SATCHER: Earl is doing an outstanding job at HRSA, too, so we are very, very proud to be able to work with him.
Well, we are going to move forward now to our focus areas and objectives discussion. I appreciate all of your participation in this morning's discussion, and it was a very rich discussion.