Systems Strategies for Better Health Throughout the Life Course: A Vital Direction for Health and Health Care
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This publication is part of the National Academy of Medicine’s Vital Directions for Health and Health Care Initiative, which commissioned expert papers on 19 priority focus areas for U.S. health policy by more than 100 leading researchers, scientists, and policy makers from across the United States. The views presented in this publication and others in the series are those of the authors and do not represent formal consensus positions of the NAM, the National Academies of Sciences, Engineering, and Medicine, or the authors’ organizations.
Learn more: nam.edu/VitalDirections
Health and health care outcomes for Americans should be better for most, and much better for some. This should be possible with currently available knowledge and resources. Capturing the potential will require adapting our strategies and approaches to the reality that health is not immutably determined at birth, but shaped by different factors over time. Similarly, caring for health cannot be confined to singular interactions within the walls of the health care system, but must fully engage powerful determining influences residing in other systems—e.g., education, employment, justice, transportation—which are natural parts of our lives. Exploring the nature and strategic opportunities inherent in these intersecting influences is the focus of this paper, and the implications for societal attention and resources suggest the promise of shifting emphases across the life span, across systems, and within the health care system.
Our assessment begins with an overview of the prominent health and health care challenges for Americans, and they are many. U.S. life expectancy at birth ranks 43rd in the global community, and has even recently declined among some specific groups (IOM, 2014b). Unacceptable disparities in health outcomes and access persist among certain populations, in particular African Americans and Native Americans (Pearcy and Keppel, 2002). The U.S. health system ranked in a World Health Organization assessment only 37th in performance among 191 member nations (WHO, 2001), and in a recent study of 11 highly industrialized Organisation for Economic Co operation and Development nations, the United States ranked last (Davis et al., 2014). These deficiencies are all the more glaring in the face of health expenditures that are clearly the highest in the world, about 50% higher than the country next behind us, and requiring investment of nearly 18% of our total economic productivity (GDP) in 2015 (Squires and Anderson, 2015). Why are we performing so poorly relative to our potential? A major reason lies in the fact that the primary foci of our attention, our resources (Murray, 2013) and our incentives, are too narrow and too late: despite an increasingly strong and specific understanding of the preventable elements in the development of many of our health challenges—social, behavioral, environmental—our investments are primarily directed to their biomedical manifestations, well after the problems have taken root.
Health is the product of our experiences layered onto the biological matrices we inherit. Those experiences begin at conception, and, through the intersecting influences of genetics, environment, social circumstances, behaviors, and medical care, health emerges and takes form. Figure 1 presents schematics of the relative overall impact throughout the population of each major health determinant domain on the occurrence of early deaths (McGinnis et al., 2002). The specific impact of each domain varies by individual, and most important are the dynamics at the domain intersections for each individual.
Each of us represents, in essence, a complex system in constant and dynamic interface with other systems that shape our fates in manners great and small. The process is not linear, but one in which similar experiences may exert variable influences at different points. In this paper, we explore the implications of these dynamics for efforts to improve health prospects throughout those interwoven influences at various stages over the course of people’s lives (Halfon and Hochstein, 2002). Because emerging health problems and potential required solutions span well beyond a single determining factor or single point in time and place, it is necessary to take a systems-oriented perspective (Emanuel et al., 2012). In doing so, we respect the simple fact that optimal health will not be achievable or affordable—for society or individuals—without attention to the effectiveness, efficiency, and availability of essential services within and among the various sectors important to health outcomes.
Fortunately, transformational insights, tools, and initiatives are emerging that offer practical prospects for dramatic advances in the ability to mobilize information, cooperation, and collaborative action for more effective and efficient progress from the national down to the community and individual levels, on behalf of better health throughout the life course. We review these prospects by touching briefly on several questions:
- What are the most common health threats at each stage throughout life?
- What are the root sources of diseases, disability, and death most prominent among Americans?
- Why do we spend so much and get so little for our national health system investment?
- Which systems and partner stakeholders must be seamlessly engaged?
- How can financing, accountability, technology, and culture be aligned to foster system-wide transformation for better health over the life course?
Health and Disease over the Life Course
What are the most common health threats at each stage throughout life?
In terms of morbidity and mortality rates, health profiles vary substantially by life stage. Four of every 10 childhood deaths before age 15 occur among babies in their first 28 days of life (WHO, 2011), about half due to congenital malformations, disorders related to short gestation and low birth weight, and maternal complications during pregnancy (CDC, 2016). Throughout infancy—the first year of life—the major causes of death are complications related to birth and birth defects, sudden infant death syndrome, and unintentional injury (CDC, 2014a). After age 1, injuries take over as the leading cause of death among children (Consumer Federation of America, 2013), and hold that position until age 44, followed by heart disease, cancer, and homicide, at different times and ages. Among adolescents and young adults, ages 15-24, suicide and homicide appear among the leading killers (CDC, 2006), ranking number 2 and 3, respectively, among this age group. In adults ages 35-65, the major causes of death are cancers and heart disease (CDC, 2014a), and after age 65, heart disease is the leading cause of death, followed by cancer and respiratory disease (CDC, 2006).
But illnesses and injuries that are counted most easily are often not the experiences most important to health prospects. Life expectancy at birth in the United States is now more than 81 years for females and 76 years for males, and for most of those years health status is more a reflection of the presence or absence of illness or injury, consequent level of function, sense of well-being, or predispositions, circumstances, or experiences that influence future profiles on these dimensions (Xu et al., 2016). Although death is the most striking, definitive, and tragic reflection of health status, it is far too limiting as a measure of the health of a population (Fineberg, 2013). In the United States in 2013, for example, there were fewer than 15,000 total deaths among the nearly 75 million children under age (Xu et al., 2016), but nearly 25 million children were overweight or obese, more than 30 million lived in low-income families and 15 million in poverty, in the range of some 5 million lived in a household touched by violence (Child Witness to Violence Project; Child Trends, 2016), and more than 1 million were the victims of child abuse and neglect (IOM, 2014a), with the highest rates among the youngest (Wight et al., 2010; Child Maltreatment, 2015). In 2015, about 1.1 million people under age 75 died, but those who suffer from diabetes, depression, and alcohol abuse amount to 18, 11, and 15 times that number, respectively (CDC, 2014b; Center for Behavioral Health Statistics and Quality, 2015).
In this respect, the most important overall childhood determinants of health over the life course are at least as much those related to the caring, social, environmental, and behavioral experiences as to health services they receive. This is especially the case for ages 0-3, when central nervous system development occurs at such a rapid rate, with ongoing development of physical stature and physiologic function. Advances in neuroscience have provided a much deeper understanding of brain development in the early years, as well as the remolding during adolescence that sets the stage for issues with lifelong consequences—e.g., overweight and obesity, substance abuse, and psychological disorders (Wise, 2016). It is often assumed that children are generally healthy and, if they suffer a health problem or developmental delay, they will grow out of it. However, while children can be resilient, adversity during these sensitive developmental periods is often embedded, only to emerge years later as a source of disability and ill health (Halfon and Hochstein, 2002; Essex et al., 2013; Boyce et al., 2012). The role of attention and nurturing as an influence on health status, nearly always a relevant determinant, may not be again as relatively important a focus until the final years of a natural life span (Gawande, 2016).
Over a lifetime, acute infections represent the most frequent sources of short-term functional limitation among all age groups, with asthma and short-term injuries increasing in later childhood, and obesity and depression occurring at higher rates as children move into adolescence (Gordon et al., 2016). In adolescents and young adults, substance abuse emerges as a more common near- and longer-term health threat (Blum and Qureshi, 2011), as does risky sexual behavior and violence in some populations. In the past 15 years, opioid addiction rates have rapidly increased, particularly in white, rural communities, in part as a result of neglectful prescribing behavior among clinicians, in part as a result of segmenting and marginalizing the treatment strategies for those with pain and behavioral health problems (Rudd et al., 2015). Addiction rates among active duty military personnel, which had previously been on the decline, tripled from 2005 to 2008, and rates of depression and suicide and posttraumatic stress disorder also increased (Office of National Drug Control Policy, 2010; Tanielian and Jaycox, 2008).
Throughout adulthood, various exposures, experiences, and lifestyles contribute increasingly to disease and injury, the rate and impact compounded by growing co-occurrence of multiple diseases and conditions. Among those over age 50, nearly half suffer from arthritis, 28% have heart disease, approximately 25% are overweight or obese, 22% have cancer, and 6.5% have lung disease (CDC, 2013). Approximately 45% of those over 50, and 75% of those over 65, report multiple co-occurring conditions that restrict their activities in some fashion (DHHS, 2010). Among people over age 75, approximately 14% suffer from some form of dementia. Crippling societal impact is resulting from the increased occurrences of obesity, diabetes, depression, and dementia (Alzheimer’s Association, 2015). Successfully reducing the occurrence of most of these conditions, and the extent of incapacities imposed, requires multifaceted, life course–oriented strategies.
Some people—and some groups—differ substantially from the aggregate profile. Differences occur among various race, ethnic, and socioeconomic groups, but the largest overall disparities occur among African Americans relative to whites. For example, despite the relative safety of gestation and birth in the United States, African American babies are more than twice as likely to be born with a low birth weight or to die in their first year of life (Reichman, 2005; Collins et al., 2004). Interestingly, babies born to mothers who are immigrants from Africa experience low birth weight and related problems at rates similar to whites, suggesting the existence of other factors or stressors for African Americans (Braveman, 2008).
Beginning at birth, the experience of disparities tends to accumulate and widen over time. Black children are twice as likely as white children to have asthma, and obesity is twice as common among American Indian children compared to their white and Asian counterparts (CDC, 2016b). Obesity disparities emerge as early as preschool (Anderson and Whitaker, 2009), and the prevalence of overweight and obesity among black girls ages 2-19 is about 6% higher than for their white counterparts (Skinner and Skelton, 2014). Because obese children are at higher risk for obesity and cardiovascular disease as adults, the disadvantage extends into adulthood.
Almost one-half of black adults suffer from hypertension, the highest population-specific prevalence in the world (Freedman et al., 2009). The annual incidences of stroke and heart disease among African Americans in the United States are about 2 and 1.5 times, respectively, those among whites (Mozaffarian et al., 2015). Although the yearly cancer incidence among African Americans is about the same as whites, cancer death rates projected through 2018 for African Americans are expected to be about 14% higher for women and 27% higher for men (American Cancer Society, 2016). Rates of Alzheimer’s disease and other dementias among African Americans range in estimates from 14% to 100% higher (Alzheimer’s Association, 2002). Life expectancies are shorter for African Americans by about 3 years for women, and 5 years for men (CDC, 2011a). On the other hand, for those who reach age 75, the difference in life expectancy between whites and blacks is only about 0.4 years (Xu et al., 2016).
The Determinants of Health
What are the root sources of disease, disability, and death most prominent among Americans?
Why do different groups and individuals demonstrate such different health profiles? A great deal has been learned in the relatively recent past about the answer to these questions, and the answer is not “fate.” As noted earlier, health is the measure of our functional capacity that results from the interplay of factors in five domains shaping our life courses: our biological predispositions, social circumstances, physical environments, behavioral patterns, and access to the health care we need (McGinnis et al., 2002). Figure 2 presents a schematic of how some of these factors might play out to shape health status and health prospects at various times and in various circumstances (Halfon et al., 2014a).
Point: It is not all about genes. The starting point is indeed with our genes, the predispositions we inherit from our parents. Although very few diseases can be classified as purely genetic in nature, work throughout the world daily identifies new associations between known conditions and specific gene profiles. Importantly, however, more is continuously being learned about epigenetics, the multiple cellular and molecular mechanisms by which genes can be turned on or off and the information modified as it is expressed in cells by different exposures and experiences, and even how experience-related epigenetic modifications can be passed on to subsequent generations. As insights deepen about sensitive periods of health development and the impact of the interactions of our individual gene compositions with our physical, social, and behavioral environments, the better equipped we will be to act on that knowledge in ways that buffer impacts and optimize health development over the life course.
Point: It also is not all about medical care, unless one is ill or injured. In 2015, total U.S. expenditures for health were about $3 trillion, with medical treatment receiving more than 90% of the total. Yet, the impact of those expenditures on the aggregate health of the population was very limited (Lu, 2010). They were not expenditures aimed at the factors most important to the nation’s health profile. Shortfalls in the access or quality of medical care are especially surprising in the context of the high U.S. expenditures, and require remediation, but other approaches are required for better health. Illustrative is the fact that approaches to improve birth outcomes and address disparities that have primarily focused on enhancing access to prenatal care have proven insufficient in achieving the gains possible (Mokdad et al., 2004; McGinnis and Foege, 1993). Addressing barriers to care access is a basic social responsibility, but effective engagement of health improvement opportunities requires strategies and investments that are broad and multisystem in nature.
Point: Health behaviors are central, but are also more than choice. Among the influences on health, those related to behavioral patterns represent the single most prominent preventable source. Tobacco, dietary factors, physical inactivity, and alcohol misuse account for many preventable deaths among Americans, including from coronary heart disease, stroke, cancers of the colon, breast, and prostate, and diabetes (Mokdad, et al., 2004). Diet and physical activity factors together account for about a third of preventable premature deaths among Americans (CDC, 2014c). Unintended pregnancies significantly impact individual and community health, yet one in three births in the United States is unintended, including most of those born to teens (World Bank, 2015; Mosher et al., 2012). Illicit drug use is one of the few leading causes of death with increasing rates and, along with alcohol abuse, imposes a broad and leading social, morbidity, and mortality burden on Americans and their communities (CDC, 2011b). Behaviors are, however, driven at least as much by external factors as internal, as, for example, in the access and affordability of healthy foods. Behavior patterns reflect culture, access, economics, and other factors such as the quality of early experiences and the central importance of supportive human relationships, underscoring the intersections among the domains of influence that require sustained systemwide strategies across communities.
Point: For many, health is substantially about social circumstances. Health is powerfully influenced by our social conditions and services—education, income, employment, housing, neighborhoods, racism, and social networks (Braveman et al., 2011). For the population as a whole, the most consistent predictor of the likelihood of death in any given year is level of education. For those ages 45-64 with limited education, the chance of death in a given year is four times those with graduate degrees (Hummer and Hernandez, 2013). Income levels have consistently been associated with life expectancies, and one measure of income inequality holds that a 1% increase in inequality doubles the likelihood of death over a decade (Zheng, 2012), presumably due to disproportionate exposures to neighborhood violence, suboptimal school environments, and unstable households (Addy and Wright, 2012). Also important is that perceptions matter—perceptions of income inequality, perceptions of limited choices, perceptions of community cohesion (Chetty et al., 2016). Stress “gets under the skin” and exerts an effect that can grow over the life course (Lu, 2010; McEwen, 1998; Arias, 2016).
Point: The pace of progress will reflect the integrity of our environments. Environments affect health in myriad ways: silent and invisible inadvertent toxic exposures to workplace and product hazards; zoning and design features of our built environments that structurally impair or facilitate health-promoting or health-degrading life and workstyle patterns; ecosystem changes from human activities that foster novel zoonotic infections (Frist, 2015). Two of the largest and most rapidly occurring epidemics to confront the United States—and the world—in recent years have roots in changes in our physical environments: obesity and HIV. They also underscore the intersecting character of the domain determinants, and the importance of tending simultaneously to the dynamics across systems of influence.
Causes and Consequences of System Shortfalls
Why do we spend so much and get so little for our national health system investment?
Substantially, this is due to constraints on our lines of sight. Because most health improvement efforts—disease and injury prevention, treatment, and rehabilitation—are designed around a single encounter or issue, it is there that they often end. Immunizing a toddler, delivering a baby to a young mother, setting a broken arm, counseling someone depressed, testing a blood sugar level, screening for high blood pressure, treating a leg ulcer, explaining an employee safety program, preparing a school meal plan, scheduling for chemotherapy, preparing a hospital discharge—each represents the dedicated work of a skilled health professional usually delivered with a focused sense of purpose in anticipation of the best result. Yet the reasons care is needed, and the likelihood of its optimal impact on health prospects, depend on myriad factors beyond a single precipitating event or diagnosis, such as a heart attack, stroke, or diabetic retinopathy—factors that include the interplay of behaviors, environments, socioeconomic status, ethnic and gender biases and prejudices, factors that can course throughout communities and throughout lives. Our aims must clearly orient beyond the singular (Berwick et al., 2008).
On the other hand, our payment and reward systems clearly focus on the singular and the serial—occurrence of an illness and its treatment, sometimes repeatedly. Health care financing is largely structured around separate charges for individual components of services provided for a particular diagnosis, presenting powerful organizational and financial disincentives to the health care stewards we trust to be focused on producing optimal health results for patients and families. Even when focus is turned to results rather than services—value rather than volume, as the saying goes—unless incentives are aimed to present and engage the longer term, multisystem factors often involved, attention will be more naturally drawn to a near term and narrow single condition perspective (Daschle et al., 2013b). A clinical team attempting to help a person manage diabetes will be substantially hindered if the focus is limited to the presenting vital signs and blood chemistry profiles, when the most basic success factors reside in patient distinctions as to medication cost and access, literacy, family circumstances, mobility, digital accessibility, dietary patterns, employment status, and neighborhood character.
The consequences of short-term and narrowly focused interventions impact more than morbidity and mortality. Performance inefficiencies and shortfalls are expensive. Costs are personal for people and their families; they are collective for organizations whose efficiency and effectiveness are tightly linked to the health status of those who populate them; and they are societal for populations whose aggregate vitality and capacity are sapped both by the economic burden of waste and by the dispiriting and debilitating impacts of unnecessary disparity and marginalization.
Children born in low-income, high-risk circumstances, and who are not seamlessly linked to the support they need, risk being delayed or disabled from the outset. The lifetime costs of the resulting services required and lost productivity experienced will likely far exceed what would have been the cost of the initial investment. Without effective linkage of activities, as indicated, among schools, clinicians, social service, law enforcement, and juvenile justice organizations, teens and young adults who are passing through the challenges natural to that period will be placed at greater risk—and lifelong expense and loss of income potential—from issues such as pregnancy, alcohol and drug abuse, depression, and violence. People who live and work in communities in which the cultural signals, norms, and opportunities are aimed at fostering attention, support, and priority to health and health promoting strategies are more likely to be healthier, with the attendant personal economic advantages.
At the organizational level, the burden of our failure to capture system-wide opportunities for greater efficiencies can be considerable. In 2011, hospital readmissions due in part to missed opportunities to better manage care coordination at discharge imposed more than an estimated $40 billion dollars (Health Policy Brief, 2012; Kasper et al., 2002; Hernandez, 2010; Hines et al., 2011.) The cost of lost productivity due to illness imposes a substantial burden on workplaces, often generating costs well beyond those for health care alone (Loeppke et al., 2008). In the aggregate, the full extent of the economic consequences of our fragmented system are unknown, but the costs are staggering. We do know from various studies that about 30% of overall health expenses in the United States are unnecessary—the costs of unneeded services, care delivered inefficiently, charges that are too high, excessive administrative costs, missed prevention opportunities, and fraud (IOM, 2010; Berwick and Hackbarth, 2012). Beyond this are the personal and social costs imposed by unwanted pregnancies, learning disabilities unaddressed, overweight and obesity, alcohol and substance abuse, criminality and incarceration, and others that could potentially be avoided or modified if the interfaces and incentives were aligned for their cooperative engagement. Still more consequences reside in the resulting loss of economic productivity among those affected.
Potentially Transformative System Partnerships
Which systems and partner stakeholders must be more seamlessly engaged?
Harnessing society’s full potential for optimizing health outcomes across the lifespan requires reaching out well beyond the health care system, from the earliest days of childhood. That potential is determined by the robustly networked interplay among systems and services that, in diverse ways, have central bearings on health prospects, and for which insights are applicable from other sectors using integrative platform models to manage the flow of goods and services (Parker et al., 2016). Examples follow of some of the relevant stakeholders identified in the discussion of the issues mentioned here.
Clinicians, Health Care Organizations, Pharmacies
Across the board, no country can claim a cadre of health professionals that is more skilled, more dedicated, or more highly resourced than those in the United States. Yet, clinicians and health care organizations often are challenged in addressing issues of great social and developmental importance to patients (Diaz and Manigat, 1999). Prevailing cultures, financing, standards, accountability, accessibility, and organizational structures are largely designed to foster narrow perspectives and poorly coordinated activities, certainly between health care and other systems important to optimizing health prospects, but also among different health care institutions providing relevant services, and even among service units within the same organization. Successful models of team care, linked interventions, and information system platforms indicate not only that the care delivery process itself can feasibly operate in a fashion transformative for near-term and lifelong health prospects, but it has the potential to operate as a system that continuously learns and improves (Margolis, et al., 2013; Forrest et al., 2014). By promoting consistent leadership messaging on health progress, underscoring key trends, identifying groups within their own institutions with disproportionate shortfalls, emphasizing the intersecting system-wide influences, indicating steps to marshal community-based corrections, and monitoring progress within their own communities, effective leaders can move organizations beyond disconnected efforts to implement system-wide strategies for better health.
People and Their Families
Since the appearance of the first village healers, health and health care have operated through a flow of authority and expertise that went in only one direction, from healer to patient. With transformations in access to knowledge and tools, the prospects are at hand for an unprecedented democratization of health and health care decision making and delivery (Fineberg, 2012b). Unimagined a generation ago, the speed at which advancing digital technology has put health improvement potential literally at our fingertips is simply stunning (Frist, 2014). Already possible is support through virtually immediate access to information and assistance, online and real-time advice and counseling for specific circumstances, rapidly growing applications for decision assistance for a variety of health and medical issues, GPS (geographic positioning) tailored care access and care monitoring facilitation, remote site diagnosis and assessment of certain laboratory and physiologic parameters, and even the early stages of remote site therapeutic measures. Patient portals and teleconsults have already improved the quality of information available for ongoing care, reduced the need for outpatient visits in many facilities, and made possible improved care for homebound and geographically distant people. The growing capacity for gathering, assessment, and use of individual clinical data dramatically accelerates to prospects for continuous learning and care that is better tailored to an individual’s life-course circumstances. Barriers come not so much from the limits of technology as from inequity in access, the need for greater priority on system interoperability, the development and testing of reference standards to ensure reliability, cross-sector strategies for deployment, and adoption of an operative personal linkage approach to allow the service integration, improvement, life-course tailoring, and learning that is technically feasible.
In the spirit of the adage that the advancement of a society can be judged by the way it treats its most vulnerable, some of our most important gains as a nation have come as a result of efforts to reach out and engage the basic needs of the poor and the isolated. As a society, there is substantial common ground on the fundamental notions: that every person has the basic food and shelter they need; that care is available to all pregnant women; that newborns and their mothers have the appropriate services required; that young families contending with unfamiliar experiences and new financial pressures have helpful assistance, including the lifelines and links of home visits if required; that young children get an early start with positive socialization and educational experiences; that schools and care organizations be alert for social circumstances placing children in jeopardy; that those who are ill, infirm, and homebound have ready access to assistance that meets them where they are; and that those in the late stages of life suffer as little pain, displacement, and as little loss of dignity as possible.
Although these are social values around which beliefs are broad, the public and private efforts to act upon them can often be sporadic, disjointed, uncoordinated, with limited follow-through—multiple organizations tending individually to responsibilities for narrow segments of the needs. Promising intersectoral and multisystem models have been demonstrated for high health care utilizers—the so-called “hot spotters” (Gawande, 2014)—through the work of various organizations. The Camden Coalition used targeted and tailored multifaceted services with a group of high-cost, high-utilizer individuals and reported a 50% reduction in costs and hospital visits (Green et al., 2010). A community-oriented organization, Health Leads, using a multidisciplinary team-based model to connect high-risk individuals with community-based resources such as employment, health insurance, and food, reported broad-based positive impact in reducing those needs (Garg et al., 2012). The Commonwealth Care Alliance is a not-for-profit delivery system for complex medical need patients served by Medicare and Medicaid. Using multidisciplinary clinical teams, their Senior Care Plan model reported nearly half the rate of hospital stays of those in fee-for-service plans, as well as much lower medical spending growth over 5 years (Meyer, 2011). These promising results suggest the need to deepen the partnership between clinical and social organizations in the interest, first, of the patients served, but clearly as well for community and financial sustainability.
Public Health and Safety Agencies
Public health holds society’s front-line responsibility for identification and engagement of health threats to the population. Many of the most important health gains of the past century have come as a result of public health measures ranging from those of sanitation and hygiene to safer food, reductions in deaths among mothers and babies, immunization and infection control programs, and on to campaigns on tobacco and lifestyle issues. The effectiveness of public health has long been dependent on a close relationship with the clinical community, and, if the number and variety of newly emerging diseases is increasing with population expansion and ecosystem change—e.g., Lyme Disease, HIV, SARS, Ebola, and Zika, among others—the seamless interface of public health and clinical care systems is essential. Of related importance is the ability of public health be able to draw upon, and share the results of, emerging laboratory, genetic, GPS, information processing, and crowd-sourced data for strategic community-wide planning and response. Simply stated, public health should be a central steward of system interfaces and strategic direction for better health throughout the life course.
Schools and Preschool Facilities
Virtually every child in the nation attends a school, and, while education has to be the first priority for our schools, for too many children their school is the closest thing they have to an agent with a dedicated interest in their welfare. Beyond the fact that educational level is the most powerful determinant of lifelong health prospects, schools have also served as the anchor locus for community health interventions such as immunizations, drug and alcohol use, teen pregnancy, and health behavior efforts. If schools are to be able to effectively manage their basic educational responsibilities, while also helping advance the agendas of the health and social service sectors, the communication interfaces with those sectors have to be as seamless and fluid as possible, the databases interoperable, and the reward structures fully aligned.
Income and Payment Organizations
Employers have a clear incentive for keeping their workforces healthy, as do those who manage the health care payments for their employees and other stakeholders. Although as a group, no sector may have a greater stake in the long-term health prospects of the population as a whole, whether from a productivity or cost of care perspective, the current payment systems, as well as the rate of turnover among employee groups and beneficiaries, all provide adverse incentives for the longer-term view needed. Shorter-term approaches oriented to value-based and bundled payment models are of interest, as are accountability initiatives tailored to focusing payments on proven interventions. But for these stakeholders to be able to bring to bear their considerable influence in the interest of system-wide strategies for better health throughout the life course, the prevailing payment system will have to move more directly to one that aims to improve overall population and community-wide health outcomes, with accountability measures directed to and focused on systemwide performance in improving health. Similarly, state flexibility to use Medicaid and other categorical federal funding to improve a shift to population-based care and accountability structures may help reduce fragmentation and stimulate systems-oriented leadership and integration at the community level.
Broadcast and Social Media
The nature of our digital lives is changing so rapidly, it is difficult to know the trajectory of its evolution. But it is clear that it is a rapidly spreading and global force that is likely to have a very important influence on health related dynamics over the life course. The use of social media, by virtue of its nature, has the ability to instantly cross lines of previously disparate and separate sectors. Whether from the perspective of the use of communication channels to influence perspectives, or to draw attention to emerging problems, or to rally support for action, or to use crowdsourced data as a research tool, this is an arena of direct relevance for life-course strategies.
Consumer Product Retailers
Marketing is a clearly established accelerant of human behavior, for better or for worse. Television marketing in the 1950s and 1960s drove the ascendance of cigarette use and pushed tobacco to the leading spot among the nation’s killers. On the other hand, televised counter-tobacco marketing in the time from 1968 to 1970 yielded the historically steepest decline in tobacco use, and actually led to some relief in the tobacco industry when television advertising—and the mandatory counter-ads—were eliminated. Advertising of food products targeted to children clearly had an impact on their attitudes and food choices, and probably on the rates of childhood obesity. The potential effectiveness of sustained social marketing strategies to facilitate positive behavior change suggests that marketing awareness is clearly relevant to conceptualizing life-course strategies for health improvement (IOM, 2006).
Law Enforcement and the Courts
The nation is currently experiencing a resurgence of addiction, in this case fueled by increased use of opioids by young people. Accordingly, we are reminded of the central role of the law enforcement and the courts in any strategy aimed at effective engagement of those afflicted with addiction. Police have clearly said “We can’t arrest ourselves out of this problem.” These circumstances, as well as those in which the first surfacing of childhood endangerment may be in family courts, underscore the critical importance of common agendas and strong and effective communication channels between and among the justice, social services, education, and clinical care systems.
Community Commons Stewards
Sustained multisystem progress for health improvement across the life course starts where people live, work, and play (Lavizzo-Mourey, 2015). In part, health care organization leaders can play a natural role in this respect. Hospitals can advance community-wide strategies for health improvement, and have an economic incentive to do so, via community benefit programs. Municipal public health departments are poised to steward a coordinated agenda linking health, community, and economy in development efforts. Community agencies planning and setting not only standards for food, sanitation, and environmental safety, but also standards for green space, for activity-friendly building designs, for zoning in the placement of fast food and alcohol outlets, and for working with employers in the development of community-wide initiatives, all can have important influences on the extent to which a community culture of continuous health improvement becomes a central element of a community’s identity (Lavizzo-Mourey and McGinnis, 2003). Community leadership, with the elected leader at the lead, is central to fostering the bridges across sectors, and ensuring the establishment and tracking of key indicators necessary for attention and progress throughout the life course (Inkelas and Bowie, 2014).
Vital Directions for Better Health Throughout the Life Course
How can financing, accountability, technology, and culture be aligned to foster system-wide transformation for better health over the life course?
With so many issues and stakeholders—in the face of such complexity—how can a life-course, systems-oriented approach be envisioned, much less implemented? Our view is that it is substantially achievable with more effective use of the tools and aggregate resources already available and in use at some level today, but which require the leadership and will to refine, implement, and spread (1) health care financing that supports and rewards health improvement at the population level, in addition to the best care for individuals; (2) a parsimonious set of validated core measures to drive sustained systems-wide focus and accountability for actionable factors most important to health—the vital signs for our vital directions; (3) seamless digital connectivity affording operative real-time interfaces across sectors and across time; and (4) a transformative culture of health equity and continuous health improvement in every community throughout the nation. Each can be accomplished, and is dependent only on strong collaborative-minded public and private leadership at every level—national, state, local, organizational, and individual (Fineberg, 2012a; Halfon et al., 2014b).
Vital Direction: Shift health care payments to financing that rewards system-wide health improvement. Basic expenditure principles—personal, private, and public—including knowing what you want, knowing its price, and paying for its delivery. Because for the prevailing health care financing pattern, none of these pertain, our payment model has resulted in substantial system distortions (IOM, 2012). With larger and larger sums in play, health care payments are made not for health outcomes or treatment packages, but for many—sometimes hundreds—of individual components; the prices of either those individual components or their likely total cost is rarely known until completion of a course of uncertain duration; and, as noted, payments made are often unrelated to delivery of results (Frist and Daschle, 2015). The result is a fragmentation of incentives down to a focus on the smallest possible unit, rather than the overall performance of the system for an individual or a population. We pay for illness, not for health (Daschle, 2009). If we are to forge effective interfaces among the various system elements importantly shaping health outcomes, then payments need to shift to reward overall system performance in delivering those outcomes, including incentives for more effective attention to children at risk (Lavizzo-Mourey, 2016). Some prepaid health plans—e.g., Kaiser Permanente, Group Health, and parts of Geisinger—are based on this philosophy and, as a result, tend to have more prominent community-facing dimensions. The Centers for Medicare & Medicaid Services has initiated a broad-based payment Learning and Action Network with the aim of developing alternative payment models for accelerated transition from payments for individual services, ultimately to a system profile that maximizes payments based on value delivered to a population (Daschle et al., 2013a). By assuming financial responsibility for specific populations, health care organizations have a vested interest in better linking to the community, including local health and social service departments, schools, senior centers, and faith-based institutions. What’s required is a substantial acceleration of the progress toward a health financing system that clearly supports and rewards health improvement at the population level, in addition to the best care for individuals.
Vital Direction: Initiate multilevel standardized measurement of system performance on core health indices. In order to make progress toward better health, we must know where we stand on representative issues for each of the dimensions most important to health: health care, social circumstances, environment, health behaviors, individual and community engagement, and, of course, health status. The challenge is that if the measures are too numerous and are inconsistently formulated from place to place and time to time, they are ineffective and even counterproductive. There remains an urgent need to align and condense our current measurement approaches to a core set of standardized measures reliably available for broad comparison across institutions and across time. If our restructured payment systems are aimed at a substantially improved focus on results—on the performance of the system in producing better health in the near and the long terms—then our assessment models must be similarly designed to assess system performance. Ironically, as we have become better able to measure clinical activities, and as our focus on accountability has imposed requirements for more measurements, the result has actually been to shift focus away from the performance of the system to the delivery of individual services. Moreover, multiple, often incompatible approaches to measuring delivery of the same service have further complicated the issue. Across clinical care, thousands of individual measures are collected to measure results on hundreds of clinical conditions, and without harmonization the opportunities for reliable cross-institutional or system-wide lessons are highly limited. On the grounds that a small set of standardized and harmonized core measures aimed at system performance should be collected at every level—national, state, communal, and, as indicated, institutional—the Institute of Medicine’s recent report, Vital Signs, recommends such a core set. It proposes just 15 core and composite measures of health, health care, costs, and engagement, including measures such as high school graduation rate, teen pregnancy rate, and obesity (IOM 2015). Additional refinement remains for practical implementation of the 15 measures at all levels, but, again, this is a feasible potential tool to shift attention and action to broader and more effective system interfaces and performance. We need vital signs to assess and direct progress toward our vital directions.
Vital Direction: Speed development of a universally accessible and interoperable digital health platform. The most basic element defining a system is the network of nodes important to a functional objective—improving health for a defined population—and basic to the effectiveness of the system’s operation is the timeliness and reliability of information flow among those nodes. In a substantial departure from the historical limits, we now have the practical possibility of virtually instantaneous communication among the stakeholders. The barriers that exist to achieving that possibility are formidable, but they are not technically prohibitive. Agreeing to standards for interoperability, ensuring their system-wide application, working out use and privacy protocols, ensuring interface and personal access capacities for individuals, and embedding analytic tools for continuous learning are all feasible and their accomplishment would establish the infrastructure for transformative multisystem, multisectoral initiatives enabling life course—oriented strategies for health improvement. With our rapidly accelerating capacity for real-time linkage and learning, we have in place the potential to establish and grow a continuously learning and improving health system.
Vital Direction: Foster awareness and action on a community culture of continuous health improvement. Ultimately, transformative changes in health and health care require transformative leadership and action at the community level. Effective integration, application, and assessment of multisector and multidomain strategies to mobilize the clinical, social service, educational, voluntary, commercial and related stakeholders—to mobilize the citizenry—on behalf of better health for all, requires leadership to catalyze the emergence of the community-wide vision of the possible. It takes a culture change on many dimensions, away from one that is focused on the narrow and proximate, to one inspired by what is feasible to achieve, and how to achieve it, for the issue that ultimately matters most to people: their health, the health of their families, and the health of their neighbors. This is the aim, for example, of the Culture of Health movement envisioned by the Robert Wood Johnson Foundation (Lavizzo-Mourey, 2015). Building on what has already been demonstrated on the ability to use a well-developed digital platform to improve services and linkages and to accelerate knowledge and evidence development, as well as what has been accomplished by continuous improvement initiatives in health care and elsewhere, the beginnings of a move toward a community culture of continuous health improvement are also in place. Using provisions of the community benefit requirements in the tax code that compel the many nonprofit health care organizations to assess and work toward meeting community needs, tools are available for community leaders to mobilize support and movement toward a transformative community health culture.
Especially given the considerable resources available and used in the American health care system, we are substantially underperforming. Yet, compelling and actionable knowledge is now available about the ways health is shaped from its very beginning by factors outside the health system, as well as how engaging those factors more effectively can improve health prospects over a lifetime. With the tools available and the prospect of reinforcing leadership, technical assistance, and policy initiative from the national, state, and private sectors, the possibility should be at hand for better health prospects at the start of life, throughout its course, and at its conclusion. By aligning financial incentives, by employing measures that drive attention and accountability to where it matters most, by taking advantage of the potentially stunning power of the emerging digital platform, and by determined efforts to strengthen community capacity to catalyze necessary changes in community culture and priority, substantial advances in health, health care, and health equity is attainable for Americans.
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