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1
Elizabeth Bradley, PhD
Professor of Public Health
Yale School of Public Health
Elizabeth.Bradley@yale.edu
Follow @EHBYal...
Acknowledgements
Robert Wood Johnson Foundation
Blue Cross Blue Shield of Massachusetts Foundation
Co-author: Lauren Taylo...
3
Acknowledgements
Robert Wood Johnson
Foundation
Blue Cross Blue Shield of
Massachusetts Foundation
Co-author Lauren Tayl...
0
2
4
6
8
10
12
14
16
18
20
Health Care Spending as a % of GDP, 2009
Knee Replacements
Kidney Transplants
MRIs
Some Very Real Benefits
5
Some Very Enduring Challenges
Out of 34 OECD Countries
25th in maternal mortality
26th in life expectancy
28th in low birt...
What determines health? SOCIAL,
ENVIRONMENTAL,
and BEHAVIORAL
FACTORS
(60%)
GENETICS
(20%)
HEALTH CARE
(20%)
Job training and
employment
programs
supportive
housing
& rent subsidies
nutritional
support & family
assistance
other soc...
9
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
Total Investment in Health as a % GDP
Social Service Spending,
%GDP
...
0.00
0.50
1.00
1.50
2.00
2.50
Ratio of Social-to-Health Spending, 2009
*Switzerland and Turkey are missing data for 2009
In OECD, for $1 spent on health care,
about $2 is spent on social services.
In the US, for $1 spent on health care,
about ...
Determinants
SOCIAL,
ENVIRONMENTAL,
and BEHAVIORAL
FACTORS
(60%)
GENETICS
(20%)
HEALTH CARE
(20%)
12
HEALTH CARE
SPENDING
...
Does it matter?
13
Countries with higher ratios of social-to-health
spending have statistically better health outcomes.
Lower infant mortalit...
15
What about inside the United States?
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
20.0%
All Social
Services
Education Income
Support
Transportation P...
Ratio of social-to-health care spending*
*Medicare and Medicaid spending 17
LOWEST QUIINTILE
MEDIAN QUINTILE
HIGHEST QUINT...
18
Ratio social-to-health
spending
Percent of population
that is obese
LOWEST QUIINTILE
MEDIAN QUINTILE
HIGHEST QUINTILE
H...
States with higher ratios of social-to-health
spending have statistically better health outcomes.
Lower mortality among th...
What to do?
Spend more! 28% GDP  35% GDP?
Transfer $$ from health care to social services
20
Incentivize collaboration on...
Evidence Supports Integrative Models
Health Care Sector
Community Outreach
Mobile Clinics
Case Management,
Patient Navigat...
Mobilizing collaboration for health
nationally
Mitigate financial incentives to medicalize health
Establish common metrics...
Health = Health Care
Thank you
Follow @EHBYale
@laurentaylorMPH
24
Extra slides for reference
25
Public Health Services Defined
Description: Provision of services for the conservation and
improvement of public health, o...
Social Services Spending Categories
Education (primary, secondary, and higher education)
Transportation
Environment
Public...
% State GDP
State Variation in Health Care Spending
(Medicaid and Medicare) (as % of GDP, 2009)
0
2
4
6
8
10
12
WV
MS
ME
V...
Spending on Social Services
Education
Income Support, TANF, SSI, Social Security, SNAP
Transportation, Public Safety and E...
% State GDP
State Variation in Social Services Spending
(as % of GDP, 2009)
0
5
10
15
20
25
30
WV
MS
ME
VT
KY
AR
MI
RI
SC
...
31
Social Services-to-Medicaid & Medicare Spending Ratio, 2009
0
1
2
3
4
5
6
AK
WY
UT
HI
CO
NV
DC
WA
VA
OR
ND
MT
GA
CA
ID
...
C-TRAIN (Portland, OR)
32
• Academic medical center
• 570-bed facility
• 33% of patients are un- or
under-insured
• 501c3 ...
33
Academic Medical Center
2,600 beds
Community Center with
childhood asthma rates
3 times national average
Bilingual Comm...
The 10th Decile Project
Works with hospitals to identify the 10% of homeless
people with the highest hospital costs and to...
Opportunity costs
1 Emergency department visit = 1 month’s rent
2 hospitalization = 1 year of child care
20 MRIs = 1 socia...
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Spending More and Getting Less

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Elizabeth Bradley, PhD
Professor of Public Health
Yale School of Public Health

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Spending More and Getting Less

  1. 1. 1 Elizabeth Bradley, PhD Professor of Public Health Yale School of Public Health Elizabeth.Bradley@yale.edu Follow @EHBYale Getting to Better Health: CONNECTing Care and Community UNIVERSAL HEALTH CARE Foundation of Connecticut Spending More and Getting Less
  2. 2. Acknowledgements Robert Wood Johnson Foundation Blue Cross Blue Shield of Massachusetts Foundation Co-author: Lauren Taylor Presidential Scholar, Harvard Divinity School Collaborators: Erika Rogan, Maureen Canavan, Kristina Talbert-Slagle, Chima Ndumele, Leslie Curry 2
  3. 3. 3 Acknowledgements Robert Wood Johnson Foundation Blue Cross Blue Shield of Massachusetts Foundation Co-author Lauren Taylor Presidential Scholar, Harvard Divinity School
  4. 4. 0 2 4 6 8 10 12 14 16 18 20 Health Care Spending as a % of GDP, 2009
  5. 5. Knee Replacements Kidney Transplants MRIs Some Very Real Benefits 5
  6. 6. Some Very Enduring Challenges Out of 34 OECD Countries 25th in maternal mortality 26th in life expectancy 28th in low birth weight
  7. 7. What determines health? SOCIAL, ENVIRONMENTAL, and BEHAVIORAL FACTORS (60%) GENETICS (20%) HEALTH CARE (20%)
  8. 8. Job training and employment programs supportive housing & rent subsidies nutritional support & family assistance other social services that exclude health benefits Social Services
  9. 9. 9 0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 Total Investment in Health as a % GDP Social Service Spending, %GDP Health Care Spending, %GDP *Switzerland and Turkey are missing data for 2009
  10. 10. 0.00 0.50 1.00 1.50 2.00 2.50 Ratio of Social-to-Health Spending, 2009 *Switzerland and Turkey are missing data for 2009
  11. 11. In OECD, for $1 spent on health care, about $2 is spent on social services. In the US, for $1 spent on health care, about $0.90 is spent on social services.
  12. 12. Determinants SOCIAL, ENVIRONMENTAL, and BEHAVIORAL FACTORS (60%) GENETICS (20%) HEALTH CARE (20%) 12 HEALTH CARE SPENDING (65%) SOCIAL SERVICE SPENDING (35%) Investment Mismatch
  13. 13. Does it matter? 13
  14. 14. Countries with higher ratios of social-to-health spending have statistically better health outcomes. Lower infant mortality Fewer low birth weight babies Less premature death Longer life expectancy Bradley , Elkins, Herrin, Elbel et al., BMJ Open, 2011
  15. 15. 15 What about inside the United States?
  16. 16. 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% 18.0% 20.0% All Social Services Education Income Support Transportation Public Safety Environment Housing 16 Social Services Spending by Type of Service (as % of GDP, 2009)
  17. 17. Ratio of social-to-health care spending* *Medicare and Medicaid spending 17 LOWEST QUIINTILE MEDIAN QUINTILE HIGHEST QUINTILE
  18. 18. 18 Ratio social-to-health spending Percent of population that is obese LOWEST QUIINTILE MEDIAN QUINTILE HIGHEST QUINTILE HIGHEST QUIINTILE MEDIAN QUINTILE LOWEST QUINTILE
  19. 19. States with higher ratios of social-to-health spending have statistically better health outcomes. Lower mortality among those with lung cancer Lower rates of asthma and obesity Lower rates of limitation in daily activities per month Lower rates of mentally unhealthy days per month Lower post-neonatal mortality 2000-2009 data, adjusted for region, GDP, and socioeconomic factors Bradley et al., under review 2015
  20. 20. What to do? Spend more! 28% GDP  35% GDP? Transfer $$ from health care to social services 20 Incentivize collaboration on health
  21. 21. Evidence Supports Integrative Models Health Care Sector Community Outreach Mobile Clinics Case Management, Patient Navigators, Care Coordination Nutrition support Housing First
  22. 22. Mobilizing collaboration for health nationally Mitigate financial incentives to medicalize health Establish common metrics for health and social services - % obese, % depressed… - % on target to finish high school - % employed - % housed Talk differently about health and health care 22
  23. 23. Health = Health Care
  24. 24. Thank you Follow @EHBYale @laurentaylorMPH 24
  25. 25. Extra slides for reference 25
  26. 26. Public Health Services Defined Description: Provision of services for the conservation and improvement of public health, other than hospital care, and financial support of other governments’ health programs. Included examples: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), protective inspection services, health related inspections, community health care programs, regulation of air and water quality, rabies and animal control, ambulance and emergency medical services (unless operated by local fire department), and hazardous waste cleanup. Also includes medical appliances, supplies, or services as part of public assistance programs as well as construction and maintenance of nursing homes, homes for the elderly, orphanages, and veterans' homes. 26
  27. 27. Social Services Spending Categories Education (primary, secondary, and higher education) Transportation Environment Public Safety Housing Corrections Income Support, including: – Social Security (Old-Age, Survivors, and Disability Insurance) – Supplemental Security Income (SSI) – Temporary Assistance for Needy Families (TANF) – Supplemental Nutrition Assistance Program (SNAP) Public Health Programming, including: – Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) – Protective inspection services – Health related inspections – Community health care programs – Regulation of air and water quality – Rabies and animal control – Hazardous waste cleanup
  28. 28. % State GDP State Variation in Health Care Spending (Medicaid and Medicare) (as % of GDP, 2009) 0 2 4 6 8 10 12 WV MS ME VT KY AR MI RI SC NY FL PA AL OH NM MO LA TN OK AZ MA WI IN MT NC ID NH CT IA MN IL NJ MD KS OR CA TX SD NE GA ND WA HI DE VA NV AK CO UT WY DC
  29. 29. Spending on Social Services Education Income Support, TANF, SSI, Social Security, SNAP Transportation, Public Safety and Environment Corrections and Housing Other social services excluding health care * And public health spending
  30. 30. % State GDP State Variation in Social Services Spending (as % of GDP, 2009) 0 5 10 15 20 25 30 WV MS ME VT KY AR MI RI SC NY FL PA AL OH NM MO LA TN OK AZ MA WI IN MT NC ID NH CT IA MN IL NJ MD KS OR CA TX SD NE GA ND WA HI DE VA NV AK CO UT WY DC
  31. 31. 31 Social Services-to-Medicaid & Medicare Spending Ratio, 2009 0 1 2 3 4 5 6 AK WY UT HI CO NV DC WA VA OR ND MT GA CA ID DE MN KS IA NE NJ WI MD NM SD NH IL VT MI IN OH TX AZ SC PA AL NC RI CT OK FL MA NY AR MO TN KY LA ME WV MS
  32. 32. C-TRAIN (Portland, OR) 32 • Academic medical center • 570-bed facility • 33% of patients are un- or under-insured • 501c3 serving Portland • Serving individuals and families facing homelessness, poverty and addiction • Affordable housing is primary service, plus health care, recovery services and employment assistance RCT has found C-TRAIN patients have lower mortality and better quality of care; hospital is funding expansion Englander, J Hosp Med, 2012
  33. 33. 33 Academic Medical Center 2,600 beds Community Center with childhood asthma rates 3 times national average Bilingual Community Health Workers provide asthma education and referrals for housing, immigration, and mental health services. 50% decline in emergency visits and hospitalizations; 30% decline in school absenteeism WIN for Asthma http://nyp.org/services/acn_outreach_win.html
  34. 34. The 10th Decile Project Works with hospitals to identify the 10% of homeless people with the highest hospital costs and to find permanent housing with strong medical and mental health support. 34 Healthcare costs decreased by 72%, from $58,962 to $16,474 per person. http://www.economicrt.org/pub/Getting_Home_2013/Getting_Home_2013.pdf
  35. 35. Opportunity costs 1 Emergency department visit = 1 month’s rent 2 hospitalization = 1 year of child care 20 MRIs = 1 social worker for a year 60 echocardiograms = 1 public school teacher for a year 35SGIM Presidential Speech, Dr. Moran, 2015

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