Dear Colleagues:

For those of us in the health policy business, one of the underlying issues, which manifests in many contexts, is the relationship, or balance, between medical care and the field of public health. This week we welcome Scott Frank, founding and long-time Director of CWRU’s Masters in Public Health program, to address recent trends in that relationship.

Discussions often start from an observation that is nearly a cliché. Analysts agree that during most of the 20th century life expectancy improved mainly not because of improved medical care but due to public health measures as part of social and economic development – such as routine immunizations, improved sanitation, improved nutrition for pregnant women and for children, and policies to shape behavior such as anti-smoking campaigns. Even in the past few decades, with major gains from public health achieved and rapid improvement in medical technology, public health initiatives are estimated to explain close to half of life expectancy increases. Looked at another way, most of current differences among people in premature mortality has been attributed to differences in behavior rather than differences in health care. Yet spending on public health policies is a small fraction (2-3% in some analyses) of total spending on medical care. This looks like an imbalance – an indication that more could be achieved by increasing public health spending than by the continual surge in health care expenditures. Both practitioners and academics in the public health field continually pointed this out, and they were generally ignored by policy makers.

The past two decades, however, have seen a major shift in policy talk, though not in budgets. As U.S. policy makers have desperately struggled to control health care costs without doing what any sensible country does (regulate prices), they have been attracted to the idea that if people could be kept from getting sick, that would save lots of medical care dollars down the road. Public health prevention could be cheaper than cure. At the same time social scientists, especially economists and health services researchers, have gained more prominence in the health policy community, at the expense of physicians. Seeking to “rationalize” health care, they do statistical studies which by their nature focus on population health statistics – showing, for example, that geographic areas with more medical services seem often to have no better, or even worse, health outcomes. One recent study concluded that higher spending on social programs relative to medical care was associated with lower mortality. These analyses have not only cast doubt on the value of medical care, but subtly shifted focus from care for individuals to outcomes for populations.

These views were crystalized in 2008 by Donald Berwick and colleagues, who provided a slogan: that health policy should pursue a “Triple Aim” of “improving the experience of care, improving the health of populations, and reducing per capita costs of health care.” They have also been reflected in a series of policy initiatives, mainly focusing on getting medical providers, especially hospitals, to take responsibility for the health of populations rather than just the patients who come in their doors. Improving population health theoretically means acting to improve the social determinants of health, such as “socioeconomic status, residential environment, education and income, access to transportation, technology, telephone, and nutritious food.” Nonprofit hospitals, for example, are now required to complete “community health needs assessments” every three years – something that has nothing to do with their core function of treating patients sick enough to need a hospital. In a more significant move, federal law now encourages hospitals and other providers to set up “Accountable Care Organizations.” These ACOs would be paid fixed sums per patient for which they are “accountable,” and the theory is that ACOs will have incentives to invest in social determinants of health in order to keep their own medical expenses below the fixed payment amounts.

It should be no surprise that medical provider organizations are finding that addressing social problems that are outside their core competencies and that nobody else has been able to solve is rather difficult. Dr. Frank emphasizes a further and fundamental problem: that “population health” as a concept is not the same as the field of public health. In his words, “the rise of Population Health, promoted by the Healthcare Triple Aim, has sweeping implications for both Public Health and Medicine.” The new focus on population health challenges both fields, not just medicine. He doubts that population health is the path to recognizing and enhancing the “complementary reciprocity” of public health and medicine that is, “the best hope of repairing the broken U.S. healthcare system.” Please join us as one of CWRU’s leaders in this field shares his perspectives.

Signing In

This semester’s discussions will begin at 12:30 p.m., the usual time. The meeting will be set up as from Noon to 2:00 p.m., so people are not all signing in at the same time and to allow for the discussion to run a bit long. Each week we will send out this newsletter with information about the topic. It will also include a link to register (for free) for the discussion. Every Monday the same information will be posted on our website: fridaylunch.case.edu.

If you register, you will automatically receive from the Zoom system the link to join the meeting. This week’s link for registration is:

https://cwru.zoom.us/meeting/register/tJYpceCrrTMjHdQUdmEDoVCCzC3-azKnrz2X

After registering, you will receive a confirmation email containing information about joining the meeting.

Please e-mail padg@case.edu if you have questions about how the Zoom version of the Friday Lunch will work or any other suggestions. Or call at 216 368-2426 and we’ll try to get back to you. We are very pleased to be partnering this semester with the Siegal Lifelong Learning Program to share information about the discussions.

Best wishes for safety and security for you and yours,

Joe White
Luxenberg Family Professor of Public Policy and Director, Center for Policy Studies

About Our Guest

Dr. Scott Frank is a Public Health and Family Medicine educator, researcher, and practitioner. He founded the Master of Public Health Program at CWRU School of Medicine and served as Director for 18 years. Dr. Frank served as Director of Health for the City of Shaker Heights from for 25 years. He recently retired from clinical practice after 35 years of serving Cleveland’s east-side residents. He is now Director of Public Health Initiatives, Department of Population and Quantitative Health Sciences; and Senior Advisor to the Cleveland Department of Public Health on the Covid-19 pandemic response. Dr. Frank was the creative director for the Neighborhood Immersion from Compassion and Empathy (NICE) simulation to teach about health equity and social determinants of health. He a member of the HEALing Communities Study team on the opioid overdose death epidemic. Academic interests include Public Health systems and services, social justice, racism as a Public Health crisis, public health information technology, adolescent health, tobacco control, mental health, and substance abuse prevention.

Schedule of Friday Lunch Upcoming Topics and Speakers:

April 16: Dropping the Pilot? Assessing Angela Merkel’s Chancellorship. With Kenneth F. Ledford, Ph.D., Chair, Department of History.

April 23: Depression’s Past and Future. With Jonathan Sadowsky, Ph.D., Theodore J. Castele Professor of History.

April 30: The Republican Party and Demographic Change. With Girma Parris, Ph.D., Visiting Assistant Professor of Political Science.

May 7: Defending Disability Insurance. With Kathy Ruffing, former Senior Fellow, Center on Budget and Policy Priorities.