What's Missing in the National Quality Strategy?

Last week, the Centers for Disease Control and Prevention released data showing life expectancy in the U.S. declined in 2017 for the third consecutive year. The good news was improvement in the two leading causes of death—heart disease and cancer—but the bad news was death rate increases for Alzheimer’s, diabetes, flu and pneumonia, drug overdoses, suicides and firearm deaths.

There’s a startling reality to these data: we’re doing a good job as a system battling conditions that involve drugs, technologies, facilities and approaches for which there’s a good business case to be made, but not so good when the upside is not quite as lucrative. Otherwise, recognition as one of America’s top heart hospitals wouldn’t carry so much weight or institutions wouldn’t have spent $207 million last year promoting their cancer brands. 

In the next 10 years, epidemiologists forecast cancer will eclipse heart disease as our #1 cause of death, killing 640,000 people annually; the number of hepatitis C-related deaths will triple, and Alzheimer’s will become the 4th leading cause of death, killing 150,000 people/year. That’s good news for drug manufacturers, geneticists, infomaticists, medical specialists and clinical investigators keen to harness precision therapies and companion diagnostics more effectively. But despite advances in these notable areas, our life expectancy is likely to decline even further.

 “In 1960, Americans had the highest life expectancy, 2.4 years higher than the average for countries in the Organization for Economic Cooperation and Development (OECD). But the US started losing ground in the 1980s. US life expectancy fell below the OECD average in 1998, plateaued in 2012, and is now 1.5 years lower than the OECD (35 nation) average.Failing health of the United States” BMJ 2018; 360 doi; Life expectancy at birth in the US and the Organization for Economic Cooperation and Development, 1995-2015.

We take great pride as the hub for global clinical innovation but perhaps we should rethink our National Quality Strategy. Something’s missing.

Background: The National Quality Strategy

Section 3011 of the Patient Protection and Affordable Care Act specifies that the Secretary of the Department of Health and Human Services (HHS) establish the National Health Care Quality Strategy and Plan that includes priorities to improve the delivery of health care services, patient health outcomes, and population health. Per the ACA, it requires that the plan be developed in a transparent way, align with the National Prevention and Health Promotion Strategy and include provisions for 1) agency-specific plans and benchmarks; 2) coordination among agencies; 3) strategies to align public and private payers; and 4) alignment with meaningful use of health information technology (IT).

More than 300 organizations had input in the plan first published in March, 2011 by the Agency for Healthcare Research and Quality. It set forth three aims:

Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe.

Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and, environmental determinants of health in addition to delivering higher-quality care.

Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

And to advance them, the National Quality Strategy laid out six priorities:

Making care safer by reducing harm caused in the delivery of care.

Ensuring that each person and family is engaged as partners in their care.

Promoting effective communication and coordination of care.

Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.

Working with communities to promote wide use of best practices to enable healthy living.

Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

Objectively, we’ve made strides in each area. The safety of care we provide is improved. The efficacy of our methods of care—how we diagnose and treat—is improving. But we struggle with the notion of healthy living and affordability is, in most communities, a moonshot. We’re talking about social determinants of health while cutting public health funding. And public despair is an epidemic at the heart of the decline in life expectancy: anxiety, hopelessness, loneliness and depression are pervasive and growing in our communities, schools, workplaces and families.

Grassroots efforts by hospitals, physicians, health insurers, employers, and public health agencies have institutionalized quality improvement efforts and popularized its measurement. And more recently, attention to “social determinants of health” is getting attention as correlations between food security, access to transportation, freedom from loneliness/isolation, access to insurance coverage and other factors are shown to be positively correlated to lower health costs and better outcomes.

Ironically, the 2018 National Quality Strategy has not been published. Given evidence life expectancy is decreasing, maybe AHRQ’s leader Gopal Khanna, M.B.A., should take a fresh look starting with the public’s sense of wellbeing. That’s the root cause of the decline.

Wellbeing: The Missing Focus in the National Quality Strategy

Webster defines wellbeing as “the state of being happy, healthy or prosperous”. In its State of American Wellbeing report, the Gallup-Sharecare Wellbeing Index concluded “2017 was a challenging year for Americans’ well-being. The national Well-Being Index score for the U.S. in 2017 was 61.5 – a decline from 62.1 in 2016. This overall drop was characterized by declines in 21 states, easily the largest year-over-year decline in the 10-year history of the Well-Being Index. Not a single state showed statistically significant improvement compared to the previous year…which is also unprecedented in Well-Being Index measurement. With the exception of community well-being, all of the national well-being elements suffered declines in 2017. Two key elements of well-being – social and purpose – declined particularly sharply.”

According to the Anxiety and Depression Association of America, anxiety disorders affect 18% of adults and 25% of children 13-18 years of age but only 37% receive treatment. And they’re five times more likely to go to physicians and six times more likely to be hospitalized. Addressing the public’s wellbeing is good business and good health policy.

Wellbeing is complicated. It involves physical health, a safe environment, emotional connectivity, financial security and a sense of purposeful existence. It’s more than health screenings, accessible clinicians, mental health programs, convenient facilities and insurance coverage. It requires an orchestrated, community-wide effort to give hope, dignity and purpose to lives in disarray.

Left unattended, low wellbeing means poor health and high health costs—for families, for employers and entire communities. It leads to acts of defiance, violence or suicide. It’s prominent and growing in every income, ethnic and social grouping in our society.

The science about wellbeing management is evolving, but the signals are clear: unless and until wellbeing is central to the National Quality Strategy, efforts to improve health and rein in avoidable health costs are moot.

Paul

 P.S. The wellbeing of two populations drew my attention last week:

Veterans: This weekend marked the 150th observance of Memorial Day. It’s a day we honor the 1.35 million military fallen in the 78 wars we’ve fault since 1775. But sadly, Veterans commit suicide at an alarming rate of 20 per day. They’re 22% more likely to end their lives than their non-veteran counterparts and only one in three is under the care of health professional. Our 21 million living veterans, including 9 million who are dependent on Veteran’s health, deserve more than our gratitude; they deserve attentiveness to their wellbeing.

Insurance Enrollees: Last week, the Congressional Budget Office released its latest analysis of health insurance coverage: 3 million more were uninsured between 2018 and 2019 due to repeal of the individual mandate bringing the uninsured rate to 12.8%--the same rate as 2015 and down from 16.3% in 2014. The number of uninsured will increase to 35 million by 2028. The individual market will shrink by 3 million from 2018-2019 and their premiums will increase 15%

The loss of health insurance contributes to the erosion of wellbeing.