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Vital Directions for Health and Health Care Priorities from a National Academy of Medicine Initiative

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Vital Directions for Health and Health Care Priorities from a National Academy of Medicine Initiative DISCUSSION PAPER Vital Directions for Health and Health Care Priorities from a National Academy of Medicine Initiative Victor J. Dzau, National Academy of Medicine; Mark McClellan, Duke University; Sheila Burke, Harvard Kennedy School; Molly J. Coye, AVIA; The Honorable Thomas A. Daschle, The Daschle Group; Angela Diaz, Icahn School of Medicine at Mount Sinai; The Honorable William H. Frist, Vanderbilt University; Martha E. Gaines, University of Wisconsin Law School; Margaret A. Hamburg, National Academy of Medicine; Jane E. Henney, National Academy of Medicine; Shiriki Kumanyika, University of Pennsylvania Perelman School of Medicine; The Honorable Michael O. Leavitt, Leavitt Partners; J. Michael McGinnis, National Academy of Medicine; Ruth Parker, Emory University School of Medicine; Lewis G. Sandy, UnitedHealth Group; Leonard D. Schaeffer, University of Southern California; Glenn D. Steele, xG Health Solutions; Pamela Thompson, American Organization of Nurse Executives; Elias Zerhouni, Sanofi March 21, 2017 About the Vital Directions for Health and Health Care Series This publication is part of the National Academy of Medicine’s Vital Directions for Health and Health Care Initiative, which called on more than 150 leading researchers, scientists, and policy makers from across the United States to assess and provide expert guidance on 19 priority issues for U.S. health policy. 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. The United States is poised at a critical juncture in and opportunities. The National Academy of Medicine health and health care. Powerful new insights are has identified priorities central to helping the nation emerging on the potential of disease and disabil- achieve better health at lower cost. ity, but the translation of that knowledge to action is hampered by debate focused on elements of the Af- Context: Fundamental Challenges fordable Care Act that, while very important, will have Health care today is marked by structural inefficien- relatively limited impact on the overall health of the cies, unprecedented costs, and fragmented care deliv- population without attention to broader challenges PREPUBLICATION COPY – UNCORRECTED PROOFS Perspectives | Expert Voices in Health & Health Care DISCUSSION PAPER ery, all of which place increasing pressure and burden widespread than in peer nations (Lasser et al., 2006; on individuals and families, providers, businesses, and Avendano, 2009; van Hedel et al., 2014; Siddiqi et al., entire communities. The consequent health shortfalls 2015). Over the past 15 years, individuals in the upper are experienced across the whole population, but dis- income brackets have seen gains in life expectancy, proportionately impact our most vulnerable citizens while those in the lowest income brackets have seen due to their complex health and social circumstances. modest to no gains (Chetty et al., 2016). And while This is evidenced by the growing income-related gap in health inequities are seen most acutely across socio- life expectancy for both men and women (see Figures economic and racial/ethnic lines, they also emerge 1 and 2). Today, higher-income men can expect to live when comparing other characteristics such as age, longer than they did 20 years ago, while life expectancy life stage, gender, geography, and sexual orientation for low-income males has not changed. Higher-income (Braveman et al., 2010; Artiga, 2016). However, health women are also anticipated to live longer, but life ex- status is not predetermined; rather, is the result of the pectancy for low-income women is projected to decline. interplay for individuals and populations of genetics, Beyond systemic and structural issues, this country is social circumstances, physical environments, behav- faced with serious public health challenges and threats: ioral patterns, and health care access (McGinnis et al., emerging infectious diseases; an evolving opioid epi- 2002). Similarly, inequities in health are not inevitable demic; alarming rates of tobacco use, obesity, and relat- (Adler et al., 2016; McGinnis et al. 2016); efforts to ed chronic diseases; and a rapidly aging population that lessen social disadvantage, prevent destructive health requires great support from our health care delivery behaviors, and improve built environments could have and financing systems. Following are summarized fun- important health benefits. damental challenges with which our health and health care system must be better prepared to contend. Rapidly Aging Population By 2060, the number of older persons (ages 65 years Persistent Inequities in Health or older) is expected to rise to 98 million, more than In spite of the United States’ great investment in health double the 46 million today; in total population terms, care services and the state-of-the-art health care tech- the percentage of older adults will rise from 15% to nology available, inequities in health care access and nearly 24% (Mather et al., 2015; ACL, 2016). This trend status persist across the population and are more is explained by the fact that people are living longer 90 88.8 Wealthiest 87.8 Upper-middle income 85 e 83.4 Middle income Ag 80 78.3 Lower-middle income 76.1 Poorest 75 1980 2010 Year Figure 1 | Widening inequality in life expectancy for men in the United States. SOURCE: Data from NASEM, 2015. PREPUBLICATION COPY – UNCORRECTED PROOFS Page 2 Published March 21, 2017 Vital Directions for Health and Health Care: Priorities from a National Academy of Medicine Initiative 91.9 Wealthiest 90 85 e 83.1 Upper-middle income Ag 82.4 Middle income 80 79.7 Lower-middle income 78.3 Poorest 75 1980 2010 Year Figure 2 | Widening inequality in life expectancy for women in the United States. SOURCE: Data from NASEM, 2015. and the baby boomers are entering old age. The aging devastating natural disasters, such as hurricanes San- population is placing increasing demand on our health dy and Katrina (Morens and Fauci, 2013). The emer- care delivery, financing, and workforce systems, includ- gence of these threats, and in some cases the related ing informal and family caregivers. As more and more responses, highlights the need for the public health people age, rates of physical and cognitive disability, system to better equip communities to better identify chronic disease, and comorbidities are anticipated to and respond to these threats. rise, increasing the complexity and cost of delivering or receiving care. In particular, Medicare enrollments Persisting Care Fragmentation and Discontinuity and related spending will rise, as will Medicaid and While recent efforts on payment reform have aimed out-of-pocket spending for long-term care services not to advance coordinated care models, much of health provided under Medicare (CMS 2016a; ACL, 2016). En- care delivery still remains fragmented and siloed. This suring that the elderly can be adequately cared for and is particularly true for complex, high-cost patients— supported will require greater understanding of their those with fundamentally complex medical, behav- social, medical, and long-term needs, as well as work- ioral, and social needs. Complex care patients include force skills and care delivery models that can provide the frail elderly, those who are disabled and under 65 complex care (Rowe et al., 2016). years old, those with advanced illness, and people that have multiple chronic conditions (Blumenthal et al, New and Emerging Health Threats 2016). High-need, high-cost patients comprise about U.S. public health and preparedness has been strained 5% of the patient population, but drive roughly 50% of by a number of recent high profile challenges, such health care spending (Cohen and Yu, 2012). Individu- as lead-contaminated drinking water in several of our als with chronic illness and/or behavioral health con- cities; antibiotic resistance; mosquito-borne illnesses ditions often experience uncoordinated care which such as Zika, Dengue, and Chikungunya; diseases of has been shown to result in lower quality care, poorer animal origin, including HIV, influenzas, Severe Acute health outcomes, and higher health care costs (Druss Respiratory Syndrome (SARS), Middle East Respiratory and Walker, 2011; Frandsen et al., 2015). Syndrome-Coronavirus (MERS-CoV), and Ebola; and PREPUBLICATION COPY – UNCORRECTED PROOFS NAM.edu/Perspectives Page 3 DISCUSSION PAPER Health Expenditure Costs and Waste outdated regulatory, education and training models. In It is widely acknowledged that the U.S. is experiencing the drug and medical device review and approval pro- unsustainable cost growth in health care: spending is cess, uncertainty and unpredictability around approval higher, coverage costs are higher, and the costs asso- expectations adds complication, delay, and expense to ciated with gaining access to the best treatments and the research and development process, and can trans- medical technologies are similarly increasing. In 2015, late to a disincentive to investors (Battelle, 2010). Si- health care spending grew 5.8%, totaling $3.2 trillion multaneously, there are concerns that the movement or close to 18% of GDP. Of that, it has been estimated toward population-based payment models may stifle that approximately 30% can be attributed wasteful or innovation and patient access by placing excessive excess
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