Opening session: 'The biggest risk of American health care today is that it will fail the moral test'

Uncertainty. It's a theme that many public health practitioners are all too familiar with these days. So much is changing so fast. And yet it's vital that public health keep up, adapt, transform, move forward — make itself into a lean, mean disease-fighting machine. It's a lot for a public health plate that's not only already overflowing, but being asked to hold more and more food with tinier and tinier plates. (Excuse the food metaphor; this blogger skipped lunch.)

Luckily, North Carolina — our generous host for the Midyear Meeting — has had some success tackling the problem. Its answer: Focus on continuous quality improvement; really zero in. According to opening session speaker Laura Gerald, North Carolina's state health officer, the state has fully embraced the concept of quality improvement. A few examples: The state was the first to mandate all local health departments achieve accreditation; strategic public-private partnerships, such as the North Carolina Center for Public Health Quality, are rapidly driving momentum toward quality improvement across the state; and work to coordinate healthy living efforts and build capacity in under-served communities is creating new opportunities for better health all the time.

Gerald said cost-containment measures and budget cuts are driving the need to find quality improvement strategies that increase efficiency while preserving and enhancing health outcomes. But even with quality improvement, budget cuts present a huge challenge, she said. For example, she said this year the state shifted its master settlement agreement monies that used to go toward tobacco education and prevention back to North Carolina's general fund. That means tobacco funds have gone from $18 million to $2.7 million. It also means that Gerald doesn't know how the state is going to sustain the hard-fought declines it has accomplished in youth tobacco use.

"'It appears I wasted my time studying medicine and public health when I should have been studying magic...(now that I'm being expected to) pull stuff out of thin air," she said to a roomful of knowing laughs.

Opening session speaker E. Winters Mabry, health director with the Mecklenburg County Health Department, noted that if you've seen one North Carolina Health Department, you've seen one North Carolina Health Department. However, accreditation has become the common bond that brings the state's health departments together, he said.

He told attendees about the department's largest effort — its school health program. Mabry said the department has worked hard to build close relationships with local school systems and now has a school health staff of 150 and a budget of $10 million. With more than 10 percent of students coming to school with serious chronic illnesses, such as asthma and diabetes, the school nurses provide case management and track specific indicators, such as grades, behavior and health outcomes. Last year, Mabry said, nurses managed thousands of children and had positive outcomes in the 95 percent. This is "special work," said Mabry, who ended his time at the opening session mic with a quote from Frederick Douglass: "It is easier to build strong children than to repair broken men."

Next up came keynote speaker Donald Berwick. A man who APHA Executive Director Georges Benjamin introduced with this quote: "When the dust settles...people will clearly see that the steps and programs that he initiated...will transform the way medicine is practiced in this country and many people will live longer because of that."

Berwick, former administrator of the Centers for Medicare and Medicaid Services, started off by noting that while he has great affection for the public health community and readily accepted APHA's invitation to speak, he didn't actually know what to say. He had writer's block (a common and not always preventable affliction among bloggers too.) The question he was asked to speak on — how public health can thrive in a changing health care landscape — was a hard one; one that doesn't submit itself well to easy soundbites, he said. Nevertheless, it's a problem with a solution, Berwick told attendees.  

First, he spoke about the Affordable Care Act — a law that he said holds great promise. Berwick said the law does two things: it tries to make health care a human right as well as make health care sustainable through improvement measures. Improvement, he said, was his compass when he was working in Washington, D.C. And you need a compass, "so you don't lose your mind," he joked. Improvement was the "how" to improve the system; the "what" was defining what improvement meant. That "what" question is what brought Berwick and CMS to pursue its now-famous triple aim: population health, experience of care and cost per capita. At the end of the day, Berwick said the system must embrace improvement strategies to sustain itself and serve the people.

"The biggest risk of American health care today is that it will fail the moral test," he said.

So, what does it all mean for public health? Berwick said the honest answer is that, well, he doesn't know. He discussed some of the classic problems that public health still faces: Like how do we tell the story of a disease we prevented from happening in the first place? How do we effectively make the case in an era of economic restraint that prevention has value that goes beyond saving money? That even though prevention doesn't always save money, it's still worth doing. And, finally, how does public health communicate its story?

Here was his prescription for public health: reduce costs in public health where you can; cooperate — don't work in silos; partner with nontraditional entities, such as employers and health systems; help reduce health care costs and waste; and focus and mobilize.

"Public health needs mobilization too," he said. "If there isn't political force behind the public health endeavor, it will remain frail."

To hear more from Berwick, check out this video (which is also at the top of this post) on APHA's YouTube Channel.