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The American Health Care Paradox: Spending More and Getting Less November 2015 1 Elizabeth Bradley, PhD Professor of Public Health Elizabeth.Bradley@yale.edu Follow @EHBYale
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Acknowledgements Additional Collaborators: Erika Rogan, Maureen Canavan, Kristina Talbert- Slagle, Chima Ndumele, Leslie Curry 2 Co-author Lauren Taylor Funders Robert Wood Johnson Foundation Blue Cross Blue Shield of Massachusetts Foundation
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Knee Replacements Kidney Transplants MRIs Some Very Real Benefits 4
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Enduring Challenges Out of 34 OECD Countries 25 th in maternal mortality 26 th in life expectancy 28 th in low birth weight
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What determines health? SOCIAL, ENVIRONMENTAL, and BEHAVIORAL FACTORS (60%) GENETICS (20%) HEALTH CARE (20%)
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job training and employment programs supportive housing & rent subsidies nutritional support & family assistance other social services that exclude health benefits Social Services
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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.
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Does it matter? 11
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Globally, it seems to matter 12 Maternal Mortality Ratio per 100K Ratio Social-to-Health Care Spending U.S.
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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
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Is the same pattern found inside the U.S. across the states? 14
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15 Social Services Spending by Type of Service (as % of GDP, 2009) Health care
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Opportunity Costs 1 emergency department visit = 1 month’s rent 2 hospitalizations = 1 year of child care 20 MRIs = 1 social worker for a year 60 echocardiograms = 1 public school teacher for a year SGIM Presidential Speech, Dr. Moran, 2015 16
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Ratio of social-to-health care spending* *Medicare and Medicaid spending 17 LOWEST QUINTILE MEDIAN QUINTILE HIGHEST QUINTILE
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18 Ratio social-to-health spending Percent of population that is obese LOWEST QUINTILE MEDIAN QUINTILE HIGHEST QUINTILE MEDIAN QUINTILE LOWEST QUINTILE
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19 Post neonatal mortality rate per 100,000 live births Red: highest mortality 5 th Yellow: median mortality 5 th Green: lowest 5 th Ratio social-to-health spending Red: lowest 5 th Yellow: median 5 th Green: highest 5 th
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States with higher ratios of social-to-health spending have statistically better health outcomes. Less adult obesity, less adult asthma Fewer adults reporting 14+ mental unhealthy days Fewer adults reporting 14+ days of activity limitations in last 30 Lower lung cancer and type II diabetes mortality rates Lower post-neonatal mortality rates Greater physical activity and consumption of fruits and vegetables Less smoking tobacco Bradley et al., Health Affairs, under review
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21 Medicalization
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Two Perspectives Give a small boy a hammer and he will find that everything he encounters needs pounding. - Abraham Kaplan
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Experience in Other High-income Countries 23
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Values (Scandinavia versus U.S.) 24 Differences (P<0.05) Scope of social contract Views of income, equality and social mobility Degrees of trust in “the other” Similarities (P>0.05) Personal freedom Views about competition Technology as source of progress
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What to do? Spend more! 28% GDP 35% GDP? Transfer $$ from health care to social services 25 Taxes? NON-STARTER Unlikely Incentivize collaboration on health
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What does the evidence tell us about which types of social services produce the best health-related outcomes? 26
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Literature review 27 Total Number of Papers n=74 Positive Findings n=60 Health Improvement n=22 Both n=10 Null Findings n=14 Health Care Cost Savings n=38 CONCLUSION: The literature is mixed.
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Supportive housing, and Integrated health care and housing Bud Clark Commons Minnesota Supportive Housing 28
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Nutritional assistance for high-risk women, infants, and children as well as older adults with disabilities 29
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Case management and community outreach 30
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DOES IT MATTER? The Work Ahead 31 Changing Our Mental Models: Health and social services are distinct levers to achieve common goals. Changing Financial Incentives: To promote collaboration between health care and social services. Exposing Latent Networks: Connections already exist between health care and social services but are not always leveraged.
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Health = Health Care
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Thank you @EHBYale 33
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