JAMA Forum: Latent Natural Resources for Health

By Dave A. Chokshi, MD, and Christopher C. Jennings

Latent natural resources are those that exist in our world today, waiting to be tapped. Think of wind before windmills. Or in a more modern example, private apartments before Airbnb. What else is out there right now, awaiting our development, specifically to advance health?

This question becomes more consequential when we consider major forthcoming health challenges—such as the care and cost burdens associated with the aging of the US population. In just 4 years, the first baby boomers turn 75; there is little dispute that their care needs and associated costs will place extraordinary pressure on the nation’s health care delivery system and the federal budget. Indeed, by 2030, there will be more than 34 million individuals aged 75 years or older, a 78% increase from the more than 19 million individuals in 2012.

More aggressive payment reform, delivery system changes, and strategic investment in public health and biomedical research are needed to help with this “silver tsunami” and other health priorities. Yet our current political gridlock is ill-matched to the urgency of such challenges. In this context, innovation around latent natural resources could help drive breakthroughs—in both the private and public sectors—to promote health and reduce medical spending.

Three categories of latent natural resources particularly worth developing for health are people, policy, and data.

 

People

Much of health care spending reflects workforce costs; the most important work of health care is usually delivered person to person. But could we think more broadly about people who could be a part of—or at least strategically supplement—the health care workforce, particularly for older adults?

The company AgeWell Global, originally launched in South Africa, adapts a peer-to-peer model to address the needs of an aging population. The model is oriented around the latent ability and time of able older persons to serve as lay health workers for more vulnerable elders. After undergoing a training program, the employed “AgeWells” visit other older persons in their homes, providing companionship, monitoring health status, and making referrals to medical and social service providers. Similarly, a program known as Call and Check expanded the role of postal workers on the island of Jersey (between England and France). The local postal service was interested in diversifying its business, and decided to pilot a service that checks in on frail elders and delivers medications at a low cost. Although the program merits further study, other locales in Europe are already considering the initiative.

Another global innovation is the concept of mental health first aid, pioneered in Australia and targeted at people across the life span. The approach elevates the role of community members, particularly teachers and first responders (including police), in identifying and responding to signs of mental illness and substance use disorders and in making referrals as needed. More than 1 million people have been trained in mental health first aid across the United States, and Congress has supported dedicated funding to train school personnel and community organizations serving youth.

 

Policy

A long-standing movement toward “health in all policies” recognizes how some policies not explicitly about health can nevertheless engender significant health improvement (or decline). However, it can be paralyzing to consider all of the ways that housing, employment, education, and transportation affect health—and what to do about these factors. One way forward is to start with specific interventions that have a plausible effect on health or medical costs, and then demonstrate that effect in rigorous evaluations. For example, a recent study showed that participation in the Supplemental Nutrition Assistance Program (SNAP, also known as food stamps) was associated with a reduction in health spending of $1400 per person per year among low-income adults. The insurer Humana, after seeing promising results in a physician-based SNAP screening and referral pilot, is now conducting a randomized trial measuring health and cost outcomes of a comprehensive food insecurity intervention, as part of their population health program.

SNAP is likely one of a broader category of existing government policies (not least of which are environmental protections for actual natural resources) with a latent, or at least underappreciated, effect on health. Rigorous evaluation of that effect is just the start; the evidence must be sufficiently convincing for payers (private health plans and government insurance such as Medicare and Medicaid) and health systems to shift resources to leverage those policies. Value-based payment that focuses on expensive, avoidable hospital use provides incentive for such nascent efforts, though up-front costs often remain a barrier for both systems and payers.

 

Data

David Blumenthal, MD, the former National Coordinator of Health Information Technology, has called for thinking about digital health data as a natural resource. With billions of dollars flowing into this area, mostly through private investment, there is a data “gold rush” based on the promise of mostly untested technology. Setting aside the hype, it is difficult to believe that we can’t do better at unlocking the potential of clinical data, particularly when we stack up the exabytes of information already collected in our medical records against the many failures in diagnosis, care coordination, and engaging patients that occur in our health care system.

One example is the movement to share clinicians’ notes with patients, known as OpenNotes. The simple act of opening up access to existing documentation is associated with patients feeling more in control of their care; early study also shows other clinical benefits, such as improved medication adherence. The elegance of this approach is that it leverages the latent natural resource of data already generated each day through clinicians’ keystrokes. In the same vein, data about how physicians work through medical cases could be mined to build a map of clinical decision making. This is the idea behind the Human Diagnosis Project, which is building an online platform to join the collective intelligence of thousands of clinicians collaborating on case vignettes with a machine learning approach to “store” their medical insights.

The common thread across the realms of people, policy, and data is that latent natural resources may help achieve cost-efficient health improvement at scale. Implementation at scale is a fundamental weakness of our current health system. Even programs that have been found to be effective, such as the federal Diabetes Prevention Program, which reduced inpatient admissions and health care spending among Medicare beneficiaries, have struggled with respect to uptake. A focus on latent natural resources, by starting with elements in our world often already at scale (like medical notes or the postal service), could help us move beyond the incrementalism that characterizes most health interventions in clinical settings. As our health system comes under growing strain, we believe it is a useful frame for considering and, over time, demonstrating how novel strategies can improve health and lower costs.

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About the authors: 

Dave A. Chokshi, MD, MSc, is the chief population health officer of OneCity Health and senior assistant vice president at New York City Health + Hospitals—the largest municipal health system in the United States. He is a primary care internist at Bellevue Hospital and clinical associate professor of population health and medicine at the New York University School of Medicine. Follow him on Twitter at @davechokshi. Disclaimer: The views expressed in this post do not necessarily reflect the position of NYC Health + Hospitals nor NYU. (Image: NYU Langone Medical Center)

 

Chris Jennings is a former senior health care advisor to Presidents Clinton and Obama, 3 US Senators, and the founder and president of Jennings Policy Strategies, a health care consulting firm that works with foundations, think tanks, public and private purchasers and consumer organizations to secure public policies and system practices that produce higher quality, more affordable and sustainable care. (Image: Ralph Alswang)

 

Conflict of Interest: Dr Chokshi reports serving on the board of directors of the nonprofit Human Diagnosis Project, Ltd; he receives no compensation for this role.

About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

 



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