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Targeting Environmental Quality to Improve Population Health and Lower Healthcare Costs
Cascio, W., S. Katz, G. Robarge, J. Benforado, S. Deflorio-Barker, Y. Jain, AND D. Lobdell. Targeting Environmental Quality to Improve Population Health and Lower Healthcare Costs. National Association of County and City Health Officials (NACCHO) Annual Meeting, Pittsburgh, PA, July 11 - 13, 2017.
Impact Statement: The presentation outlined opportunities afforded by the transition of U.S. health care from volume-based to value-based care and payment for healthcare systems and insurers to consider environmental quality and conditions as important modifiable factors affecting clinical and population health, thereby motivate multi-disciplinary cooperation among healthcare systems and city and county public health and regional planners to take actions to improve environmental quality to protect health. Few individuals in the room knew of ORD resources and tools such as the EJSCREEN, C-FERST, EnviroAtlas, Healthy Heart and the Environmental Quality Index that provide information and interactive models to increase knowledge and guide action. The presentation had a substantial impact in increasing the awareness of the presence and utility of ORD tools and resources and will encourage the application of these tools and resources by city and county health officials.
Key goals of health care reform are to stimulate innovative approaches to improve healthcare quality and clinical outcomes while holding down costs. To achieve these goals value-based payment places the needs of the patient first and encourages multi-stakeholder cooperation. Yet, the stakeholders are typically all within the healthcare system, e.g. the Accountable Care Organization or Patient-Centered Medical Home, leaving important contributors to the health of the population such as the public health and environmental health systems absent. And rarely is the quality of the environment regarded as a modifiable factor capable of imparting a health benefit. Underscoring this point, a PubMed search of the search terms “environmental quality” with “value-based payment”, “value-based healthcare” or “value-based reimbursement” returned no relevant articles, providing further evidence that the healthcare industry largely disregards the quality of the environment as a significant determinant of wellbeing and an actionable risk factor for clinical disease management and population health intervention. Yet, the quality of the environment is unequivocally related to indicators of population health including all-cause mortality. The EPA’s Environmental Quality Index (EQI) composed of five different domains (air, land use, water, built environment and social) has provided new estimates of the associations between environmental quality and health status on a National scale at the county level. Across the U.S. when the county’s EQI index falls by one-standard deviation all-cause mortality increases significantly. Among the various domains air pollution has the strongest effects on all-cause, cardiovascular, and cancer mortality. So what might be achieved by including public health, environmental health systems as contributing stakeholders and the inclusion of environmental factors to help new and emerging health care delivery models and healthcare industry partners (professionals, hospitals, healthcare systems and insurers) meet their goals? One approach would be for local public health officials to collaborate with the health care systems and providers engaged with their population to assess modifiable environmental quality issues, and advocate for a health and promote well-being through healthier built environments. The EPA provides a number of databases and tools that could provide the foundation of such an approach. These tools include the Air Quality Index (AQI), the Environmental Quality Index (EQI), the Environmental Justice Screen (EJScreen), Community Focused Exposure Risk Screening Tool (C-FERST, and for tribes T-FERST), and the Health Impact Assessments (HIA). Presently there appears to be little to no consideration by healthcare systems or insurers that the quality of the environment might be a modifiable factor to improve the overall clinical outcomes of the population they serve and improve the overall health of the people within communities. Expansion of the group stakeholders contributing to value-based healthcare to include assessments environmental quality and environmental and public health expertise operating at the level of the community’s population might provide a new source of benefit and savings. Improvement in environmental quality might offer an opportunity to prevent the onset and/or progression of disease and overall improve population health.