Secretary's Council on Health Promotion and Disease Prevention Objectives for 2010

MS. SOFAER: Thanks for being here. When you said that there was going to be violence done--I'm in the middle of jury duty and I thought I was going to be a juror, but I didn't think I was going to be a victim. I've got danger here to watch out for.

DR. BOUFFORD: It was only an idle threat.

MS. SOFAER: Okay. As Dr. Boufford mentioned, GW took on the responsibility at the request of ODPHP to conduct a series of focus groups to get input from--we also worked with the entire steering committee through a wonderful retreat that was held in September--to get input from the groups that have been most involved in and affected by the Healthy People 2000 document as we move forward to Healthy People 2010.

We conducted seven focus groups with a total of 58 individuals that represent a very broad array of the organizations, of the members of the Consortium. For example, one of the groups included the American College of Occupational and Environmental Medicine, the American Dental Hygienists Association, the National Osteoporosis Foundation, the National Civic League, the Red Cross, the Rhode Island Department of Health, the International Lactation Consultant Association, the Utah Department of Health, and NACCHO, the National Association of County and City Health Officials.

The final moderators guide focused on some of the key questions here. Does the Healthy People document need a major overhaul or does it just need minor tweaking? What works and what doesn't work about how the document functions, and what are the implications of the kind of changing health care environment for changes that may be needed in Healthy People? Should the organization, principles, the priority areas be changed and how, and should the criteria for setting objectives be changed and how?

In addition to sort of rounding up the usual suspects, of people that are involved with the Consortium, we also reached out somewhat beyond that group in order to be able to address the changes in the health care environment. We held one group in particular that focused on the perspectives of purchasers, especially in the private sector and the managed care, industry because we were trying to think through again the potential for making Healthy People 2000 a document that could help to, in a sense, shape what's going on in the marketplace, since we've sort of chosen a pathway to health care reform that is a whole lot more market-driven than it is driven by legislation and sort of centralized policy. That was the last group we held, and in that group we asked questions about what are the opportunities presented by changes in health care for the development and use of Healthy People, what are the challenges? We wanted to ask what specific changes were needed in building 2010 so that it could have a more positive impact on each one of the participants' organizations and on health care.

Let's leap right into findings. The bottom line is that people find Healthy People an incredibly valuable resource and reference document and most people do not want it changed too much, because they value the potential for continuity and trend development, and because of the kind of legitimacy that it has given to public health in general and to a very wide range of public health activities.

Many State health departments told us that they deal with the size of the document, which has been growing enormously, by selecting a smaller number of objectives as their State level. And many people thought that the strength, in fact, of the document was its range, its diversity, its comprehensiveness. The associations that are in the Consortium really like the depth in a particular area, because they feel like this sort of legitimizes their particular situation and gives them marching orders and allows them to see things.

But there was a distinction, a couple of distinctions, that I would like to point out. First, there was a distinction between the value of what's the content of Healthy People 2000 and the presentation of Healthy People 2000, where folks felt that there were a lot of opportunities for real creativity and improvement in terms of how this very complex document is put together.

The other distinction that I would like to make is between the folks that we talked to that are in the Consortium currently and the kinds of viewpoints that we got when we turned to people from industry, people from managed care. That latter group really did want the document to, as we put it, go on a diet. I think that's Dr. Fox's phrase actually, because they felt--I think this sort of comes from their business orientation. Their ideas of priorities are not 22 things. Their idea of priority is three things or four things or five things. So, what their perspective was--we need to get a number of very high priority items so that we can focus resources, because I think another critical link that people want to make is between the Healthy People objectives and how dollars are really allocated across programmatic areas. As everybody in this room knows, of course, one of the toughest things for anybody to do is the kind of priority setting that affects resource allocation.

Okay. It's interesting that we did not get an awful lot of input on the criteria for objectives, in part because people were saying that they thought there needed to be a lot of objectives. There were a couple of areas that we probed on, however. One area has to do with whether or not we want only objectives for which there is today an extant data collection system that permits tracking on performance. There was really, I think, a split vote on that. Most people felt that that would be ideal, but they recognized the limitations and saw that there was a certain symbolic value in including certain objectives, even if there might not be, today, the data to deal with them.

The other kind of statement, again from the managed care groups and from others, was that people wanted objectives that were actionable. In other words, if there's nothing much we know how to do and we have a good science base, let's put those aside and include in Healthy People 2000 primarily those things that we know that we can do something about today.

Now, let's talk about the presentation issues, because that's where we got a lot of creative ideas. The Consortium members believe that Healthy People 2010 could be packaged into a number of very different kinds of formats, including workbooks, patient pamphlets, community resource books. It was felt that it could be viewed as a database which could be sorted through a variety of different kinds of means, that it could be put up on the Internet, and also that there should be linkages made, for example, to connect the risk behaviors that are related to multiple diseases. So that was one thing, multiplicity of forms and forms of presentation and media for distribution. Obviously, this is telling you that the World Wide Web is something on which you're going to get an audience here.

But the other statement that was made is, right now, Healthy People 2000 is written in language which primarily speaks to people in health departments and public health professionals. If these are really going to be national objectives, and we are beginning to recognize more and more how many different segments of society contribute to the health of individuals and populations, if we're going to take that viewpoint, we need to start reaching out and involving people by using language and by using formats that isn't just the kind of language and the kind of--I will use the word jargon--that public health professionals really understand and know about and use sort of as a matter of course.

Another kind of audience issue that was raised here was that what we're seeing all over the United States is a real growth of community-driven, community-based health improvement initiatives. I was at a meeting about 10 days ago at the New York Academy of Medicine, where the Medicine and Public Health Initiative there, for example, has catalogued nearly 500 such community-level initiatives. This is a happening thing, and a lot of people in these Consortium focus groups felt that we needed to make Healthy People 2010 something that could really facilitate and support those kinds of community-level efforts.

The employer-based folks made another interesting point. What they said is that the document needs to make the business case for health promotion, so that employers will understand the advantage of paying attention to preventive services. So that's another kind of issue of how we make what Healthy People 2010 is about relevant to a variety of different stakeholder groups.

We in Healthy People 2000 have three goals, which are not put in measurable terms, and lots and lots of priority areas and objectives. People felt that the goals have sort of disappeared into the woodwork and need to be brought out, and there needs to be a connection made between the priority areas and objectives and the goals, and that perhaps the number of goals need to be increased and given more focus. In particular, one goal that was felt to be important was a goal that speaks to the public health infrastructure and its essential contribution to the achievement of all of these other objectives.

The other thing, however, was that people wanted to be able to link objectives to action. There's a real hunger out there for people not just to say, this should be our objective, but for people to have a source to turn to for evidence-based information about how to reach the objective. So, in terms of making this especially community-friendly and even State and local health department-friendly, in a sense, people wanted us to move beyond just putting in objectives and say, okay, how do we start tomorrow to work on these kinds of things?

And in this context, the other issue that was raised was the issue of the linkage of objectives such as are in Healthy People 2000 to the burgeoning number of measurement systems that are under development right now for measuring the performance both of health care delivery systems and of government agencies, as everybody around the room who has been involved in the kind of GPRA activities would focus on. People would like to see Healthy People 2000 objectives being folded into things like HEDIS 3.0, because they feel like that's going to have some clout. It's interesting that some folks at CDC actually have done sort of a crosswalk between the things that are in HEDIS 3.0 and the things that are in Healthy People 2000.

But the other thing that this raises is that accountability is always a very tricky business in any field, and it certainly is in health care. One of the things that people raised as an issue was that most of the things that we're trying to achieve in terms of community health improvement and individual health improvement require action by multiple groups and by multiple sectors, not just by one. So the conundrum that people feel they're facing is, how do you begin to fairly assign responsibility and assign accountability in situations where there really needs to be a broader concept of shared accountability? The challenge is going to be, how do you say this is the contribution that you can make to this objective, so let's see whether or not you can make it?

Another issue that was raised was the issue of making sure that we don't have a multiplicity of objective systems out there. People were really looking for the Federal government to sort of simplify things and make sure that we don't have a different set of objectives over here for Healthy People 2010 and then multiple other kinds of objectives sets for other kinds of issues and activities.

I think that what I'm going to do right now--there's one other area that we need to talk about and that is partners in Healthy People. We had some very interesting discussions, and I think there's another section of your briefing book that speaks to the issue of business participation in Healthy People. There was a lot of discussion of both the sort of slippery slope and the lines that may need to be drawn in terms of business involvement. On the other hand, I think there were a lot of people out there who were saying that business is a major stakeholder. They bring major resources and we have to find creative and appropriate ways to partner effectively with the business community, with the private sector in general, if these are really to be national health objectives, rather than just sort of public sector Federal government kinds of objectives.

I think it probably is appropriate for me to stop now so that you all get a chance to say your say and ask some questions.

DR. BOUFFORD: Okay. Let me, just by way of context for opening up the floor for discussion--why don't we hold discussion of the data question. Shoshanna has kind of given us an overview of the variety of issues we're going to deal with this afternoon. Let's hold the data issue until we get into Ed's presentation because I think there's a lot of issues underneath that. Similarly, the partners question on the business, until we get to that at the end of the afternoon. We will try to focus on--I'm just sort of taking notes--she has talked about the question of priority setting, even within the tension of the resource document versus actually what are the priorities, and they're sort of focused on action, collective action. The issue of should we have things in there that we can't do anything about, even though they're there and we ought to talk about that in the short-term, medium-term? Then this issue of linkage to other--the formats and languages question for different audiences and linkage to other measurement systems, which we may also want to get into a little bit later. I'm trying to keep us out of these sort of huge bramble bushes. I think if we look at the priority setting question, the actionable issue and the formats and language, that's a lot to talk about at this point. Dr. DuVal, do you want to jump in here?

DR. DUVAL: I wanted to ask a question at the moment. With respect to those who feel there should be only three objectives, and let's all work on those, I don't happen to agree with that, but I respect the viewpoint that they represent. I think that it poses, however, a larger question and that is, are we being clear or have we been sufficiently clear as we enunciate and distribute the objectives that they are distributed in such a way and to the end that you can chew off only those parts that are of interest or concern to you and ignore the rest?

One always has the feeling, and I've seen this in our own State health department, that they feel somehow that this constitutes almost a roll call and, one way or another, they have to address every one of the issues. I think that's a great mistake if that view is afoot. I raise the question only because you brought it up in the context of the extreme between, let's have lots of objectives for people to choose from, as opposed to those groups who say, just give us three and we will do them.

MS. SOFAER: What the State health departments told us that they did was exactly what you said. They sort of said, we're going to use this as a guide in selecting out those kinds of issues that we think are our priorities, and those are going to be a more limited set. On the other hand, we also had State health departments say, but you don't have a priority area in here for forensic medicine and forensic medicine is included in our health department, so we think you should have that. I think there's a tension even there.

The associations in some ways have an easier time. They're very mission-driven. They look at the parts of the document that are relevant to their mission and they feel absolutely no sense of guilt about the fact that they're not paying any attention to the rest of the document. So they're going on ahead.

I think the issue has to do with the fact that when you use the word priority, people think you maybe mean it. They think that perhaps what you're saying is that these are the Federal government's priorities that will drive resource allocation. So I think you may be right, Dr. DuVal, that there needs to be some clarification of what the terms are that are used here so that people don't sort of expect something a little bit different than what they're getting.

DR. BOUFFORD: It gets back to the question Phil, I think, raised earlier--what's the conceptual framework around how these things are being used? Marty--I'm sorry, I just want to let Marty talk and then David.

DR. WASSERMAN: I was just going to comment, in Maryland what we did was, we looked at it from the State perspective. We measured against as many of those objectives as we could and sort of published Healthy Maryland 2000 and used the McGinnis/Foege model and then used Maryland data when we did talk about behaviors that could be changed.

What we also did, though, was to ask our State agencies, as well as our local health departments, to concentrate on specific areas where they could build partnerships. You have to build partnerships in your local communities and you have to pick one or two of these objectives. You could do whatever your community wanted you to do.

So I guess the way I would look at this--you like to have a full range, a whole set of opportunities out there. I think they should be realistic. I don't think you should have expectations that you can't meet, but I also think you have to allow choices, so that each local community or local group can begin to act and be successful. I think it's very important at the State and local level in particular to reward those partnerships and the effort that goes into building partnerships to successfully meet some of those objectives.

DR. SATCHER: I was struggling with that. As I understood it, you were talking about how many priority areas should there be, right? There are now 22 and some people would argue that there should be no more than five, and I understand that, because some people would argue that everybody should be able to remember things as priorities. If you woke him up at 2:00 in the morning and said, Clay, what are our priorities, he would be able to name all of them.

[Laughter.]

I think there's something to be said, but I think it's really important that there be some things that are not negotiable. I think, if we say that we expect children to be immunized by the age of two with these 10 antigens, I think we ought to expect that for the whole country. I think it would be a mistake to say you can choose whether or not you're going to immunize children. I think there's some "priorities" that should be priorities for the whole country and others that people maybe should be allowed to select, to choose among. That's the only thing I would argue. I think it would be a mistake to say that everybody--I know you understand that, Marty.

DR. WASSERMAN: If you didn't have an immunization program and you didn't have federal leadership and payment for that, you wouldn't have that. The other thing is, if you funded--if you took away immunization money and funded injury prevention, then you could set injury prevention in all the States. I think the resources will drive that. That's where the Federal government can show that initiative and leadership, by selecting out a few of those areas, encouraged with additional resources.

DR. SATCHER: The example--and I think Jo was involved in this--that was discussed at one point when we were talking about performance measures was, if one State decided that it was not going to set goals for the control of TB, and so people with TB would move easily across the border, even from one nation to the other, how could you protect the nation if it were not a national priority?

DR. BOUFFORD: Ed and then Phil.

DR. SONDIK: I was just going to say--actually the results surprised me, because I thought it was fairly obvious that this was a broad set, and that one would tailor this to your local situation. It's interesting that people didn't necessarily react to it in that way.

MS. SOFAER: I think we should clarify that most people did react in that way, Ed. I think when we moved out of the folks that are within the traditional sphere of public health and their sort of associated groups, and you moved into groups of people who think with a more business orientation--whether it's because they work for a large corporation that's not in the health field, or because they work for a large corporation that is in the health field--when they use the word priority, they're usually using it to be restricted to a very limited number of issues that they strategically have chosen. They're going to be the things that they work on the most in the coming period of time. But most people that are involved today in Healthy People 2000 took the position that you just articulated.

DR. LEE: I want to support David's position and just use as an example the desegregation of the hospitals in the South with Medicare. If that had been left up to the States or left up to the hospitals or left up to the doctors, it never would have happened. It was decided that that was the right thing to do. There was no budget for it. People were allocated, hundreds of people in the Public Health Service and Social Security. They did it, and the President was 100 percent behind it from the get-go. They did it not because the focus groups said so or not because the polls said so, but because it was the right thing to do.

So I think there are some of these things, like David points out as a priority, and Julie talks about priority for kids. There are certain things that we ought to do. I think we can use focus groups and use polls and all that stuff, but only up to a point. So I would say that there are some national priorities, and we ought to be very clear about what those are.

DR. FOX: Two comments. One, you say that we have had a unique opportunity here that did not exist with the previous iteration of Healthy People--that was the Consortium. The Consortium as a group and, with the agencies, function with the priority areas--to come back and to work with different groups who have dealt with this over the last 10 or so years, who have feelings that are negative or positive or whatever, that hopefully will be constructive in helping rethink this. So again, not that the focus groups will be an end all, but certainly it's an opportunity to get reactions to kind of, how has it been for you over the last decade, that we didn't have before.

The second thing is that we currently have sentinel objectives in Healthy People. We just don't pay any attention to them as sentinel objectives. So the point being, if we choose--these are objectives that are intended to receive additional attention and emphasis within the document beyond the 300 and some odd that exist there. But from a practical standpoint, I can only speak for the last year and a half that I've been dealing with this, and I don't know about before--maybe David wants to comment--but these have not been treated as objectives that would receive any additional emphasis. So if we're going to do that this next go round, we've somehow got to put some oomph behind it to get them the attention and the resources or whatever to make them indeed sentinel or core objectives or whatever, because we have them as defined now. It's just that nothing has been done with them.

DR. BOUFFORD: Just to comment too--it's a very different political strategy in an interesting way because, in the UK, they basically--when the first health document came out, Health Goals for the United Kingdom--they identified five goals that came out of Michael Peckham's process, where he had advisory groups looking at the evidence base for picking the goal in terms of the amount of morbidity or mortality--I don't remember the specifics and whether one could do anything or not. Then it really did become a focus for mobilization of the central government around those issues.

Now, those issues change, but the point is we haven't--at least I don't think--I mean we have had clearly national initiatives on immunization and other things, but not necessarily in a planning process saying, these are the major problems we have and let's really mobilize around three or four things for X period of time, even though the rest of it would continue to be collected, actioned at different levels. But it's this question that also came up in the performance partnership grant discussions. Could the Secretary say, these are national health problems and require national health action? If your State doesn't have this problem, just tell us why you don't have it and what your level is and use the money for something else. We haven't taken either of those strategies, I think, as a Federal government.

DR. LEE: New York's approach settled on five things. There was a lot of discussion, but then a decision was made. The commissioner said these are the priorities, five priorities.

DR. BOUFFORD: It's not either-or, but the issue is using the baseline document in a different way.

DR. WASSERMAN: I was just going to comment, it doesn't take much, I think, within a community or within a State to focus, because almost every one of those goals and objectives has merit to it. If there is a stimulus that comes from the outside resources, then it would be easy to get on board. I think we've watched the breast and cervical cancer program grow over the last decade or so from when it started to get funding. So I think that it doesn't take a whole lot of activity, but it does take something to get it started, and then people will support it.

So I don't think that you're saying anything different. If there are national goals and sentinel objectives, then the Federal government can very easily get States and locals to do it, but I think it's with dollars and with other emphases. Then the other sort of background, where you can get your groups and your consortia together within your State to respond.

MS. SOFAER: I think I wanted to make the comment that, from the perspective of the Consortium members, as I said these are very mission-driven folks. What you do when you say something is a priority is that you legitimize it. You legitimize therefore the work of that organization. So in that context, Marty, it isn't even really resources, resources as in money. It's resources as in attention; it's resources as in visibility and legitimacy for their particular area of expertise. I think that is what people value and what they are concerned about.

Now that we've gotten all these people involved in the process, because we have legitimized something that's in their mission, now they want to keep that going, because it's really bought them something. An example from the very last group was the National Council on Patient Information and Education, who is responding specifically to an objective that says that the FDA area should inform consumers, which is my area of interest, about each of the drugs that they're taking. So they've gone whole hog on that particular objective and would be, they feel, diminished in their capacity were that objective not a part of something like Healthy People 2000. So that's, I think, the dynamic tension that we're facing here.

DR. STOIBER: I think, nonetheless, it's enormously confusing and it's one thing to validate the importance of all these different areas by having it be part of the plan. Let's not kid ourselves, validating it is also a resource tool for all of these organizations that are lobbying for more appropriations or whatever for their area. But if you're out in the community, the business community or the local community, and you're trying to decide out of all this menu what would really make a difference, I think we really abdicate our responsibility of being able to say out of all of this, all of which is worthwhile, these really are the five or 10 things that, if we did them, would make a meaningful difference in the public health, which is not to devalue the rest of it, but is to take on the analytic responsibility which really only we can do of saying, put your energy behind these if you're going to have a major impact.

I think that would take a lot more than simply identifying five objectives as sentinel objectives out of 50 or 25 or whatever number we had there. So I guess I would go the other direction, if we really want to make a major effort to take Healthy People beyond the public health community and into the nation.

DR. BOUFFORD: Bob.

MR. WILLIAMS: By narrowing goals, one of the risks you run, is losing our focus on eliminating disparities in health across very diverse communities. I think we can have a balance by identifying and highlighting a small number of clearly critical national goals and then constituency-specific goals.

DR. BOUFFORD: Yes, I think you put your finger on a big issue, which we will get to later, because also we know we have data problems in some of these areas. If we narrow down the focus, we could very well lose that attention. So I think this balance is really a critical policy question for us, no question about it.

DR. LEE: Jo, I think Bob states the goal number two in part, which is narrow the gap. It seems to me we really have to address that and say shouldn't the goal be to close the gap? I know we have data, and I know it's difficult, but when we say, well, for American Indians or Alaska Natives, we're only going to get halfway there, or for African Americans, or for Hispanics. I think that's a fundamental issue that has been raised.

DR. BOUFFORD: I think we want to spend--I think a good bit of the data question comes back to that exact issue, and we need to spend--we will not lose that because we really need to be focused on it. Earl and then Susan.

DR. FOX: We've asked each one of the lead agencies to come back and tell us which priority, which objectives need to be deleted, where we have duplication and what new ones need to be added, based on where the science is going. Frankly, what we've gotten thus far is about a wash. We were hoping we could reduce the objectives some, but it hasn't worked out that way.

The other thing that we've talked about is the idea of having a virtual document that is on the Internet, that could be indexed in a way so people could pull it up in whatever way they might want. Or, if you're a health department, or you're a managed care organization, or you're involved in work site health promotion, then maybe what we could do is construct some individual documents that will be targeted specifically to your audience. In fact, we talked to the American Association of Health Plans and said, would you be willing to work with us after we've pulled together the draft 2010 document, and let's pull out a subset of objectives that managed care organizations would be interested in, and let's put it together in a way that your members would find useful that will be targeted to your audience so that we might have--one scenario would be to have a master document that would have all the objectives. We would have a series of companion documents that would be targeted at specific audiences, in which the companion documents might only contain a subset of the objectives that would be of particular interest to that audience. Then have a virtual document on top of that that people could pull up on the Internet and index it and apply it any way they might want. So there are a variety of ways we could structure it that is a little different than the way Healthy People 2000 was done.

DR. BLUMENTHAL: In talking about priorities, women's health and the health of minorities clearly must be there. These are issues that have been long neglected at the research bench, at the clinical bedside, and clearly in the halls of public policy. Several years ago, we went through the Healthy People 2000 objectives and tried to pull out the ones that were specific to women's health, and really felt that we needed to go beyond the focus on maternal morbidity and mortality, as well as on reproductive health issues, and that there was really room to include specific gender-based objectives.

Perhaps when we get to the data part, we could talk about how we could rectify this as we look to the year 2010 because, not only for gender-based differences but also for racial/ethnic differences, I think this is really critical in terms of gathering information and in crafting objectives that will really focus on bridging the gap and the health disparities that exist for some of our special populations.

DR. SIMPSON: I just want to follow up on Earl's statement a few minutes ago as he sent out a request to reduce the number of objectives. Were there any criteria given?

DR. FOX: Actually, I think we did that through one of the meetings with work groups, I forgot which one. We actually went through and tried to establish some parameters for the leading objectives. I don't remember what we sent out, but I think there were some criteria. We worked within--they submitted it back to our office, so we had a common string on what was done. Do you want to comment on the criteria, Debbie?

MS. MAIESE: Certainly one of them we looked at was whether or not to eliminate duplicate objectives. Some of you know that nutrition objectives or physical activity objectives are shared among priority areas, because obviously those are strategies for reducing multiple chronic diseases. But when I went to the NIH Prevention Coordinating Committee two weeks ago, some people questioned even whether that's a good strategy, because, in fact, what that means in some of the chronic disease priority areas are the mortality objectives, maybe the morbidity objectives, but certainly not the strategy objectives. So I think we're still debating about sharing objectives among priority areas. Of course, that's one of those things that is a decision sort of down the road, as today we sort of debate more about the goals and the priority areas.

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