The Art of Translating Research Into PolicyJoseph W. Thompson, MD, MPH
Surgeon General, State of Arkansas
Director, Arkansas Center for Health Improvement
Associate Professor, UAMS Colleges of Medicine and Public Health 2008
National Network of Public Health
Institutes
Arkansas Center for Health ImprovementMission:
Improving health through evidence-based health policy research, program development, and public issue advocacy
Core Values:
Initiative, Trust, Commitment, and Innovation
Health Care
Finance
Access to Needed
Quality Care
Health Policy & System Integration
Health Promotion &
Disease Prevention
ACHI Scope of Work
ACHI’s Scope of Work
A Model for Health Policy Development
Opportunity
Principals for Decisions
Empirical Assessment
Education
Program Development
Political Discourse
ImplementationJ. Thompson et al, Society for Public Health Education July 2004;5(3)57-63.
Identified areas of need:• Health care
financing• Health promotion/
disease prevention• Access to quality
care
Proposed tools to create solutions:• Executive• Legislative• Judicial• Private
Empirical evidence:• Scientific studies• Program evaluations• Secondary data
analyses• Primary data analyses
Trusted sources for consensus guidelines(including but not limited to):• U.S. Community Preventive Services
Task Force• Arkansas Health Insurance Roundtable• Institute of Medicine• National Quality Forum
ACHI Health Policy Board decision making process considerations:• Impact assessment (Arkansas health impact and
ACHI’s ability to effect change)• Support, oppose, or remain silent• Level of engagement (see table below)• Specific to a topic (e.g., fluoridation) or an action
(e.g., support a specific House bill)
Identified issue
Proposed solution
Empirical evidence
Consensus process
ACHI HPB decision
ACHI Health Policy Board: Decision Support Document
Level of engagement
Support proposal Neutral Oppose proposal
Policy position — Policy position
Position statement — Position statement
Letter of support — Letter of opposition
Board testimony — Board testimony
Public support — Public opposition
On-going ACHI staff activities:Proactive• Identify needs• Develop proposals• Engage collaborative partners• Develop methods to improve policy developmentResponsive• Respond to external requests for
information/analyses• Respond to external requests for proposal
developmentMonitoring• Scan for opportunities and vulnerabilities• Tracking health indicatorsDefensive• Raise awareness of potential threats
Agendas, Alternatives and Public Policies J. Kingdon - Framework for Policy EnvironmentPreparedness• Awareness
– Policymakers– Ownership– Environment
• Support– Their problems– Their needs
• Engagement– Trustworthy– Credible– Interpreter– Source
Policy process• Agenda
• Options / alternatives
• Information– Credible– Useful– Appropriate– Balanced
• Policy Window– Immediate– Future– Created
Be Strategic
Arkansas Center for Health Improvement(1999 Public challenge to elected leadership)
Four Principles for Tobacco Settlement Decisions– All funds should be used to improve and optimize the
health of Arkansans.
– Funds should be spent on long-term investments that improve the health of Arkansans.
– Future tobacco-related illness and health care costs in Arkansas should be minimized through this opportunity.
– Funds should be invested in solutions that work effectively and efficiently in Arkansas.
Tobacco Settlement Initiated Act - 2000• Staged political
process
• ~ $60m / year
• $$ in perpetuity
• All new health programs
• External evaluation in place
• No changes in 4 sessions
Thompson et al, Health Affairs 2004;23(1)
Empiric Information in Graphical Format
Patchwork quilt of Arkansas health insurance coverage
Income
Age
Medicaid w/ Disability
Private Insurance
100% FPL
200% FPL
0 10 20 30 40 50 60 70
300% FPL
ARKidsFirst B Medicaid for
Pregnant Women/Family
Planning
Currently Uninsured:~400,000
Med
icar
e
ARKids First A
(Medicaid)
Income
Age
Medicaid w/ Disability
Private Insurance
100% FPL
200% FPL
0 10 20 30 40 50 60 70
300% FPL
ARKidsFirst B Medicaid for
Pregnant Women/Family
Planning
Currently Uninsured:~400,000
Med
icar
e
ARKids First A
(Medicaid)
~520,000
ARHealthNet – Program Details• Partnership between small businesses, state, and federal government
• Premiums subsidized for employees / spouses with incomes <200% FPL
• Targeted to Arkansas employers not currently offering health insurance
• 1115 Waiver program with potential to expand coverage to as many as 80K uninsured Arkansans
• Commitment to incorporate health promotion and disease prevention
Constructively Educate
1998
Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1998, 2006
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2006
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Cardiac Pathway
Cardiac death
Cardiac disability
Heart Attack
Coronary artery blockage
High cholesterol / Limited blood flow
Tobacco / Obesity / Physical inactivity
Show them the $$
Obese32%
Daily Cigarette Users12%
Physically Inactive
21%
No Risks11% O+P
9%
C+P1.5%
C+O2%
C+O+P1%
HRA Respondents Eligible to Incur Claims (N=43,461)
O = ObeseP = Physically
InactiveC = Daily
Cigarette Use
C7%
O20%
P 10%
AR State Employees Self-Reported Risks
Other Risks39%
Average Annual Total Costs (Med + Rx)Average cost for all HRA respondents eligible to incur claims
$3,097
Average cost for
those with no risks$2,382
Average cost for those with
any of the three risk
factors
$3,427
Obese
Daily Cigarette Users
Physically Inactive
Obese$3,679
Daily Cigarette Users$3,081
Physically Inactive$3,643
No Risks$2,382 O+P
$4,158
C+P
$3,257
C+O
$3,529
C+O+P
$4,432
C
$2,690
O
$3,441
P
$3,169
Average Annual Total Cost for State Employees by Risk Factor
O =ObeseP =Physically
InactiveC =Daily
Cigarette Use
Annual Average Total* Costs Linked to Obesity
$1,597
$2,441
$785
$1,238
$0
$1,500
$3,000
$4,500
No Risk Obese
Pharmacy
Medical
*Includes medical (inpatient and outpatient) and pharmacy costs for 18-84 year old state employees.
Total difference
$1,297 (54%)
Data Driving Policy• ~26% of annual total costs associated with one or
more of three risk factors—obesity, physical inactivity, or daily cigarette smoking.
• Paradigm shift of Board recognizing current costs associated with failed past prevention
• Incorporation of new benefits:– Evidence-based preventive clinical services– Tobacco counseling and pharmaceutical coverage– Three-tiered obesity benefit
• Tiered health insurance premiums for risk• Legislative authorization provides up to 3 extra
vacation days after health improvements
-Jaster et al, Am Journal of Preventive Medicine (under review)
Make It Personal
Quality of diabetes care (HbA1c) among Employer Healthcare Coalition providers*
90
%
84
%
77
%
76
%
74
%
64
%
60
%
59
%
57
%
57
%
10
0%
10
0%
10
0%
92
%
85
%
83
%
81
%
58
%
50
%
77
%
0%
20%
40%
60%
80%
100%
P9 P6 P3 P2 P1 P7 P8 P4 P5 P10 P3 P4 P8 P9 P6 P10 P2 P7 P1 P5
Fort Smith Hot Springs
*PCPs w/ largest # of eligible diabetic participants aged 18–75 yr
Data source: ACHI analysis of EHC data (unpublished results). ACHI, 2005.
Use Innovative Strategies & Find
Non-Traditional Partners
84th General Assembly Act 1220 of 2003
Goals:• Change the environment within which children go to
school and learn health habits every day• Engage the community to support parents and build a
system that encourages health• Enhance awareness of child and adolescent obesity
to mobilize resources and establish support structures
An act to create a Child Health Advisory Committee; to coordinate statewide efforts to combat childhood obesity and related illnesses and to improve the health of the next generation of Arkansans;
Act 1220 Requirements1. Establishment of an Arkansas Child Health
Advisory Committee2. Vending machine content and access changes3. Physical activity / education requirements4. Requirement of professional education for all
cafeteria workers5. Public disclosure of “pouring contracts”6. Establishment of local parent advisory
committees for all schools7. Confidential child health report delivered
annually to parents with body mass index (BMI) assessment
- Ryan et al, Health Affairs July/August 2006;25(4):
Demonstrate That Change Can Happen – Share Success
Percentage of students classified as overweight or at risk for overweight by Arkansas public school district (’05–’06)
Source: ACHI. The Arkansas Assessment of Childhood and Adolescent Obesity—Tracking Progress (Year 3 Fall 2005–Spring 2006). Little Rock, AR: ACHI; September 2006.
National and Arkansas Childhood Obesity Trends
03-04 N=2,15903-04 N=981
0
5
10
15
20
25
1963-651966-70
1971-741976-80
1988-9499-00
01-0203-04
US 6-11 yr
US 12-19 yr
0405
0607
Avg N=150,881Avg N=212,011AR grades K-6
AR grades 7-12
19.0
19.5
20.0
20.5
21.0
21.5
22.0
2004 2005 2006 2007
AR grades K-6AR grades 7-12
Thompson et al, Morbidity and Mortality Weekly Reports January 2006; 55(1)
Challenge to the Institutes
In Summary:
• Be Strategic
• Empirical Information in Graphical Form
• Constructively Educate
• Show Them The Money
• Make It Personal
• Use Innovative Strategies & Non-traditional Partners
• Demonstrate That Change Can Happen / Share Successes
Translation of knowledge into policy• Integration of research skills and empirical
information into relevant queries
• Environmental awareness of political processes, structures, and issues
• Personal “risk-tolerance” for non-traditional roles and undertakings
• Relationship development with decision-makers – supporter, informant, advisor
• Engage, Engage, Engage!!!!
Arkansas Surgeon General (Act 384)Governor may appoint a SG of Arkansas to:
• Serve as a cabinet level advisor to the Gov.
• Review, assess, and develop health policy options for the state across state agencies
• Review and analyze legislative proposals under consideration
• Provide policy options and position statements for the Governor and senior state agency officials
• Raise awareness of healthcare and health issues to advance the state population’s health