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