Population Health Targets: Unpopular But Needed

Originally posted 10/12/2010

Thinking about the upcoming release of the federal Healthy People 2020 (HP2020) report has brought me back to a 2008 JAMA commentary I wrote with Yukiko Asada and Bridget Booske titled “A Population Health Framework for Setting National and State Health Goals.” Our recommendation was for a population health model framework to guide federal and state planning processes. Specifically, we called for the setting of five to ten year targets for broad outcomes. We suggested that the targets could be established based on trend comparisons across other nations or states and be set at different levels, e.g., ranging from “minimal” to “achievable” to “challenging.”

It is not clear at the moment if HP2020 or similar plans in individual states will include targets for broad health outcomes, such as years of healthy life or overall disparity reductions. In the past, targets have been set for specific narrower objectives such as cancer deaths and smoking rates. I think it’s time to also focus on the broader comprehensive measures of health that these narrower objectives produce.

There are both political and practical reasons why governments resist such explicit projections. As Smith and Busse say in a recent MATCH essay on the European target setting experience, one purpose of target setting is to “enhance the accountability of government to parliament and the electorate,” but such future accountability may not be politically advantageous. Even in a politically progressive state like Wisconsin, neither Republican or Democratic elected officials or appointed public health leaders have set such targets; this is one reason our University of Wisconsin Population Health Institute initially developed the Wisconsin County Health Rankings in 2003 and issued the first Health of Wisconsin  Report Card in 2007 in which we graded the state a “B-“ for overall health and “D” for health disparities. While these reports have been widely used, the recent Healthiest Wisconsin 2020 State Health Plan does not include broad 5-10 year targets.

My management experience has taught me that you can’t manage what you can’t measure. Since improving broad population health outcomes requires the actions of multiple sectors, Smith and Busse identify a need for targets that transcend traditional sector boundaries and emphasize “coordination, persuasion, and engagement if they are to be successful.” Of course, long term targets cannot be set precisely, but a set of minimal to challenging goals could be devised. They could be used by those community entities — such as  United Way, a local or regional health department, or a Triple Aim project — which aspire to provide the integration that population health improvement requires. Targets should help shape community health improvement processes by helping identify local health priorities as well as corresponding sets of cost-effective policies and programs.

We can and should set reasonable, broad targets for mortality and morbidity improvement and disparity reduction at the federal,  state, and community levels. These will guide investment, inform public accountability—and hopefully improve population health.

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