Vital Directions

for Health & Health Care

An Initiative of the National Academy of Medicine

Victor J. Dzau, Mark B. McClellan, J. Michael McGinnis,
and Elizabeth M. Finkelman, Editors

WASHINGTON, DC
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NOTICE: This publication has undergone peer review according to procedures established by the National Academy of Medicine (NAM). Publication by the NAM signifies that it is the product of a carefully considered process and is a useful contribution worthy of public attention, but does not represent formal endorsement of conclusions and recommendations by the NAM. The views presented in this publication are those of individual authors and do not represent formal consensus positions of the NAM; the National Academies of Sciences, Engineering, and Medicine; or the authors’ organizations.

Support for the NAM’s Vital Directions for Health & Health Care Initiative was provided by the California Health Care Foundation, The Commonwealth Fund, the Gordon and Betty Moore Foundation, The John A. Hartford Foundation, the Josiah Macy Jr. Foundation, the Robert Wood Johnson Foundation, and the NAM’s Harvey V. Fineberg Impact Fund.

Library of Congress Cataloging-in-Publication Data

Names: Dzau, Victor J., editor. | McClellan, Mark B., editor. | McGinnis, J. Michael, editor. | Finkelman, Elizabeth, editor. | National Academy of Medicine (U.S.), issuing body.

Title: Vital directions for health and health care : an initiative of the National Academy of Medicine / Victor J. Dzau, Mark McClellan, J. Michael McGinnis, Elizabeth Finkelman, editors.

Description: Washington, DC : National Academy of Medicine, [2017] | Includes bibliographical references.

Identifiers: LCCN 2017034965 (print) | LCCN 2017036005 (ebook) | ISBN 9781947103016 (ebook) | ISBN 9781947103009 (pbk.)

Subjects: | MESH: Health Policy | United States

Classification: LCC RA418 (ebook) | LCC RA418 (print) | NLM WA 540 AA1 | DDC 362.1--dc23

LC record available at https://lccn.loc.gov/2017034965

Copyright 2017 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

Suggested citation: Dzau, V. J., M. McClellan, J. M. McGinnis, and E. M. Finkelman, editors. 2017. Vital directions for health & health care: An initiative of the National Academy of Medicine. Washington, DC: National Academy of Medicine.

“Knowing is not enough; we must apply.
Willing is not enough; we must do.”

—GOETHE

ABOUT THE NATIONAL ACADEMY OF MEDICINE

The National Academy of Medicine is one of three Academies constituting the National Academies of Sciences, Engineering, and Medicine (the National Academies). The National Academies provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president.

The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on issues of health, medical care, and biomedical science and technology. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

Learn more about the National Academy of Medicine at NAM.edu.

VITAL DIRECTIONS FOR HEALTH & HEALTH CARE

Steering Committee

NAM Staff

Development of this publication was facilitated by contributions of the following NAM staff, under the guidance of J. Michael McGinnis, MD, MPP, NAM Leonard D. Schaeffer Executive Officer and Executive Director of the Leadership Consortium for a Value and Science-Driven Health System.

REVIEWERS

The papers in this volume were reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with review procedures established by the National Academy of Medicine. We wish to thank the following individuals for their review of the papers in this volume:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the papers, nor did they see the final drafts before publication. Review of these papers was overseen by Elizabeth M. Finkelman, MPP, Associate Program Officer, NAM; and J. Michael McGinnis, MD, MPP, Leonard D. Schaeffer Executive Officer, NAM. Responsibility for the final content of these papers rests entirely with the authors and the NAM.

PREFACE

In summer 2015—nearly 18 months before America elected its new president and health reform resumed center stage in the policy arena—the National Academy of Medicine (NAM, formerly the Institute of Medicine) launched Vital Directions for Health and Health Care, a major policy initiative that brought together leading experts from across the nation to identify the most promising opportunities to improve health and health care in the United States. The initiative was born out of anticipation of a new administration and recognition that health and health care in the United States, while having achieved significant recent advancements—including reduced overall mortality, accelerated technological innovation, and a record-low uninsured rate—still faces critical challenges. Perhaps most notably, health care costs are rising at an unsustainable rate. The United States spends more than $10,000 per person per year on health care, amounting to a total of $3.2 trillion, or 18 percent of national GDP. Unsurprisingly, studies continue to indicate that our health system is inefficient; in 2013, the Institute of Medicine estimated that upwards of $750 billion of health care spending could be attributed to excess costs. And, evidence is mounting that inefficient health care spending is crowding out investments in critical social services and other priority areas for improving population health. So, despite our great investment, we fail to see a corresponding improvement in health outcomes; in fact, we fall measurably behind our international peers across important measures of access, equity, and efficiency. This concerning trend has been acknowledged and written about for years, and there is a great need for a strategic framework to help policymakers tackle these issues.

As America’s most trusted health advisor, the NAM is committed to illuminating pressing issues that require attention and remediation, and to guiding and informing health leaders and policymakers about the best possible solutions. Past reports from the National Academies have helped shape the nation’s health agenda—from the response to the AIDS epidemic to the crisis of medical error, from recommended dietary intakes to a safe vaccine schedule for children. We launched Vital Directions in keeping with this valued tradition. Under the

leadership of an 18-member, nonpartisan steering committee, we commissioned over 150 of our nation’s best researchers and health policy experts to assess 19 prominent areas in health, health care, and biomedical science. In completing their assessments, authors were asked to go beyond simply describing the pressing challenges and issues, and instead to focus on identifying the most promising and tangible policy opportunities to achieve progress. In keeping with the charge, they proposed approximately 68 recommendations across the 19 expert papers contained in this volume.

The steering committee next undertook the task of synthesizing and prioritizing the experts’ recommendations. The committee found four key action priorities—pay for value, empower people, activate communities, and connect care—and four essential infrastructure needs—measure what matters most, modernize skills, accelerate real-world evidence, and advance science—that resonated across the papers as the most essential levers for advancing American health, health care, and scientific progress. Nonpartisan and rooted in an extensive evidence base, these eight vital directions constitute a comprehensive and succinct framework for improving health that spans well beyond the current discussions and debates around insurance coverage. And, while very important, reforming coverage alone cannot drive the change that is needed. For coverage to have value, the health system must work toward attaining its fullest potential. As such, these eight directions are essential to future health policy legislation and related program activities, and represent the fundamental principles around which any approach to health reform should be structured.

Finally, the importance of the Vital Directions initiative in the existing policy context cannot be overstated. Health reform is currently the subject of intense political polarization and scrutiny—discussions sometimes so sharp that they obscure focus on the issues that matter most in improving health and health care. In taking on this initiative and executing its work, the NAM strove to rise above the partisan rhetoric and debate to provide independent, impartial, and strong evidence-based policy guidance, and to refocus needed attention on shared goals and common principles. Beyond presenting a blueprint to drive needed progress toward better health care and lower costs, the initiative has sought to provide an avenue for bipartisan leadership and policymaking in health.

We are at a critical inflection point for health and health care in the United States. The challenges are great, but the opportunities to achieve progress are even greater. Altogether, the evidence suggests that refocusing is essential, and that our health policy framework must evolve to fully capitalize on the knowledge and capacity we now have to improve health and more efficiently deliver care.

We hope that our colleagues, community and health leaders, and policymakers at all levels will use and implement the Vital Directions framework as they seek to drive meaningful change and achieve better health for all.

—VICTOR J. DZAU AND MARK B. MCCLELLAN
Co-Chairs, Vital Directions for Health & Health Care
May 2017

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ACKNOWLEDGMENTS

The Vital Directions for Health and Health Care initiative would not have been possible without the insights, contributions, and time invested by so many. From its inception to the completion of this final publication, the initiative was a collaborative effort in the truest sense, and we wish to recognize its contributors and thank them for their hard work and dedication.

First, we would like to thank the sponsors of the initiative, whose support made the work possible: the California Health Care Foundation, The Commonwealth Fund, the Gordon and Betty Moore Foundation, the John A. Hartford Foundation, the Josiah Macy, Jr. Foundation, The Robert Wood Johnson Foundation, and the National Academy of Medicine’s Harvey V. Fineberg Impact Fund.

Members of the initiative’s steering committee did a superb job guiding and overseeing the initiative. Their perspectives, experience, and wisdom were integral to making every step a success, and we are so deeply appreciative of the knowledge and time they invested in driving this effort over its 18-month duration.

Of course, the steering committee and the NAM alike are most grateful for the participation and contributions of the authors of the 19 discussion papers—over 150 people who collaborated for 9 months writing and revising the individual perspectives. Their work is at the heart of this initiative, and the final products reflect the extensive time and knowledge they invested. Special recognition must be paid to the papers’ lead authors, who played key roles not only in the drafting of the work but also in coordinating and guiding their writing teams.

We would also like to thank those who participated and spoke at the September 2016 symposium, “Vital Directions for Health and Health Care: A National Conversation,” and the public release event in March 2017. In particular, the conversations and feedback gathered at the symposium helped inform the final versions of the 19 discussion papers, as well as the steering committee’s synthesis paper.

We must also express our sincere appreciation and gratitude to Howard Bauchner, Stacy Christiansen, Phil Fontanarosa, and the staff at the Journal of the American Medical Association (JAMA) for their sterling collaboration and wise counsel. Their cooperation and meticulous coordination ensured a seamlessly

smooth process. Altogether, JAMA published 20 Viewpoints, 3 editorials, and a Special Communication related to the Vital Directions initiative.

Finally, we would like to thank the staff in the National Academy of Medicine and those in other offices at the National Academies for their contributions over the course of the initiative. In the NAM: Adrienne Anzanello, Celynne Balatbat, Bruce Block, and Morgan Kanarek. In the Office of News and Public Information: Molly Galvin and Jennifer Walsh. In the Office of Development: Julie Ische. In the National Academies’ Research Center: Rebecca Morgan. And, a final, special thanks to the initiative’s core staff, whose tremendous work and efforts were crucial to its success: J. Michael McGinnis, who oversaw the work of the initiative; Elizabeth Finkelman, who closely managed the initiative and production of its core products; Laura DeStefano, who led communications and publishing; Kyra Cappelucci, who provided critical production, communications, and event support; and Molly Doyle, who assisted with special communications projects.

CONTENTS

1. Vital Directions for Health and Health Care: Priorities from a National Academy of Medicine Initiative

Victor J. Dzau, MD, Mark B. McClellan, MD, PhD, Sheila P. Burke, MPA, RN, Molly J. Coye, MD, The Honorable Thomas A. Daschle, Angela Diaz, MD, PhD, MPH, The Honorable William H. Frist, MD, Martha E. Gaines, JD, LLM, Margaret A. Hamburg, MD, Jane E. Henney, MD, Shiriki K. Kumanyika, PhD, The Honorable Michael O. Leavitt, J. Michael McGinnis, MD, MPP, Ruth M. Parker, MD, Lewis G. Sandy, MD, Leonard D. Schaeffer, Glenn D. Steele, Jr., MD, PhD, Pamela Thompson, MS, RN, and Elias A. Zerhouni, MD

PART I: BETTER HEALTH AND WELL-BEING

2. Systems Strategies for Better Health Throughout the Life Course

J. Michael McGinnis, MD, MPP, Donald M. Berwick, MD, The Honorable Thomas A. Daschle, Angela Diaz, MD, PhD, MPH, Harvey V. Fineberg, MD, PhD, The Honorable William H. Frist, MD, Atul Gawande, MD, MPH, Neal Halfon, MD, MPH, and Risa Lavizzo-Mourey, MD, MBA

3. Addressing Social Determinants of Health and Health Disparities

Nancy E. Adler, PhD, David M. Cutler, PhD, Jonathan E. Fielding, MD, MPH, Sandro Galea, MD, DrPH, Maria Glymour, ScD, Howard K. Koh, MD, MPH, and David Satcher, MD, PhD

4. Preparing for Better Health and Health Care for an Aging Population

John W. Rowe, MD, Lisa F. Berkman, PhD, Linda P. Fried, MD, MPH, Terry T. Fulmer, PhD, RN, FAAN, James S. Jackson, PhD, Mary D. Naylor, PhD, RN, FAAN, William D. Novelli, MA, S. Jay Olshansky, PhD, MPH, and Robyn Stone, DrPH

5. Chronic Disease Prevention: Tobacco, Physical Activity, and Nutrition for a Healthy Start

William H. Dietz, MD, PhD, Ross C. Brownson, PhD, Clifford E. Douglas, JD, John J. Dreyzehner, MD, MPH, FACO, Ron Z. Goetzel, PhD, Steven L. Gortmaker, PhD, James S. Marks, MD, MPH, Kathleen A. Merrigan, PhD, Russell R. Pate, PhD, Lisa M. Powell, PhD, and Mary Story, PhD, RD

6. Improving Access to Effective Care for People Who Have Mental Health and Substance Use Disorders

James R. Knickman, PhD, K. Ranga Rama Krishnan, MB, ChB, Harold A. Pincus, MD, Carlos Blanco, MD, PhD, Dan. G. Blazer, MD, PhD, MPH, Molly J. Coye, MD, MPH, John H. Krystal, MD, Scott L. Rauch, MD, Gregory E. Simon, MD, MPH, and Benedetto Vitiello, MD

7. Advancing the Health of Communities and Populations

Lynn R. Goldman, MD, MPH, Georges C. Benjamin, MD, Sandra R. Hernández, MD, David A. Kindig, MD, PhD, Shiriki K. Kumanyika, PhD, MPH, Carmen R. Nevarez, MD, MPH, Nirav R. Shah, MD, MPH, and Winston F. Wong, MD

PART II: HIGH-VALUE HEALTH CARE

8. Benefit Design to Promote Effective, Efficient, and Affordable Care

Michael E. Chernew, PhD, A. Mark Fendrick, MD, Sherry A. Glied, PhD, Karen Ignagni, MBA, Stephen T. Parente, PhD, Jamie C. Robinson, PhD, MPH, and Gail R. Wilensky, PhD

9. Payment Reform for BetterValue and Medical Innovation

Mark B. McClellan, MD, PhD, David T Feinberg, MD, MBA, Peter B. Bach, MD, Paul Chew, MD, Patrick H. Conway, MD, Nick Leschly, MBA, Gregory D. Marchand, Michael A. Mussallem, and Dorothy Teeter, MHA

10. Competencies and Tools to Shift Payments from Volume to Value

The Honorable Michael O. Leavitt, Mark B. McClellan, MD, PhD, Susan D. Devore, Elliott S. Fisher, MD, MPH, Richard J. Gilfillan, MD, H. Stephen Lieber, CAE, Richard Merkin, MD, Jeffrey A. Rideout, MD, and Kent J. Thiry, MBA

11. Tailoring Complex-Care Management, Coordination, and Integration for High-Need, High-Cost Patients

David Blumenthal, MD, Gerard F. Anderson, PhD, Sheila P. Burke, MPA, RN, Terry Fulmer, PhD, RN, Ashish K. Jha, MD, MPH, and Peter Long, PhD

12. Realizing the Full Potential of Precision Medicine in Health and Health Care

Victor J. Dzau, MD, Geoffrey S. Ginsburg, MD, PhD, Aneesh P. Chopra, MPP, Dana P. Goldman, PhD, Eric D. Green, MD, PhD, Debra G.B. Leonard, MD, PhD, Mark B. McClellan, MD, PhD, Andrew S. Plump, MD, PhD, Sharon F. Terry, MA, and Keith R. Yamamoto, PhD

13. Fostering Transparency in Outcomes, Quality, Safety, and Costs

Peter J. Pronovost, MD, PhD, FCCM, J. Matthew Austin, PhD, MS, Christine K. Cassel, MD, Suzanne F. Delbanco, PhD, Ashish K. Jha, MD, MPH, Bob Kocher, MD, Elizabeth A. McGlynn, PhD, Lewis G. Sandy, MD, FACP, and John Santa, MD, MPH

14. The Democratization of Health Care

Paul C. Tang, MD, MS, Mark D. Smith, MD, MBA, Julia Adler-Milstein, PhD, Tom Delbanco, MD, Stephen J. Downs, SM, Giridhar G. Mallya, MD, MS, Debra L. Ness, MS, Ruth M. Parker, MD, and Danny Z. Sands, MD, MPH

15. Workforce for 21st-Century Health and Health Care

Steven H. Lipstein, MHA, Arthur L. Kellermann, MD, MPH, Bobbie B. Berkowitz, PhD, RN, Robert Phillips, MD, MSPH, David P. Sklar, MD, Glenn D. Steele Jr., MD, PhD, and George E. Thibault, MD

PART III: STRONG SCIENCE AND TECHNOLOGY

16. Information Technology Interoperability and Use for Better Care and Evidence

Jonathan B. Perlin, MD, PhD, Dixie B. Baker, PhD, David J. Brailer, MD, PhD, Douglas B. Fridsma, MD, PhD, Mark E. Frisse, MD, John. D. Halamka, MD, PhD, Jeffrey Levi, PhD, Kenneth D. Mandl, MD, MPH, Janet M. Marchibroda, MBA, Richard Platt, MD, MS, and Paul C. Tang, MD, MS

17. Data Acquisition, Curation, and Use for a Continuously Learning Health System

Harlan M. Krumholz, MD, SM, Philip E. Bourne, PhD, Richard E. Kuntz, MD, MSc, Harold L. Paz, MD, MS, Sharon F. Terry, MA, and Joanne Waldstreicher, MD

18. Innovation in Development, Regulatory Review, and Use of Clinical Advances

Michael Rosenblatt, MD, Christopher P. Austin, MD, Marc M. Boutin, JD, William W. Chin, MD, Steven K. Galson, MD, MPH, Sachin H. Jain, MD, MBA, Michelle McMurry-Heath, MD, PhD, Samuel R. Nussbaum, MD, John Orloff, MD, Steven E. Weinberger, MD, and Janet Woodcock, MD

19. Targeted Research: Brain Disorders as an Example

Alan I. Leshner, PhD, Steven E. Hyman, MD, and Story C. Landis, PhD

20. Training the Workforce for 21st-Century Science

Elias A. Zerhouni, MD, Jeremy P. Berg, PhD, Freeman A. Hrabowski, PhD, Raynard S. Kington, MD, PhD, and Story C. Landis, PhD

APPENDIXES

A. Vital Directions Steering Committee Biographies

B. Related Publications from the National Academies of Sciences, Engineering, and Medicine

C. “Vital Directions for Health & Health Care: A National Conversation” Symposium Agenda (September 26, 2016)