Healthy People Consortium Meeting November 7, 1997

Summary of Breakout Group Discussion Concerning Priority Area 21: Clinical Preventive Services

I. Summary

In the discussion concerning the use of the term "Eliminate" instead of "Reduce Health Disparities," overall, the participants appeared to be philosophically uncomfortable with the statement "eliminate disparities." Despite an awareness of the philosophical and political reasons for the reach to "eliminate disparities," the participants felt that HHS was committing itself to achieving an unattainable, unrealistic goal. In discussing target and goal setting issues and the proposed structure of 2010, the discussion was linked repeatedly to the issue of "eliminating" disparities. At the close of the discussion, the group edited the fan diagram of the proposed structure for 2010 to place the statement "eliminate disparities" directly under HEALTH FOR ALL, thereby setting forth the idea as a philosophical goal, not as a performance goal. In addition, the fan diagram was edited by rotating it 180 degrees so that HEALTH FOR ALL appears at the top as the topmost goal, achieved upon the foundation of actions described in the underlying structure. The group emphasized that the final graphic must clearly indicate that Enabling Goals apply to all focus/cluster areas, and that special populations must be addressed in every focus area. The term "special populations" was replaced by "populations at risk."

II. Discussion

With regard to the subpopulation issues and disparities, the group stated that the reality is that health disparities never will be fully eliminated, that new disparities will emerge as others are reduced or eliminated. Moreover, the negative impacts of setting unrealistic goals must be considered. If the term "eliminating disparities" is used, the group stated that HHS must find a way to convey that the agency endorses the idea while recognizing the inability to achieve the "elimination" of disparities by 2010.

It was noted that the socioeconomic factors underlying disparities, such as access to quality primary care, also must be recognized. Socioeconomic drivers clearly influence the delivery of and nature of health care services; therefore, the Public Health community needs to identify how it can drive and influence the business community. The group had concerns about taking too audacious an initiative (HP2010) to the business community.

Concerning the proposed use of one uniform target across populations for each objective versus relative targets for the various special populations, the group asked for process clarity on how special populations that have met the target or goal would be handled: Would the goal be reset? How were goals and targets arrived at in Healthy People 2000? And, do we have an "ideal" goal or an achievable goal? The group emphasized that using an average as a uniform target across populations may conceal that we have disparity. Criteria for developing targets are needed, and more than one model for target or goal setting might be required (such as sometimes using a percentage reduction in incident across populations).

The group agreed that the following criteria should be met for setting goals and targets: every goal/target should have a scientific basis; community input is needed; and goals should be audacious but, at some point, achievable. The group felt that targets should be set to drive resources into the communities of greatest need. There was sensitivity to the potential for political problems if targets set in Healthy People 2010 were different from targets set in comparative initiatives, like the Administration's Race Initiative.

A. Framework and Criteria for Objectives

The group felt the proposed structure of Healthy People 2010 "makes a lot of sense," but expressed concerns about the broader implications in using the term "eliminate disparities." It was felt that the focus had to be kept on "health," and the group asked whether Healthy People 2010 would address issues concerning other determinants of health, such as lack of insurance and financial barriers. The group emphasized that Healthy People 2010 cannot state that the Nation will "eliminate disparities" if 2010 does not address the broader range of socioeconomic factors that also drive disparities. Some participants asked whether Healthy People 2010 would have links to other Federal agencies' objectives, such as EPA, HUD. Overall, it was agreed that the objectives must drive action and that the action must be articulated.

Healthy People must become the framework for what is meant by a healthy community. To make Healthy People work, HHS needs to develop ownership and buy-in at the community level, from the bottom up. It was emphasized that goals must be enabling and must involve the managed care community and the business community.

In the fan graphic, the focus (cluster) areas with the enabling goals in the fan shape are perceived as discrete pie wedges—the idea that all Enabling Goals apply across all focus areas was lost. Moreover, Health For All is not achievable without the elimination of disparities, so "elimination of disparities" should be elevated to appear under Health for All.

B. Arrangement of Focus Areas

In the discussion on the focus area "Health Services" and the types of services and groupings of services under Health Services, the group looked for treatment issues as yet identified. Quality health services were mentioned, and it was noted that the Quality Commission also addresses universal coverage, privacy issues, and informing the patient issues. Identifying barriers included defining the barriers to the use of Emergency Medical Care and the definition of "emergency," and questions as to where the line is drawn. The group unanimously felt that Healthy People 2010 should continue to have developmental objectives, perhaps presented in a separate section.

The evolution of the focus area from CPS to Health Services remains unclear. Among the reactions of the participants, one group felt the emphasis should remain on clinical preventive services, but that 2010 could expand the areas in which CPS delivery was addressed while including the appropriate delivery of preventive services in other settings (such as Domestic Violence and Alcohol interventions as a part of Emergency Health Services/Care, and immunizations and fall prevention as a part of Long Term Care). Others felt that objectives should consider "Health Services" more broadly and include access to care, access to emergency health services, and other potential overarching health care issues. There was concern about how quality would be expressed in all of the future and reworded objectives. Additional discussion focused on who the special populations were—whether the category of "special populations" includes rural, immigrants, incarcerated persons, and whether the category of special populations should be broadened to include other at risk and vulnerable groups. The term "special populations" was replaced by "populations at risk."

Several potential objectives under "Emergency Health Services" were proposed, including the presence of State legislation requiring the use of a "prudent layperson" standard to determine appropriateness of emergency care. Some expressed concern that there are no data to determine the extent of the problem addressed by this proposed objective or whether meeting this objective would lead to better health outcomes. A broader objective that would address some of the factors perceived as barriers to individuals seeking timely emergency care (e.g., geographic inaccessibility, lack of resources, concern over reimbursement policy, language barriers.) might be more useful, but may not be easy to assess with current data sources.

The group tabled the discussion of rewording existing objectives to include Emergency Health Service/Care and Long Term Care until there was clarity on the categories of health services that would be listed under Health Services. Moreover, if the Clinical Preventive Services category were to include Emergency Medical Services/Care, and Long Term Care Services, the group introduced the idea of whether Healthy People 2010 should recommend a package of clinical, medical, and broader health care services. The objective writing task for Healthy People 2000 for the Clinical Preventive Services Priority Area clearly was made easier by adherence to the U.S. Preventive Services Task Force's recommendations in the "Guide to Clinical Preventive Services." In any event, the group agreed that all suggested objectives must have an adequate baseline, a surveillance system and indicators defined, and be action oriented..

Apart from the content of Health Services, the group agreed that the Preamble to the Health Services focus area should contain the following statements: the Nation should assure that these services are available; that the elimination of barriers to accessing, utilizing, and receiving the appropriate health care services is a public-private responsibility; and that Healthy People 2010 must develop a social connectedness and civic involvement because population-based problems affect the entire community. Healthy People 2010 must go beyond access and quality of needed medical and other health services and look at the unmet need.

Participants

Ron Carlson, Facilitator, Health Care Financing Administration
Melissa Clarke, Recorder, Health Care Financing Administration
David Atkins, Agency for Healthcare Research and Quality (AHRQ)
Edward Bernstein, Society for Academic Emergency Medicine
Judith Dempster, American Academy of Nurse Practitioners
John Mark Hirshon, American College of Emergency Physicians
Hazel Katter, Indiana State Department of Health
Hazel Keimowitz, American College of Preventive Medicine
Amy Preston, Sagamore Health Network
Mark Smolinski, Office of Disease Prevention and Health Promotion
Mary Turner, American Association of Retired Persons

Breakout Session List