Chapter 11

Opportunities for Improvement in Public Health Practice

Learning Objectives

• Understand the major opportunities that are present for public health as the health care industry is being reformed
• Become aware of the need for a shift in the goals of the U.S. public health system to expand health education programs
• Comprehend the value of risk communication in preventing the development of chronic diseases and their complications
• Understand the value of developing technology to improve the health of the population
• Recognize the need for innovation in the development of health education and health promotion programs
• Be able to explain how health education and health promotion programs can offer solutions to the various problems found in the delivery of health care services in this country

Our system for delivering health care services to over three hundred million individuals in this country is in a state of chaos. The media reports high health care costs, problems related to countless uninsured Americans, low-quality services, and bankruptcy resulting from concentrating scarce health resources on curative rather than preventive efforts. Lee and Mongan (2009) argue that the real cause of chaos is the tremendous progress in health care every day thanks to advances in technology. A great deal of this use of technology is wasteful, and with these advances also come new dangers for many patients: costs are soaring for health services, and there is an epidemic of medical errors with no end in sight. Every time a patient is subjected to the use of medical technology there is always the possibility of medical errors in the procedure. In many cases the new procedures were not even necessary but were still completed because they represented profits to some.

The older paradigm of health care services delivery is becoming unsustainable, resulting in a revolution in the delivery of health care services (Lee and Mongan, 2009). The curative model of disease cannot work once a chronic disease becomes present in an individual. The epidemic of chronic diseases in our country is causing the medical care system and the public health system to undergo tremendous change in the way they do business, disrupting all of the components that make up health care services delivery.

This change may also produce great opportunities for improving the health of the U.S. population. As the nation deals with the problems associated with uninsured and underinsured Americans, policymakers are gaining a greater appreciation for the benefits of preventing rather than curing disease. This reform of our health care system presents opportunities for public health departments to provide real leadership in improving the health of the population. Because the vast majority of U.S. health care expenditures are for chronic disease complications, it seems logical for the medical care system and public health system to focus their attention on the increasing epidemic of chronic diseases.

Although the United States is ranked number one in spending for health care, it is ranked thirty-ninth for infant mortality, forty-third for adult female mortality, and forty-second for adult male mortality (Murray and Frenk, 2010). The United States is falling further behind other countries every year, even though the percentage of gross domestic product (GDP) devoted to health care continues to rise. The majority of policymakers cite the lack of health insurance for millions of Americans as the cause of this growing problem, but this is not the cause of the poor health. Rather, the high-risk health behaviors Americans practice, such as using tobacco, eating unhealthy food, and maintaining a sedentary lifestyle, result in chronic diseases, which are the real culprits. More health insurance is not going to solve this problem; reducing the incidence of chronic diseases and their complications will.

According to How, Shih, Lau, and Schoen (2008), a survey conducted on behalf of The Commonwealth Fund Commission on a High Performance Health System investigated the general public's perspectives of and experiences with the nation's health care system. The results from this representative sample of 1,004 adults revealed great dissatisfaction with the health care system, as well as problems associated with accessing care, poor coordination of care, and great inefficiency in the delivery of care. These problems are real and must be dealt with in the near future, but they are too complicated to be solved by any one part of this very large health care industry. It is going to take all segments working together—including an educated patient, or customer—to discover solutions to these very complex problems. There needs to be a catalyst, however, to get the reform process started in the right direction toward focusing on the health of the population rather than that of the individual patient. Public health departments can drive the change from an emphasis on expensive cures for individuals' diseases to a focus on investment in prevention programs for the entire population, which in turn will improve the quality of life for millions of Americans.

Quality in public health requires a commitment and accountability to public health programs that will improve the length and quality of life for all people. Maintaining this quality entails the promotion of healthy lifestyles that prevent diseases and injuries. The problem is that the current financing system including government and other third-party payers in health care delivery does not pay for outcomes or prevention programs. In fact, health care providers make more money by allowing the population to become sicker. Those paying the bills for health services have consistently designed payment mechanisms that reimburse for activities rather than patient outcomes. Public health departments, however, concentrate on the health of the population, which requires them to focus on population health outcomes.

Shi and Singh (2010) point out that even though public health is about protecting the population's health, public health agencies have been relegated to a level of unimportance by the medical care system. The medical complex in this country resents a government-funded public health system interfering with the health decisions for its patients. And yet public health has many of the answers to questions of how to control or even reduce the costs of health care.

In order to make a collaboration between the public health and medical care systems work, everyone must agree that keeping the patient healthy should be the most important goal of a reformed health care system. Such an attitude toward the need for preventive health care is growing as more policymakers recognize that the current desire to cure disease entirely is not working. It is one of the factors contributing to chaos in health care delivery, and creativity and innovation are required to produce a new model of health care services delivery.

This chapter is about pursuing innovation in the delivery of public health services to the population of the United States. It is also about making creativity and innovation a large part of public health departments in order to achieve the goals of those organizations. In order for public health departments to become innovative in responding to the chronic disease epidemic, they have to first ask and then answer two very important questions:

Disruption and Change in Public Health

Public health departments in America have received neither a great deal of credit for their many accomplishments nor an appropriate budget for their various mandates. In recent years there has been renewed interest in the public health sector of health care. Shi and Singh (2010) argue that the war against bioterrorism has elevated public health departments to a new level of respect in this country. These departments have also received a great deal of media attention in response to the threat of an H1N1 influenza epidemic. The increased need for public health expertise has also given these departments an infusion of monetary resources. Public health departments seem to gain respect and increased funding every time there is a health emergency, but then both the interest in public health and the funding for its operations disappear as health threats facing the population recede.

In order to retain respect and funding, public health departments are forced to rethink how they do business. Public health leaders have never been able to command respect (supported by a reasonable budget) for long. This is because many such leaders are political appointees concerned only with keeping their job and are usually not interested in the long-term success of public health programs. It is time for this situation to change, because our health care system needs public health expertise. Public health departments have the opportunity to lead the way in system reform as the United States faces the epidemic of chronic diseases and their complications.

Lee and Mongan (2009) point out that in order to improve the health care system in this country there must be greater coordination between physicians and their patients. This is going to require a better understanding of health by each patient, who will need up-to-date health information, especially concerning the potential complications from chronic diseases. Public health departments can take on the new task of using technology to provide this health information and education for the patient, which can go a long way toward helping the patient become an active participant in his or her own prevention or treatment of chronic diseases. In order to prevent the long-term complications from chronic diseases, patients must understand the serious complications that usually result from continuing to practice high-risk health behaviors. They must assume an active role in the long-term chronic disease prevention and treatment process.

Such health education delivery by public health departments is an example of a population-based community intervention effort. Turnock (2009) points out that enhancing community health status in this way is really an investment that will eventually pay off by reducing future health care expenditures. This is exactly the education strategy and behavior change that can lead to longer life—and better quality of life—and can solve the vast majority of health problems our country currently faces. Investing in health education programs that have been shown to work is mandatory for any reform of our health care system to be successful. Unfortunately, Americans have never had a real understanding of the true value of well-developed and adequately funded health education and health promotion programs.

The implementation of change has become so vital to an organization's survival that change management skills must be found in all layers of management (Balogun and Hailey, 2008). The ability to respond to change and deal with the disruption it causes has become a very important and desirable managerial skill. Change management is necessary in the evolving health care system and will require public health departments to modify how they operate in order to seize the opportunities the changing system presents. This calls for leaders who will seek out change and turn it into opportunities for public health departments. Helping to change Americans' high-risk health behaviors, for example, is one such opportunity, which public health departments must exploit by using innovative and creative approaches to share important health information with large segments of the population.

The Institute of Medicine (2002) argues that because of the failure of government reform efforts in 1993, when the federal government attempted to pass a single-payer health care system similar to that found in Canada, the medical care system does not interact effectively with the largely government-financed public health system in this country. Therefore, the medical care system does not allow time for external relationship building, which is so very necessary for the development and expansion of disease prevention and health promotion programs. For example, public health education programs and medical care system resources should be combined in order to end the epidemic of chronic diseases in this country. This has not happened because of distrust of government involvement among medical care professionals and the failure of many public health leaders to seize the opportunity for collaboration.

This is very sad because the medical care system in this country for the most part does a poor job of providing clinically appropriate and cost-effective care for the millions of Americans suffering from chronic diseases. This clearly represents a missed opportunity for successful collaboration between public health and the medical care system. Public health departments must assume a leadership role in the reduction of chronic diseases. This has not happened for a variety of reasons, but it is clear that without the public health system's help our medical care system will continue to fail in its attempt to solve the problem of chronic diseases. We cannot afford to lose this war against chronic diseases.

According to Christensen, Grossman, and Hwang (2009), the transformational force that works well when a business is seeking to lower costs and increase the availability of a product or service has been labeled disruptive innovation, which entails making products and services simpler and more affordable. According to these authors, health care is ripe for this type of innovation, the catalyst for which could very well be the work of public health departments and the preventive strategies that they have developed. The process of disruptive innovation should occur not only in the medical care system but also in public health agencies at the federal, state, and local levels. In order to respond to the opportunities that are present because of this disruption, there will need to be strong leaders and empowered workers in public health departments.

Disruptive innovation allows the combining of resources in the production process in new and innovative ways that usually result in greater value produced by the process. This is exactly what our health care system needs to survive and to deliver better-quality services at lower prices, because both the medical care system and the public health system are faced with limited resources and demands for improved value in health care services. Professionals in our public health and medical care systems have had many tremendous successes in improving the health and life expectancy of most Americans. They need to come together again as the country faces its greatest health challenge in the form of the expanding epidemic of chronic diseases—diseases that are increasing rates of morbidity and mortality, reducing health quality, and escalating the costs of health care. This chaos in health care delivery presents an opportunity for disruptive innovation by public health departments, which can form partnerships with other health care providers to produce a new system of health care delivery that is capable of keeping people healthy rather than allowing them to become ill.

Public Health Education and Health Promotion Programs

Although the major goal of the health care system should be to keep people healthy, the majority of its resources are focused on curing diseases after they have occurred rather than preventing them in the first place. Those in charge of the U.S. medical care system care very little about the prevention of disease because current financing approaches reward interventions that are aimed at curing disease. Instead, prevention of disease is relegated to public health departments with a limited staff and an even more limited budget. This has resulted in public health agencies' being reduced to performing activities like case finding and counseling individuals with disease rather than focusing on the outcomes, such as preventing disease from ever occurring, that they desire; and well-developed health education and health promotion programs have not been as successful as they could have been. The problem is that health care providers do not get paid if individuals remain well, but they are reimbursed when individuals become ill. This is a substantial loss because these programs, armed with the requisite resources, could achieve great success in the war against chronic diseases and their complications.

The vast majority of the costs of health care delivery in this country are a direct result of chronic diseases and their complications. Currently, almost 80 percent of health care costs are for chronic diseases, and these costs are expected to rise rapidly as a result of high-risk health problems like obesity and the increase in diabetes and other diseases with no cure. Although these diseases cannot be cured, however, they could be prevented with well-funded, population-based education programs developed and implemented by public health agencies.

Individuals with chronic diseases require care that is continuous, collaborative, informative, reliable, safe, and proactive (Lee and Mongan, 2009). Our medical care system does not offer the vast majority of these components to individuals diagnosed with chronic illnesses. The patient with one or more chronic diseases is instead left in many cases to fall victim to the very expensive and life-threatening complications that may result from having a chronic disease for a long period of time—complications that could have been prevented with better information. Individuals need information about the causes of and prevention approaches for chronic diseases before they develop them so that they can prevent these diseases' occurrence. Healey and Zimmerman (2010) argue that the individual should have a primary role in determining his or her level of wellness. In order to fulfill this role, the individual requires accurate health information to make health-related decisions.

The major focus of most health promotion efforts is on high-risk health behaviors and individual lifestyle choices. Barton (2010) argues that the medical care system is not organized to systematically deliver comprehensive health promotion programs to the population, leaving a very real opportunity for public health departments to provide leadership in this area. The major goal of public health has always been the prevention of disease and the prevention of complications from disease if it occurs. This goal will only be met by the development of health promotion programs that can be delivered to large numbers of people in innovative ways.

Health education and health promotion initiatives can be expensive and produce only limited outcomes in the short term. They have to be looked at as long-term investments that will only pay dividends over time. Health behaviors develop gradually, and changing high-risk health behaviors will take a great deal of time and effort by many dedicated health education professionals. If the nation is willing to invest in health education and health promotion programs, the health of the U.S. population can be improved, ultimately reducing health care costs. This change in health care delivery will take a long time and consume many resources before yielding a healthier population, but it is well worth the investment.

Because health education programs have been almost nonexistent in most school districts, most Americans are unaware of the threat of disease as they grow older. They do not realize that they are developing and practicing high-risk health behaviors that can shorten their life. They believe that they are invincible and that they do not have to worry about potentially life-threatening diseases. They are also unaware that chronic diseases, once acquired, cannot be cured. They have generally not received any education concerning the risk of chronic diseases from the medical community, other than being told that it is not a good idea to use tobacco products.

The development of chronic diseases is also a serious concern for people in the workplace. A large number of businesses in the United States are beginning to realize the value of workplace disease prevention and wellness programs. Baicker, Cutler, and Song (2010) argue that disease prevention programs can improve health while lowering the costs of medical care. In a meta-analysis of the literature, these authors found that medical costs fell by $3.27 for every dollar invested in wellness programs and absenteeism costs dropped by $2.73 for every dollar spent. This study supports the assertion that the prevention of chronic diseases represents a long-term investment with substantial returns.

Risk communication has become a critical public health function and fulfills the public health mission of ensuring conditions in which individuals can remain healthy. This function has never received the credit that it deserves because the payment system in health care does not reward the prevention of disease, instead reimbursing for activities in medicine that are in response to the occurrence of disease. It pays for activities rather than outcomes. Unfortunately, the vast majority of the activities in health care today deal with chronic diseases that cannot be cured, but that could have been prevented with health education.

Major improvements cannot occur in health care until physicians move from paper data to computer medical records (Lee and Mongan, 2009). This is also true for public health departments, which in order to improve their services need to embrace and exploit technology. A real opportunity exists for health promotion and chronic disease education programs to be delivered in a format similar to an electronic medical record for easy patient access. Information technology can go a long way toward helping public health departments disseminate vital information to the population in order to prevent the development of chronic diseases or postpone their complications.

Optimum Health, a division of UnitedHealth Group, the nation's largest insurer, is going to offer a type of virtual doctor-patient visit using video chat in 2012 (Miller, 2008). This method of delivering health care has been developed to eliminate travel and waiting time for the patient because of the shortage of primary care physicians. This method of communication could also represent an inexpensive way to deliver highly important chronic disease information to large numbers of people.

Our health care system is not doing a very good job of dealing with chronic diseases and their possible complications (Halvorson, 2009). The good news is that the care of those with chronic diseases can be improved by providing them with better information. Halvorson calls for care registries as an important tool in the improvement of chronic disease care. These registries would include specific protocols for the data, care tracking that would include interventions and outcomes, and linkages among the various physicians dealing with the patient with comorbidities. There is also a very important role for public health departments in the improvement of chronic disease care because these departments have the necessary information concerning the prevention of chronic diseases.

The Need for a Chronic Care Model

Morewitz (2006) points out that every year three chronic diseases, heart disease (including stroke), cancer, and diabetes, account for about $700 billion in direct and indirect health care costs. These costs continue to escalate because of chronic disease complications and comorbidities. The only way to prevent these diseases is by educating the population and supplying them with information about the prevention of chronic diseases from a reliable source on a consistent basis. Creativity and innovation are clearly required to develop a mechanism for providing such population-based health information.

The major goal of chronic disease control programs in this country should be the reduction of the incidence of these diseases through prevention initiatives (Brownson, Remington, and Davis, 1998). For those who already have a chronic disease, the goals would also include the reduction of disability and prevention of premature death. These goals are nothing new, but the large number of individuals affected by these diseases is requiring immediate intervention with innovative education programs. It has become evident that the current health care system is failing to deal appropriately with the chronic disease epidemic facing America. Therefore, we need to change our strategy and use population-based health education programs available from public health departments.

Primary care doctors in our country need to implement a Chronic Care Model designed to reduce the incidence of chronic diseases and their complications. One of the most popular models of helping individuals with chronic diseases was developed by Edward Wagner at Group Health Cooperative in Seattle. The important aspects of this model include patient self-management, delivery system design, decision support, and clinical information systems, all of which are designed to improve the outcomes for chronic diseases in this country. According to Bodenheimer, Wagner, and Grumbach (2002), the Chronic Care Model has shown evidence of quality improvement and cost reduction in the management of chronic diseases. The model is expensive to totally integrate throughout the health care system but much easier to implement in any primary care practice. Public health departments can play a leadership role in the development of a Chronic Care Model for primary care practice.

Chronic diseases, unlike communicable diseases, present the patient with deferred consequences. There is a need for a definitive protocol to deal with these diseases before the expensive complications develop. Although compelling research suggests that a form of evidence-based medicine is appropriate for the treatment of chronic diseases, more research needs to be completed, and comprehensive education programs seem to offer more value at the present time. Dlugacz (2010) argues that physicians practice evidence-based medicine by heeding expert advice about best practices in dealing with the treatment of diseases, instead of relying solely on their individual, independent decisions. It has rapidly become the gold standard of modern medicine, and may represent one method for reducing the rates of complications resulting from chronic diseases.

Another important component of a Chronic Care Model involves the way patients pay for health care. Christensen et al. (2009) argue that chronically ill patients require a payment system that profits by wellness and not illness. The payment system currently pays for provider activities and not for health outcomes. It is interesting that our health insurance system has no billing code for wellness, even though creating incentives for wellness would reduce health care costs. The focus of the payment mechanism has to shift from activities to outcomes.

Minimal Political Appreciation of Public Health Activities

The vast majority of our elected representatives at the federal, state, and local levels know very little about the value and accomplishments of public health departments. This is a critical issue for public health departments because most of their funding comes from the government. Public health leaders need to become more political by sharing their successes, along with their current efforts to deal with chronic diseases, with their local, state, and federal representatives. This would allow them to demonstrate the need for their expertise in health reform by concentrating on the change necessary to defeat the epidemic of chronic diseases. It is a fact that anything can be marketed, including impressions of what well-funded public health departments could do if just given the chance. Leaders of public health departments thus need to receive education about the marketing process.

Although the vast majority of marketing activities are found in the for-profit sector, marketing is also an acceptable process in the nonprofit realm. For example, public health departments can use marketing strategies as a tool for conveying to policymakers their true value and accomplishments. In the last few decades government agencies have started using marketing techniques to improve their budget allotments and obtain better relationships with their clients and their suppliers of resources, usually government entities. Professionals in the medical sector have increasingly begun to understand the value of developing a marketing orientation as they go about delivering health services to their patients. In recent years, public health practitioners have also begun to recognize how to use marketing techniques to more effectively and efficiently deliver health-related information to community audiences.

Health services, especially public health services, include the components of individual and community needs and wants that require an exchange process in order to be satisfied. In this type of exchange there may be a nonmonetary price, such as effort or time. The marketing concept is useful in several aspects of the provision of health promotion programs, including the development, implementation, and evaluation of new health promotion efforts.

Marketing tools can help combat the rapid escalation in the occurrence of chronic diseases in our country. Many public health professionals are convinced that acquiring marketing skills can be greatly useful to public health practitioners. The use of marketing skills offers public health workers a way to better understand and motivate behavioral change in individuals (Novick, Morrow, and Mays, 2008). Therefore, the development of marketing skills in public health agencies may contribute to innovative approaches to improve effectiveness in changing high-risk behaviors in the community. These skills would include the ability to understand their market, segment their market, and develop a marketing plan to change behaviors. These new strategies involving the use of marketing skills need to be better developed, organized, and evaluated—and then expanded.

The use of marketing skills can be thought of as a series of steps that are directed at satisfying the needs and wants of the consumer through an exchange process. A need involves a condition in which there is a deficiency of something, whereas a want entails a wish or desire for something perceived to be useful (Berkowitz, 2006). Gaining a better understanding of what individuals desire from health care can be helpful in marketing the concept of good health to consumers while also advocating for practicing healthy behaviors. The key here is to make certain that a need (good health) is being satisfied in exchange for something of value (practicing healthy behaviors).

Public health departments have largely ignored marketing, most likely because very few of the directors of public health departments (or any other public health workers) have ever received any formal education in the marketing process. This is probably due to public health programs' having been considered too important for public health departments to use the marketing approach to improve their funding stream. However, when public health workers encourage changes in individual behaviors and lifestyles they are actually in the business of marketing (Siegel and Lotenberg, 2006). Many people think of marketing as only advertising, not realizing that advertising is just one component of marketing. The marketing approach to doing business has produced successful results for businesses and government agencies for many years, and it can certainly be applied to public health departments' efforts to increase their funding stream and accomplish goals.

Use of Technology in Risk Communication

The use of technology also can help in the battle against the growing epidemic of chronic diseases. Technology is available to improve the communication of the dangers of high-risk behaviors to large portions of our population. Although public health departments have the information that is necessary to help individuals prevent chronic diseases from developing in the first place, the problem has been that the money these departments receive is never enough to develop, implement, and evaluate massive efforts at dissemination of chronic disease information to the entire population. This is not to say that there have not been chronic disease education efforts by health departments—there have been many successful programs developed and implemented in schools, workplaces, and the community, but the funding stream has not been dependable because of budget reductions. Public health departments need to make greater use of technology to get more information to the population consistently and innovatively. Mukherjee (2009) argues that in a crisis situation, companies need technology that allows for intelligent adjustment to major environmental shifts and that supports their prior principles. This recommendation rings true for public health departments. The chronic disease epidemic in America is causing an environmental shift for these departments, which now must use information technology in innovative ways to resolve this disease crisis.

According to Mukherjee (2009), certain drivers will cause the bureaucratic organization to become more flexible and increase worker productivity and the quality of the products or services delivered. These drivers include the transformation of systems and the nature of work, worker skills, and the structure of organizations. He was referring to an adaptive business strategy that is applicable to making things and producing services. These drivers are also extremely important in the improvement of the health of the individual and the community, and they need to become a functional part of the new world of public health. This is going to require public health workers to develop and apply many new skills in delivering population-based preventive services that are driven by health education programs.

The public health leader needs to change the nature of work, improve workers' skills, and allow structural change, with an ultimate goal of improving the health of the population. Computers and electronic communication have improved their ability to gather, analyze, and disseminate disease surveillance data (Turnock, 2009). Public health departments have to expand their use of this technology to deal with the chronic disease epidemic by providing a continuous stream of information about chronic diseases to the entire population. The CDC (2011b) offers several examples of success stories concerning the innovative use of technology that include Epi-X and Health-e-Cards, discussed in the paragraphs that follow. On a local level, I (Bernard) have had success using voice-narrated PowerPoint slides to educate large numbers of people about colorectal cancer and H1N1 influenza.

One of the best examples of a public health surveillance and information system is Epi-X, which offers Web-based communication for public health professionals. State and local health departments and poison control centers are currently using this system to access preliminary health surveillance information and share it with large numbers of health care professionals. This system supports postings of up-to-date medical information and discussions about disease outbreaks and other public health events that involve various parts of the nation and the world. Epi-X provides rapid communication whenever there is a need, and its staff is available twenty-four hours a day, seven days a week to provide consultation. I have personally been part of this excellent public health communication system and have grown in my knowledge of communicable and chronic disease information as a consequence. This system was created to provide public health officials with current information and alerts involving the health of the public, and its primary goal is to inform health officials about important events that can affect the public's health and help them respond to public health emergencies. This type of system would be excellent for rapid sharing of chronic disease information with the U.S. population.

As another example of the innovative use of technology, the CDC currently has available over one hundred free Health-e-Cards (electronic greeting cards). These colorful cards encourage healthy living, promote safety, and can even celebrate a health-and-safety-related event. They are currently available from the CDC and many local and state health departments. This concept could be extended to address the prevention of chronic diseases and to communicate ways of avoiding the complications that can develop later in life as a result of having a chronic disease.

Public Health Leadership Required

Prevention of chronic diseases and their complications should be a major component of any health reform endeavor. Success in the effort to become proactive with the epidemic of chronic diseases requires intensive public education programs that individuals first encounter in grade school and that continue into the workplace, and the implementation of such programs is going to require the development of public health leadership. As it stands, however, the chronic disease epidemic continues to expand despite public health efforts. Many dedicated public health workers find the limitations of conventional public health practice very hard to accept—in particular the fact that they are unable to use their creativity to develop innovative programs to deal with the chronic disease epidemic (Turnock, 2009). In order to exploit the opportunities present in the current chaotic health care system, public health departments will need strong leaders. This is especially true when it comes to pursuing innovations in health education and health promotion programs for dealing with the epidemic of chronic diseases. Halvorson (2009) argues that America needs leadership from public health that will focus on chronic disease care. The tools needed to improve the care for individuals with chronic diseases in this country include electronic medical records that will also act as connectors to all of the providers required to improve the quality of life for those with chronic diseases. In order to achieve this improvement, however, there is a need for better use of available data and of the various connectors.

The vast majority of Americans are not satisfied with the system of health care in this country. They want much more than they are currently receiving from the providers of medical services. According to Lee and Mongan (2009), there are only two ways for patients to improve the health care they receive: they can demand quality from their current providers or change providers, or they can take charge of their own health care. In order to participate in their own care they will require up-to-date health information that is available when they need it and that they can understand. This is where public health departments can help the individual patient and the community, for example by delivering such information over the Internet.

Public health departments must provide the leadership in developing and using the tools for chronic disease care, because these departments' overriding core function involves improving the health of the population. They will also need to focus on more innovation in regard to finding and implementing the tools necessary to manage chronic diseases and improve health outcomes—innovation for which leadership is a very necessary prerequisite (Zenger, Folkman, and Edinger, 2009). In fact, the leader is capable of creating an environment in which new ideas develop and grow. This type of environment, in which followers trust and are inspired by the leader, is exactly what public health departments need to deal with the epidemic of chronic diseases. What is more, followers should have the freedom to be creative in their use of chronic disease data when developing educational prevention programs.

It has become abundantly clear that public health departments have to change the way they attempt to accomplish their most important goal, which is protecting the health of the population. Clawson (2009) argues that when we talk about providing leadership we are also discussing strategy development and change management. These important components of leadership actually overlap in the pursuit of successful outcomes. Public health leaders need to develop new strategies and manage change to unite this country in an effort to reduce chronic diseases, which in turn will reduce cost escalation in health care. This means moving beyond public health accomplishments of the past and toward fresh strategies for facilitating change in public health's responsibilities and direction.

The change that is required of public health departments will be monumental, and it demands public health leaders who are adaptable and capable of responding to the new challenges facing the health care system. Fairchild et al. (2010) believe that public health is well positioned to take its place as a part of the current reform movement in health care delivery. This will require empowered public health workers who can go far beyond their conventional roles in public health departments. New roles for public health workers will also entail greater collaboration with the medical community in order to improve the health of the entire population.

Balogun and Hailey (2008) argue that there are three parts to the change process: an assessment of the current organizational situation, a statement of the desired future state, and a plan to get to where the organization should go. The public health system in the United States has the skills necessary to reduce the incidence of chronic diseases and their complications. The problem has been the lack of appropriate funding and leadership to deal with such a large problem. Even when there are public health leaders with the vision of where public health departments need to go, inadequate funding for chronic disease interventions makes achieving success problematic.

The chronic disease challenge cannot be met by public health departments alone. It is also going to require leaders and followers in public health agencies to collaborate with members of the medical community to produce a medical home for managing chronic diseases and their complications. In addition to public health leadership, followership is critical. The public health leader must clear the roadblocks for his or her staff so that they can concentrate on health outcomes rather than on activities like counseling and testing infected individuals that may produce little value. Public health professionals have to move beyond reacting to population health problems and toward a proactive approach of preventing diseases before they occur.

Followership and team performance are also critical for the changing public health sector. Lighter (2009) argues that the delivery of quality medical care in America has become a matter of teamwork rather than the responsibility of individual leaders. This situation is also found in public health departments, which require leaders who appreciate the contributions of their followers and create an environment in which creativity can develop and grow. The opportunity for public health departments to lead the health care system out of chaos has arrived.

Value of Prevention Programs

Efforts to fight chronic diseases include health education programs to prevent the diseases and disease management programs to prevent the complications that may result from chronic diseases later in life. Public health departments then need to deliver the information necessary to prevent chronic diseases to younger audiences through health education programs. Further, disease management requires interventions for the community that facilitate patient self-care and involve rapid dissemination of health-related information. Public health departments have that information, and they must now become innovative in how they distribute this information to large community populations so that they can better manage their chronic diseases.

An article written by The Commonwealth Fund Commission on a High Performance Health System (2006) discusses the value of patient-centered primary care as a solution to many of the problems in health care delivery. This article cites patients' engagement in their own care as one of the most important attributes of patient-centered primary care. For patients to be thus engaged, health professionals must supply them with information on disease prevention, self-care, and treatment plans—which seems like a natural function for public health practitioners.

There is a new concept evolving in medical care that is gaining traction as a potential solution to complex medical problems. This innovative approach to patient care involves the medical home, which Bernstein (2008) describes as a way to better treat patients with chronic diseases and comorbidities. This strategy is especially appropriate for individuals who have developed one or more chronic diseases and are now facing disability, pain, suffering, and death. The medical home offers a way for patients to receive accessible and comprehensive primary care whenever they need it. One of the most important aspects of the medical home concept is the availability of accurate medical information to allow each patient to take initiative in his or her own medical care.

The Centers for Disease Control and Prevention pointed out in a 2009 report that Americans ages fifty to sixty-four require a comprehensive set of preventive services to remain healthy as they grow older (CDC, AARP, and American Medical Association, 2009). This report, Promoting Preventive Services for Adults 50–64: Community and Clinical Partnerships, revealed that only 25 percent of American adults in this age group regularly take advantage of preventive services, which poses a major problem because this is the time when adults are already incubating their chronic diseases. The report calls for public health departments to respond to this challenge with innovative education initiatives to increase these adults' knowledge about chronic diseases and aging.

Fulfilling the mission of public health to assure the health of the population includes developing, implementing, and evaluating prevention programs for all Americans. Maciosek et al. (2010) argue that public health departments need to make better use of a package of evidence-based clinical preventive services that offer value for the dollar to the patient. A number of recent research reports question the value of preventive services as an investment. In the short run, there is very little evidence that medical costs are reduced through an emphasis on prevention programs. There is even disagreement among researchers concerning the value in the long term of health education programs, health promotion activities, and screening tests that are expensive to administer and may or may not result in reduced medical costs and ultimately improved health status.

According to an article in the Nation's Health (Currie, 2010), prevention programs save lives as well as money. A recent study conducted by the National Commission on Prevention Priorities found that preventive services such as promotion of daily aspirin use, tobacco cessation support and alcohol abuse screening, and colorectal cancer screening can potentially save two million lives and nearly $4 billion annually. The study concluded that not all preventive services are equal in impact but that in some cases the benefits in regard to population health can be profound. The secret is to use only proven, cost-effective prevention programs and find an innovative way to get health information to the population. If the vision for public health is to offer innovative health education and health promotion programs to large numbers of people, then public health departments need to look outside of public health for new ways to deliver the message to the population. This could be accomplished, for example, through greater use of such social networks as Facebook and Twitter.

A recent report, Prevention for a Healthier California (Levi, Cohen, and Segal, 2008), was completed through a partnership among Trust for America's Health, Prevention Institute, the New York Academy of Medicine, and the Urban Institute. This study involved a range of community-based programs in California. The purpose of this study was to focus on actions that California policymakers could take to make prevention a greater priority, with the goal of reducing health care costs and improving the health of the population. This groundbreaking study validated the idea that community-based prevention saves money and improves lives. It demonstrated that an investment in prevention programs following a relatively simple model that incorporates proven population-based preventive services can reduce health care costs by billions of dollars.

Figure 11.1 shows how the model works, and Figure 11.2 demonstrates the return on investment for California. Figure 11.3 expands the model used for California to the entire country.

Figure 11.4 demonstrates how the cumulative benefits of the use of primary prevention programs are measured. The underlying strategy here would include improved health from the reduction of the target condition along with the reduction in the prevalence of associated conditions. There would also be increases in the productivity and the work attendance of working individuals who have achieved better health status from the prevention effort. These increased side effects that go beyond addressing the targeted condition and associated conditions are the result of the multiplier effects of well-designed community prevention efforts (see Figure 11.5).

This study demonstrated that prevention programs can produce substantial health care savings if the right programs are offered to the population. Focusing prevention programs on the population can also produce such significant economic improvements as heightened productivity in the work process, reduced disability, and even increased school attendance. The problem is how to get prevention information to the entire population in an understandable format and at a reasonable cost.

One of the major problems with the American health care system is that the consumer (patient) has usually been a passive recipient of health services that the health care system provides. The consumer is not well educated in health care and, therefore, is not usually rational when it comes to purchasing health services. His or her demand for health care is a derived demand for good health, meaning that the consumer is not really demanding health services but rather an improvement in health status. The consumer delegates his or her demand when it comes to health care, placing it in the hands of the physician. This is because our health care system is structured with information asymmetry, which is present in decision transactions in which one party has more or better information than the other party—as is certainly the case when a patient deals with the physician who is making decisions concerning the patient's health. The consumer allows this imbalance or ignorance because medical knowledge costs a great deal to acquire and has small expected benefits for the individual patient. The average patient usually does not pay the full cost of medical care because of health insurance and trusts the better-educated physician to provide advice on what is required to remain healthy.

The patient does not know when to seek care and is not completely convinced that preventive health care is worth the time and investment necessary to avert future illness. The patient is also unable to evaluate physician recommendations for care, is unable to evaluate the quality of care, and is unaware of the price of medical care. In order to improve the population's situation in regard to their dearth of medical knowledge, especially that pertaining to the value of preventive services, there needs to be innovation in the distribution of this vital information to the population. This is the opportunity that is available to public health departments today.

Public health departments have the medical information that the patient requires to become a rational consumer of health care services. The problem for public health departments has been finding an effective and inexpensive way of distributing health information, especially data concerning the prevention of chronic diseases, to the entire population on a regular basis. This is where innovation, community collaboration, and public health leadership combine to become the catalyst necessary to accomplish the mission of public health in America.

The Process of Innovation

One of the more important qualities of the leader over years of research remains the ability to develop a vision and be able to get his or her followers to follow that vision. Strong leaders and the companies they work for have been successful in recent years in allowing creativity and innovation to flow in the workplace, and the ability to innovate has become a necessity for survival in the modern world of business. This innovation is also necessary for public health departments to meet their goals of assuring conditions that promote the health of the population.

This is going to require the public health leader to make bold moves toward changing the way public health departments function. The mission of public health is to assure conditions in which people can be healthy, but public health leaders have not done a great deal to reduce the challenge of the epidemic of chronic diseases in this country. The leader needs to build a culture among his or her followers that is dedicated to the vision of meeting the chronic disease challenge.

Thanks to technology, consumers are now able to find out a great deal about a product or service before they purchase it. This is true for all industries in the United States except the health care sector—and there lies the opportunity for public health departments to reinvent themselves through innovation. We began this chapter by asking two questions.

The answer to both questions is found in the ultimate vision for innovation in public health departments. This vision entails assuring conditions that promote the health of the population through the provision of life-changing health education that is made possible through innovation in how information is delivered.

Summary

The delivery of health care in the United States is in a state of chaos, requiring immediate attention. The major culprits in the cost escalation in health care are the epidemic of chronic diseases and their complications. It has become very clear that our current system of medical care in this country is not capable of dealing with this very different type of epidemic. The current epidemic of chronic diseases along with the chaotic medical care system are producing the very real possibility of a bankrupt U.S. health care system.

The need to quell this epidemic is also producing a tremendous opportunity for public health leaders and their followers to offer their creativity and pursue innovation to restore the health of the population. This can only be accomplished, however, if the population has access to up-to-date information about chronic diseases and the prevention of complications that usually follow the development of chronic diseases.

Public health departments have to change how they seek to accomplish their most important goal—protecting the health of the population. Public health professionals need to receive extensive training in leadership, in the use of technology, and in developing communication and collaboration skills in order to fulfill their new challenges. They also need to move from a bureaucratic organizational structure to a more organic form of administration that encourages creativity and innovation in the delivery of services. Public health departments are quite capable of continuing and expanding on their past successes in improving the health of Americans, but in order to do so they must be given the necessary resources to win the war against chronic diseases.

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Discussion Questions