Namita Seth Mohta, MD, interviews Monica Bharel, MD, MPH, Commissioner of the Massachusetts Department of Public Health.
Namita Seth Mohta:
This is Namita Seth Mohta for NEJM Catalyst. I am speaking with Dr. Monica Bharel, Commissioner of the Massachusetts Department of Public Health. In this role she serves as the state’s chief physician and leads a department of nearly 3,000 individuals who run programs from environmental health to infectious diseases and injury prevention, to maternal and child health. In addition, the department operates the state public health laboratory and four public health hospitals.
Dr. Bharel, given your experience in both a provider and health setting, as well as government in the public health sector, I wanted to focus on two specific areas. First, I’d like to get your insights on the overlap between public health- and population health–related initiatives in the context of acceleration toward value-based payment models. Second, I look forward to discussing the opportunity and the challenge of public-private partnerships as it pertains to providing integrated whole-person care in communities and an overall drive toward breaking down the silos that exist in our health care ecosystem. We are delighted to have you joining us today.
Monica Bharel:
Thanks so much, Dr. Mohta, and thanks to NEJM Catalyst for having me here.
Mohta:
Let’s start with clarifying some terms. When I speak with leaders who work in the public sector, they use the term public health, and when I speak with leaders who work in health systems, they use the term population health. Oftentimes, they are referring to the same set of problems and challenges, and quite frankly, the same list of potential solutions. Tell us, from your perspective, how do you define public health and population health? What is the relationship between the two? Related to that, what are the different levers and tools that organizations in these respective environments can use to improve health?
Bharel:
How we define our work and how we use different terms can affect how we implement change, so it’s good to level-set there. One of the issues with public health is that, depending on where you look, it’s defined in different ways. One of my favorite definitions is one loosely based on the Institute of Medicine, now the National Academies, stating that public health is “what we as a society do [collectively] to assure the conditions in which people can be healthy.”1 What drives me to do my work in public health is that at the core of public health lies the principle of social justice: making sure that we are providing people the right to be healthy and to live in conditions that will support their health. So, public health is broadly defined as what we do as a society.
If you think about population health, I like one of the definitions that CDC uses, which is “an opportunity for health care systems, agencies, and organizations to work together in order to improve the health outcomes of the communities they serve.”
Broadly thinking about it, you could say public health is about what we’re doing as a society and population health is about what a system is doing for their community. I’d add one other piece: When I think about population health, I’d like to differentiate that from what I call population medicine. Population medicine, from a clinical point of view, is how we think about taking care of our population of patients.
When I had my primary care practice, the patients who were coming to see me, that’s my population of, say, diabetic patients. That’s population medicine, and at a hospital level that could be the patients who are coming in to be seen, versus population health, which I would hope as a health care community is stretching us a little bit further and saying it’s not just the people who are walking through our doors in a health care system to get care when they’re sick, but it’s however we define the population we’re responsible for. It’s taking care of all of them, as well.
Mohta:
With that latter definition, the lines blur a little bit between what a public health system might do and what a health system that’s in charge of a population in their community — and not just one of the patients walking through their door — might do. From your perspective, what are the different levers or tools that these different types of organizations use to improve outcomes?
Bharel:
It’s an important point you raise because you also mentioned when we started talking that you hear of public health more in the policy and public sector. Part of that is that we think of public health as often consisting of regulations or policy changes that can be made at the government level. It’s what levers do we have that govern it — whether it’s local, state, or federal — and that might be why it’s more commonly used in the public sector. Whereas when we’re thinking in the medical or health care system, we’re thinking more about our patients.
But I must say that this kind of distinction, which is what you’re alluding to, is artificial. As I look at it, having been deeply embedded in both the clinical world and now the public health world, the way we differentiate this does a disservice to our patients and communities because it produces an artificial divide in our work.
Mohta:
I could not agree with you more. In the silos within our health care delivery system at every level are one of the biggest barriers to transforming the way we deliver care. One of those sets of silos has been between, as you have alluded to, clinical care delivery organizations and then public health and social services organizations. You have done a lot of work in Massachusetts to break down those silos. Share some examples of partnerships and models that worked well and why they worked well.
Bharel:
Absolutely. Again, it’s such an important point you’re raising Dr. Mohta, and I want to make sure to emphasize this: The divide that we have between public health social services and medical services is bad for our patients and our communities, and it’s also bad for the value-driven care that all of us are trying to provide. This is the single most important factor in our rising cost of health care services and some of the lowest health care indicators in comparative countries.
When I think about the patients I’ve been privileged to serve over my 20 years of providing clinical care and specifically the patients I cared for at Boston Health Care for the Homeless Program, they didn’t live in these artificial silos that you’re referring to. They were getting nutritional benefits on WIC programs or SNAP programs at the state level. They were getting assistance with housing or childcare from their local social service agency. Then they were coming to see me for their medical care. While I was well trained and capable in deciding which medications they needed for diabetes or high blood pressure, this was such a smart part of what they needed in order to gain opportunities for health.
If I had to choose between making a housing appointment or getting in line for a shelter so that my child had a place to sleep or coming into a doctor’s office for a medical refill, I know what I would choose. We try to follow best practices in medicine and provide the best care we can for our patients, but the lack of coordination and [lack of] looking at our patients’ lives from a holistic systemic point of view is detrimental to the care that we are trying to provide at a health care setting.
Mohta:
We all agree that this is a problem and we all agree that we need to improve coordination across these key stakeholders and organizations providing these services. How do we align incentives such that we start doing this required coordination?
Bharel:
In each of our settings, the first thing is awareness and being definitive about what the issues are and seeing them through this holistic lens. That’s one of the reasons I’m glad we’re speaking today. The other is looking within wherever we are along the spectrum of public health, prevention, clinical care: What levers to do we have to begin to break down these silos?
I’d like to give you an example. At the state level we have dozens of data sets on different aspects of health. Until 2015, we weren’t looking across these data sets to leverage the information to help provide opportunities for health; each individual data set was looked at in isolation. This is rich and important information that, at a population level, can help us understand how to better take care of the health of our patients. It includes things like medical claims data, birth and death data, use of the prescription monitoring system, jail and prison data, and so on.
With the opioid epidemic it became imperative that we look for new ways to address addiction and take a different approach. We brought together data from over 28 different agencies across state government, the first time this was done in Massachusetts. This allowed us to gather information on when and where individuals were dying and work to prevent those deaths by moving upstream of those deaths, if you will. To give you an example, for the first time we combined health data with criminal justice data in order to make the case to treat opioid use disorder with medications while someone was incarcerated. We brought this data together in ways that opened our eyes to how, by working across the silos, we could better take care of individuals and address the opioid epidemic.
One of the key features of this: We didn’t have any new state resources to bring the data together because the resources were going to direct patient care. We accomplished this through public-private partnerships, which included our academic colleagues and others in the community who have the capacity to analyze big data but didn’t have access to the state-level data. This became a win-win because our colleagues in health care and academics who wanted to contribute to addressing the opioid epidemic and better understand how to use big data at the state level had an opportunity to access this data. We wrote papers together and, from the state point of view, got the analytics that we needed to drive policy change.
Mohta:
Thank you for that important work. Share some of the challenges of bringing all these 28 different sources of data together and how you and your leadership team overcame some of those technical and cultural challenges.
Bharel:
One of the important things about data that we collect at the state level is that we take very seriously confidentiality and protecting that data on behalf of the individuals in the Commonwealth. Part of the reason that the data sat in these independent silos was for privacy reasons. Even within the Department of Public Health I didn’t have the legal authority to bring that data together.
Our unbelievable team at the department came up with a way to bring the data together at an individual level, temporarily, in order to answer specific questions and then deidentify that and do it all behind a privacy shield. They were able to come up with a technique that enhanced our confidence that we could keep the data confidential. But one important thing to know is that we were not allowed or permitted to bring that data together until we changed the state law.
People had been talking about bringing this data together for a long time, but the unfortunate urgency of the opioid epidemic served as our call to action where our legislative partners then gave us 1 year. They said, “Okay, you can answer these seven questions.” After that 1 year and seeing how those questions helped us do things like improve the prescription monitoring program (PMP), put in place limits on how many pills we could prescribe at a time, required use of the PMP and so forth, then they gave us another year to answer more questions.
After that, the law was changed in a way that now at the Department of Public Health we can use these secure data systems to answer urgent health issues, whatever they will be, from here on out. It has allowed us an advantage to now use data in new and innovative ways to understand better what public health approach across these different silos needs to be put in place no matter what health urgency we see.
Mohta:
We have time for one last question. What are one to two advances in health care delivery that you are most optimistic about having an impact on improving health for the populations that we serve?
Bharel:
There’s a lot to be optimistic about here in Massachusetts. If you take a step back and look at what we’ve accomplished in Massachusetts in health, health policy, and health care, a lot of it comes from the fact that our community members demand good health. And they demand that of us as a state and as a health care system. Our work now is to focus — to have a laser focus — on health equity.
We’re one of the healthiest states2 in the United States. That’s something that we should all be proud of, and it’s about having access to this world-class health care system and having put in place smart health policy at all levels. Now our work is to say, in Massachusetts, how do we make sure that we all have access to the best care? That’s why at the Department of Public Health we’re focused on using big data in this precision public health manner that I’ve been talking about, by using our data to better understand the social determinants that affect our capacity to obtain health and finding those continued data disparities so that we can focus our efforts on health equity and improving health for all of us across the Commonwealth.
Mohta:
Beyond the Commonwealth and also creating opportunities, I would hope, for other states and other countries around the world to learn from what you are doing here in Massachusetts and take it back to their own institutions in their respective communities. Dr. Bharel, thank you for speaking with NEJM Catalyst today.
Bharel:
Thank you for having me.
Editors’ note: This podcast was recorded in December of 2019.
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Monica Bharel is Commissioner for the Massachusetts Department of Public Health. Namita Seth Mohta is Executive Editor for NEJM Catalyst.
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