Dr. David Kindig, Professor Emeritus of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences, University of Wisconsin-Madison
As someone who helped coin the phrase “purchasing population health,” David Kindig has been at the forefront of the move to a health care system that prioritizes outcomes, aligns incentive structures, and eliminates waste. His work has always been prophetic and ahead of its time, pushing value based purchasing in the 90s before most knew what it meant. His approach weaves population health concepts with emerging cross-sector partnership frameworks, all in an effort to prioritize health, reduce inequality, and unleash our collective potential, all in an effort to achieve longer, healthier lives for all of us.
David A. Kindig is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin-Madison, School of Medicine and Public Health. He currently is Co-Chair of the Institute of Medicine Roundtable on Population Health Improvement and Co-Directs the Wisconsin site of the Robert Wood Johnson Health & Society Scholars Program. He was an initial Co-PI on the Robert Wood Johnson MATCH grant under which the County Health Rankings were developed and was the Founder of the RWJF Roadmaps to Health Prize. From 2011 to 2103 he was Editor of the Improving Population Health blog.
He received a BA from Carleton College in 1962 and MD and PhD degrees from the University of Chicago School of Medicine in 1968. He completed residency training in Social Pediatrics at Montefiore Hospital in 1971.
Dr. Kindig served as Professor of Preventive Medicine/Population Health Sciences at the University of Wisconsin from 1980-2003. He was Vice Chancellor for Health Sciences at the University of Wisconsin-Madison from 1980-1985, Director of Montefiore Hospital and Medical Center (1976-80), Deputy Director of the Bureau of Health Manpower, US Department of Health, Education and Welfare (1974-76), and the First Medical Director of the National Health Services Corps (1971-73). He was National President of the Student American Medical Association in 1967-68.
He served as Chair of the federal Council of Graduate Medical Education (1995-1997), President of the Association for Health Services Research (1997-1998), a ProPAC Commissioner from 1991-94 and as Senior Advisor to Donna Shalala, Secretary of Health and Human Services from 1993-95. In 1996 he was elected to the Institute of Medicine, National Academy of Sciences. He received the Distinguished Service Award, University of Chicago School of Medicine 2003. He chaired the Institute of Medicine Committee on Health Literacy in 2002-2004, chaired Wisconsin Governor Doyle’s Healthy Wisconsin Taskforce in 2006, and received the 2007 Wisconsin Public Health Association’s Distinguished Service to Public Health Award.
Show Notes
Dr. David Kindig shares his extensive background in health and health care. [03:40]
What are the six core areas that need fundamental change in health care? [04:53]
How can the Robert Wood Johnson Culture of Health Prize inspire others? [09:49]
Why haven’t we achieved the optimistic vision of health care laid out in the 1997 book “Purchasing Population Health: Paying for Results?” [13:31]
Do we need government-driven policy change? [17:01]
What’s one of the most important things we can do to improve population health? [18:49]
The debate around the universal basic income policy. [19:47]
What can the future healthcare system look like if the proposed changes are implemented? [22:09]
Will artificial intelligence be an ally in integrating cross system solutions? [26:03]
How do we move past divisive, political ideology in the health care debate? [29:59]
What would be the benefits of this desired future state? [32:20]
Transcript
Jason Helgerson 0:00
Hi. I'm Jason Helgerson, and you're listening to Health2049.
Dr. David Kindig 0:08
Health can be an end in itself, it is an end in itself. But it also allows you to do other things both individually, but also productivity. I mean, one of the reasons that business leaders are on board with some of the social determinants, particularly education, for example, is that we can't be productive without a healthier workforce. So we would be healthier all across all subgroups, everybody, but it would also lead to other individual and social benefits that I doubt there can be much ideological debate of whether those would be a good thing.
Jason Helgerson 1:57
The move in health care towards value-based payment, sometimes referred to as buying better outcomes is often seen as a relatively new development. Today's guest, however, has been thinking about this topic for decades. In fact, I would argue he actually helped coined the phrase, purchasing population health, by coauthoring one of the very first books on the topic in 1997.
Dr. David Kindig is an academic and researcher who has inspired the field of population health and public health for more than 30 years. In addition to his many positions at the University of Wisconsin Madison, Dr. Kindig has been a senior federal official, the CEO of a large academic medical center, a member of the National Institute of Medicine, and one of my most important mentors. As someone who has spent his entire career dedicated to producing better health for populations, you can see why I'm so pleased and honored to have David Kindig on our show today to share his vision for what health and health care should look like in the year 2049.
I'm Jason Helgerson, and you're listening to Health2049. And it's my pleasure to welcome David Kindig to our program. David, welcome.
Dr. David Kindig 3:06
Hey, Jason, good to be talking to you again, and we miss you out here in Wisconsin.
Jason Helgerson 3:11
Well, I appreciate that. And as I said, I'm very excited about having this opportunity. I can't think of anybody whose depth and breadth of experience is better suited for the topic of looking into the future. And then, as you and I discussed before, you have a unique perspective in the sense that in the past, you've also predicted the future. And I think we'll get into that, particularly as it relates to your 1997 book that I mentioned. But first and foremost, can you tell us a little bit more about your background?
Dr. David Kindig 3:40
Well, thanks. You've covered it pretty nicely. The last 25 or 30 years here at the University of Wisconsin, I have primarily been a scholar, and a thought leader in population health. So most of my time in the recent past has been in health, not health care, although understanding that health care is an important determinant of health, but not the main one, we would argue. But before that, it's not like I haven't been in health care. I actually have both in the federal government, actually my first job I started the National Health Service Corps, which was a great job, my best probably, and I ran a big Medical Center in New York. So even though I don't focus on health care so much these days, I certainly have that background.
Jason Helgerson 4:35
Excellent. So we always like to start with our guests and give them the opportunity to peer into the future roughly 30 years, the year 2049 and ask them to tell us a little bit about what they hope health care looks like, so, David, take it away.
Dr. David Kindig 4:53
Okay, well, thanks. I actually do have a list here, as you know, I have speculated about some of these things in the past. But in 2020 a colleague did ask me what I saw looking forward for the next 20 or 30 years. So I actually made a list. But to back that up, I've written and believed for a while that the most important population health research and policy question is, what is the right balance of the different determinants of health, like health care, like social factors, like the environment, like behaviors, in improving overall health and reducing those disparities, the unacceptable gaps? That's kind of a research question. It's unfortunately a question that we see a little bit of those relationships, but it's still not clear enough to guide policy. So that's very important research, related to policy challenges. But that's why my first thing for the future is that we will have solved that equation, hopefully, with better datasets, better methods, and a lot more attention to it.
And the reason we need to do that, because my second thing for the future is that I think we have to set per capita investment benchmarks across these determinants. We do a lot of benchmarking on determinants, like smoking rates, or poverty rates, or health care quality or uninsured rates. But we don't often go so far as to go forward with what would it take per capita as a poverty investment, or a health care quality investment or an uninsurance investment, in order to improve those outcomes.
Third, we have to spend less in wasteful, unneeded health care, and reinvesting those in social determinants and particularly for poor sick kids. I would have a vision, forth, of a financial formula model, like interest deductions or crop subsidies, or for those in health care, graduate medical education payments, where those dollars kind of roll in on a formula basis, rather than having to get a grant or through other less regular investment strategies.
And then two others, I hope there will be robust multi sectoral partnerships, community partnerships across sectors to make these things happen. If population health is a multi determinant, production function, I know that's maybe a few big words, but circa economic terms for the multiple determinants that produce health, then the solution has to be a multi sectoral policy solution in our communities with health care, public health, schools, environmental factors. And so we need those partnerships with core funding for those partnerships to sort of move those things forward.
And then finally, given our times, I think we really have to find political and ideological, common ground and social solidarity, I know we have certain things that may divide us forever. But better health does not need to be one of them. And the fact that people in lots of other countries live longer, and with better quality is not acceptable, it should not be acceptable to any part of the political spectrum. So that's a tough challenge. But I'm hoping that we will make progress on that. So those are my current six.
Jason Helgerson 8:42
I love it. It's great, very clear, very concise, and lots of opportunity for us to double click into any one of those six. But I guess one of the things I want to chat about a little bit is one of things I've always appreciated about you is you're very much a systems thinker. You see the holistic challenge and the need for cross system solutions in order to address the holistic challenge. And I think, as you sort of alluded to in your list there, one of the things that needs to be done is we need to think across not just health and health care, but into education into these other systems that support the needs of vulnerable communities or challenged individuals. And so how do you see by the year 2049, putting on your optimistic hat, how do you see those systems, which oftentimes, there's been efforts, but not really all that successful at trying to get those various systems to work together. How do you see those systems working together in a coordinated and effective fashion in the year 2049?
Dr. David Kindig 9:49
I think you're right, we've made beginnings. Well, let me back up a minute. I have wondered and speculated, it's possible that each sector could do exactly their right share of the health production function, the exact amount of poverty reduction or of educational quality or of improving insurance or whatever on their own to have the efficient solution to the equation, I don't think that will happen. And so I think there needs to be some coordination across sectors.
In my book, I actually call them health outcomes trusts, these days, people talk mainly about multi sectoral partnerships. So I think the good news is that there are things going on around the country and the world, in this regard. It's primitive, often just the glue resources for coordination, I've actually had a blog on that, the glue resources for just having the time and the effort in the meeting spaces and the doughnuts for people to get together and make this work. That's not even present, much less the financial incentives that can drive that. I mean, there are lots of examples going on.
If you want to look to a successful one, so your listeners may or may not know about the Robert Wood Johnson Culture of Health Prize, it's something we started, the staff here at the University of Wisconsin. It's a prize given annually to communities that are making progress on health. And one of their selection criteria is maximizing the collective power of leaders, partners, and community members. And all these winning communities of the last year are profiled in the website, so if you want to find examples. The current group that were just selected, for example, Palm Beach County in Florida, was one of them selected and if you go on that, check that story, you'll see how they're working with public health, health care, nonprofits, and other resources in the community. And there are dozens of those examples in the Culture of Health Communities.
Jason Helgerson 12:05
Yes, and it's interesting that we've had guests on this show who work within the National Health Service in England, where there's an ongoing discussion, debate effort to try to create a more integrated delivery system, one in which the health and social care systems at the least begin to work together more effectively, because they see those silos as being major impediments to improved health and well-being in communities across the country.
So my hope, certainly is that by 2049, 30 years in the future, it'll become more than norm that will have integrated, truly effective systems of care and community as I would almost describe the world you're suggesting, but maybe we could go back down memory lane a little bit and talk about your 1997 book, Purchasing Population Health: Paying for Results, and in that book you did talk a lot about these concepts and at that point, I think were optimistic that some of these issues would be I guess, resolved by this point. Here we are in the 2020s, over 20 years later, and so almost 25 years later, actually. And so I'm just wondering, as you think back, why have we not made more progress than we have in some of these crucial areas around population health improvement?
Dr. David Kindig 13:31
Yeah, well, thank you, actually, for reminding me to go back and look at this. The book came off of a sabbatical half in York, England, focusing on outcome measurement issues, and then half in Vancouver with the multiple determinants of health crowd there. And so, and I had been thinking about, those were managed care days, and so what if you paid for health in a capitated sense, rather than health outcome, a pathway to health services, how would the outcomes move?
So that was the spirit of that. And this was 1997. Actually, I was very optimistic at that time. I said there'll be three years for debate, research and demonstration projects on this kind of idea. And then I said, phase two would be the decade of 2001 to 2010. And I focused that mainly on the outcome based payment for integrated delivery systems, what we would now call value purchasing. And then assuming that got taken care of in that decade, then phase three would be up until 2020. That would be the integration of social, environmental and other determinants. I realized, of course, that those would not have to be in parallel and they weren't, they could develop separately, and there's been progress made on each of those.
But obviously, that 20 year period or 25 year period was very optimistic. What's the reason for it? I mean, that's a really complicated, long question. I basically think, well, the subtitle of the book is Paying for Results, and I think we don't have financial incentives in place for either of those, either for value-based purchasing, although lots of experiments and work going on, and certainly for the integration of the social determinants. So, I mean, that's kind of why I had my fourth thing, this may be a fantasy, but having a financial formula model that has those incentives figured out right, and then delivers payment in a multi sectoral way to these health outcomes trusts or these multi sectoral partnerships we were talking about.
I did run an academic health center in New York, and I was amazed how the dollars for graduate medical education just rolled in every day, perhaps more than they needed to be even. But once a formula like that gets going like mortgage interests or crop subsidies, policy follows. So there's enormous resistance, obviously, to moving dollars around for all the reasons that you and I both know. So it's a big challenge. But I'm optimistic that more progress can be made in the next 30 years, than we did in the last 20.
Jason Helgerson 16:37
So in order to achieve this vision 2049, how essential is it to have substantial policy change in the United States at the federal level? Do you see any path other than government-driven change? Or do you think that there is an alternative that gets us closer to your desired future state?
Dr. David Kindig 17:01
I'm not against market forces. I think those are very powerful and building them in wherever they can, we need to really support and encourage. I don't think they're adequate at all, either on the health care side, or on the health side. I'm in the camp that believes that a quarter or a third of our spending is wasteful. And whether that can possibly somehow be recaptured or reallocated, I don't know, that may be a pipe dream. We can't even negotiate drug prices.
So the forces against that kind of change are great. And then even our attempts now, like with the Build Back Better Bill right now. I think the most important population health policy sitting on the table right now is the Child Health Tax Credit that could reduce poverty in half if it were permanent, and the impacts on that on future health and health equity and disparities would be huge. But as you probably see it in the current draft from the house, it's only put forward for one year, a single extension of a year. So that's how hard it is to do these things, but I think a lot of it probably does have to be done. I think there's a lot of room for experimentation in local communities and in states, so it doesn't all have to be federal.
Jason Helgerson 18:32
Understood. So what you were just describing, has got me thinking, and this is a question I've been wanting to ask you for a while, which is, if the federal government could do one big thing in order to improve population health, what would be that one big thing?
Dr. David Kindig 18:49
Well, I'm gonna repeat what I just said. It's not just that I am former pediatrician, but I am, I look at every time a child is born in poverty, 70-80 years of poor health outcomes are baked into the system for a whole variety of reasons that both what poverty means in terms of health care, in terms of food on the table, in terms of a living environment, in schooling, terms of what that means.
So if I had to do one thing, that's what I would do, either straight up, like a new investment, as is being proposed today. Or even possibly to reallocate from other wasteful spending in health care, that's the one thing I would do. And it's so tempting because we're on the cusp of it right now. But it's also so tantalizing and far away.
Jason Helgerson 19:47
Yeah, it's interesting, the debate around the universal basic income policy, I find to be an interesting one in the sense that I think a growing number of people from different perspectives, talking about the potential benefits of creating that floor from an income standpoint that all individuals would have and true to redistribution. But your take is that you think that would be raising incomes, particularly for families with young children would be the most powerful thing that the government could do to improve health, which isn't always the argument you hear, you hear a lot of other social justice arguments, and also just general economic arguments around say things like UBI. But you've seen a lot of movement on that issue, in the past half a decade, in terms of it being a more widely discussed idea than it had been in the past.
Dr. David Kindig 20:45
Yeah, I think that's right. Obviously when I talked about the in the beginning, solving the research challenge of getting the balance of investments right. It's not a single one, you asked me to pick one, which I did. But there are undoubtedly others that compete in the relative per capita investment equation. I mean, smoking is still maybe an old time public health issue, but it's still a contributor, and climate change, just to be more modern as we go forward, or even broadband or housing. So, there's opportunities in all, as well as things in health care itself, which is not where I focus most of my attention, but you asked me to pick one. So if I had to pick one, that's what I would pick.
Jason Helgerson 21:36
So maybe we could talk a little bit about the healthcare system in this future state of yours, and maybe try to give our audience a sense of, if we actually achieve those six core things you think are necessary, what does the healthcare system look like, feel like? What is the experience, say, take it either perspective of a patient or provider just to help the audience wrap their head around a little bit about the fundamental changes you're suggesting, could and should be accomplished by 2049?
Dr. David Kindig 22:09
I think it would be leaner and meaner first. I'm totally impressed by the comparative evidence about how much we spend, compared to what we get from our European and other developed country competitors. So whether we can dial that back at all, because there's so many forces that are in there, I don't know. I'm now a Medicare beneficiary, every time I go in I ask people, providers, what did this cost? And they just have a blank stare on their face, like they haven't thought about it. So I think we see things changing a bit about that, but not yet. So I think it'll be leaner.
And then I think somehow or other, it'll be more integrated with the other determinants of health in the local community. We talk about these multi sectoral partnerships, there are cases where progressive healthcare systems take the lead on those in their communities and that's really an important role for them to play. In other cases, it's public health departments, or United Way's or other non profits. So playing a role in that system that is not totally self interested, but geared towards the appropriate role in the system with some financial incentives to make that happen. I guess that would be my vision.
I haven't said much about patients and providers in that obviously, those kinds of changes would impact them. I actually just had an email from a colleague who was a business and health expert who's now teaching, he said his doctors in the Clinical Scholars Management Program are more interested in community health and Medicare reform. When I heard that, I got a smile on my face. So maybe there is a new future in that direction. There's obviously others who will have commented more on a changing role for providers and for patients, obviously, patients are going to be much more involved in their care. The whole information revolution is sort of daunting, and it should have a lot of positive things going forward.
Jason Helgerson 24:56
I think it's data and analytics and technology and new types of treatments, new ways to interface with patients, new types of engagement. Health care is such an episodic thing, where traditionally, it's like you get sick or you have an issue and you go to a provider and they provide you a service, and then you go home, and then you have to go back. But there's not a lot of connectivity there. The health system tends to be passive, but the world you describe is where you integrate all these determinants of health into a cohesive and proactive system where it's about preventing illness in the first place. It's about improving health, sort of the classic going upstream argument, I would imagine that technology is potentially the friend of that effort. Would you say that you see technology and then some of the latest advances, whether it's artificial intelligence as potentially very powerful ally in achieving your vision for 2049?
Dr. David Kindig 26:03
Yeah, I think so. I don't see that clearly and, of course, there's a lot of issues with technology, like artificial intelligence has so much promise and also so much fear. Some of these models of care don't have to only be future-oriented. I was a pediatric resident in the South Bronx, in one of the original OEO Neighbor Health Centers and we had family health workers and nurse practitioners, but we also did school health. The OEO Grant paid for job training in the community and stuff like that. So there have been other times where actually financial incentives supported the different kind of system that we might envision for the future. So just a little historical note there.
I'm going to say something contrarian about technology. I think there are a lot of possibilities for it, particularly like you say, in information and artificial intelligence and who knows. I am one that's concerned about the genomics and personalized medicine developments as being super expensive and producing very expensive benefits for a very small number of people. Now, I know that's contrary and difficult because it does help some people, so there are ethical issues there.
I have another valued colleague who said whenever she sees a new drug, like the new Alzheimer's drug, for example, that is a giant sucking sound, essentially, sucking resources away from much more cost effective investments, both in health care, and in the other determinants like child poverty. So that's a tricky one. And it totally can't be black and white. If there's a genetic fix for sickle cell anemia that's reasonably priced for those people that suffer from it, that's obviously a positive. But so many of these things look like they're very much on not very many quality adjusted life years per dollar. I learned that in York on my sabbatical, so I'm a devotee of quality adjusted life years per dollar saved. And many of these new things don't meet that at least yet.
Jason Helgerson 28:35
Yeah and I guess one of the challenges there is, because one of the six you mentioned is this idea that we need to move away from health being something that divides us, and my perception is that the debate around the Affordable Care Act, really in the United States politicized health and health care in ways that wasn't the case. And I think it's once again, being politicized by the pandemic, and vaccine and the various rules, restrictions that we all experience during this very trying public health emergency.
But I guess the one concern I would have from what you were just describing is that it could be so easily characterized as rationing, that this decision-making process to bring a phrase from previous political era of death panels was a classic example of taking a relatively minor thing and blowing it into a divisive political issue and so how do we navigate between purchasing population health in an efficient, effective fashion, but at the same time, not being characterized as rationing care, denying care in inappropriate ways?
Dr. David Kindig 29:59
Yeah, that's a really tricky one and a very hard one. If I had the answer, I'd probably be doing something else. I'm not sure how to overcome that. I don't believe that we have enough resources to do everything. If we did, we wouldn't have to make any choices, which are what economics is a discipline of choice. So there might be a lot of waste, but at least we wouldn't have to make choices. And I think we do have to, we're making them all the time. We may not want to call it rationing, but we do ration in all different kinds of ways. So I'm not afraid of that word. I know how a politician can't say it.
I think the finding common ground for health should not be as hard as finding common ground on issues, social issues like abortion, or those that are so challenging. Now, in the role of government, that's in between someplace that is a politically divisive thing. So to what degree is health a governmental function rather than an individual function? So those are too hard to challenge. I don't know, I read David Brooks a lot. I like him and he's been arguing so much for, somehow we've got to find ways to come together with respect that allows us to get past these things. And I don't know if you've seen but he's with the Aspen Institute, he's got a project called Weavers where he's actually in community, by community, trying to find some dialogue around common ground that goes beyond political ideology. And I don't know anything about how successful that is yet, but I think it's certainly in the right direction.
Jason Helgerson 31:55
All right. So we always like to end our interviews by asking our guests to take a step back to think about the broader implications of their vision for health and health care in 2049. And let's assume that all six of your major tenants for the desired future state, let's assume they all are achieved by 2049. My question to you is, how would the world be a better place if we actually got to that achievement?
Dr. David Kindig 32:20
Well, hopefully, we would raise the mean of our health outcomes, both length of life and quality of life. So you'll think about two parts of what is population health for the mean, but also that the gaps would be reduced between whatever subgroups, you want to think of rich, poor, black, white across nations. So health becomes more equalized, it's an equity argument.
Then health is an end in itself, but it also allows you to do other things, both individually, so happy life, but also productivity. I mean, one of the reasons that business leaders are on board with some of the social determinants, particularly education, for example, is that we can't be productive without a healthier workforce. So I think we would be healthier across all subgroups the mean, everybody, but it would also lead to other individual and social benefits that I doubt there can be much ideologic debate of whether those would be a good thing. So that's a pretty high level answer, but I kind of think at those high levels. So that's what you get from me.
Jason Helgerson 33:50
I love it. I think it's an absolutely appropriate answer. And that was David Kindig's vision for health care in the year 2049. As always, thank you for listening to Health2049. If you enjoyed what you just heard, please subscribe to us on Apple Music or Spotify, and share this podcast with a friend. Thank you and see you next time.
