From wealth to health: the relationship between investments and health outcomes

This research is based on the foundational hypothesis that it is not necessarily how much countries spend on healthcare that defines how successfully outcomes can be achieved, but rather where and how resources are allocated. The interactions and dependencies of health systems and other sectors and services make modeling in health extraordinarily complex. Most economic modeling is conducted across very specific populations, or in a particular segment of the health system, for this reason. However, in utilizing the insights gathered from such analyses for decision-making, leaders risk creating further vulnerabilities and other unintended consequences through siloed actions and short-term resource allocations.

While modeling the baseline relationships among the core indicators for the model we created, our analysis picked up a number of important factors that inform our understanding of health investment and its relationship with health outcomes, which is Steps 1 and 2 of this model (see Figure 1). As well as the relationships uncovered in our model, there are likely to be other relationships which we were not able to explore due to limitations in the data available. For example, there was no clear data which captured state health systems’ uptake of technology and innovation and their impact on the relationship between investment and included outcomes, so this could not be incorporated into the model.

Managing waste and avoidable care

Our framework confirmed that managing waste and avoidable care is one of the more effective ways to achieve desired health outcomes. In our model, preventable hospitalizations (included in avoidable care) are linked to lower healthy life expectancy and greater prevalence of low birth weight, preterm births, infant mortality, reported low health status and mortality amenable to healthcare¹. Moreover, the US does not always have strong enough systems to distinguish and regulate investments that are considered low-value, thereby harming its ability to achieve optimal outcomes². Ongoing investments in avoidable care mean that fewer resources are available for essential healthcare services alongside innovative and targeted treatments. One study looking at the impact of promoting dominant interventions among Medicare beneficiaries, which are both cost saving and health increasing, found that doing so freed up the funds for 5.5m additional beneficiaries to receive treatment, increased quality-adjusted life-years by 270,000, and generated approximately US$12.9bn in cost savings.³

Increasing workforce investment, and improving access to dental care

The model shows that a dynamic approach to workforce investment, namely investing in nurses, additional health practitioners and allied health professionals (AHPs)⁴ correlates with reduced low birth weight, preterm births, infant mortality, reported low health status and mortality amenable to healthcare. An increase in the number of family and general practitioners (GPs) are linked to fewer poor physical and mental health days, which may be indicative of better disease management, particularly of chronic conditions. This makes a clear case for a broader array of healthcare professionals in primary care, chronic disease management and other social aspects of care, such as education and patient support.

Nurses, other healthcare providers and community doctors can provide equivalent, or higher, quality of care for some tasks performed by GPs in primary care, and may alleviate capacity burdens on health systems. Though few studies explore this relationship, some evidence suggests that nurse-led care for common minor health problems is more cost-effective than GP care.⁵ Further research is needed to quantify the economic and social benefit of this approach, but our model suggests a strong relationship.

This model also demonstrates a relatively consistent story around dental health: improved dental health coverage leads to better health outcomes. Employing more dentists or offering more dental visits per capita can lead to greater healthy life expectancy and reduced infant mortality, and yield fewer days of poor mental and physical health, less reported low health status, and reduced mortality amenable to healthcare. Socioeconomic and geographical disparities may be mitigating factors in dental healthcare utilization—that is, better utilization of dental care may correlate with better utilization of healthcare services.

According to Healthy People 2030, a US government initiative to improve population health outcomes by 2030, tooth decay is the most common chronic disease in children and adults in the US.⁶ Untreated oral health problems can cause pain and disability and are linked to other diseases. These findings suggest the benefit of targeted public health messaging around the importance of dental hygiene, as well as investments in expanding the dental health workforce and facilities to improve access. Individual-level interventions, along with public health and community education on proper dental hygiene can help prevent oral health problems. Aided by such policy shifts, some argue that dental and general medical coverage could be meaningfully integrated to promote equity.

Health outcomes impacted by health disparities, public health, social determinants and behaviors

This model also confirms the influence of health disparities, public health, social determinants and behaviors, on health outcomes. For instance, smoking has a negative association with overall life expectancy, and is positively linked with greater poor mental and physical health days. The presence of a higher number of obese adults in a population is also linked to more poor physical health days. Obesity is a complex and chronic disease, and there is evidence that solely addressing short-term risk behaviors on its own is an insufficient policy, and needs to be combined with improved financial and physical access to healthier food, support for physical activity, long-term patient-provider contact and increasing access to obesity treatments.^7,8 In the past countries have not been successful in reducing obesity rates at the population level.⁹ And recent studies have also proven that body mass index is not a reliable indicator of health. For example, obese individuals with good fitness levels have lower cardiometabolic risk compared to individuals with normal weight but lower fitness levels.¹⁰

Our model also suggests that maternal and child health is another area in which targeted investment could counteract the negative economic and health impacts of health disparities. A higher number of teen births is a known factor for poorer infant health and other outcomes such as low birth weight, preterm births, infant mortality and poorer health status in adults. Also, a higher female population of childbearing age (15-49y) within the US is associated with worse life expectancy and more mortality amenable to healthcare, likely due to gender-related differences in access and affordability of care.¹¹ Women are at a higher risk of unmet need when compared to men, which may also contribute to the difference in mortality amenable to healthcare and life expectancy between men and women.^12-13 Health disparities are also more pronounced among low-income women who are racial or ethnic minorities.^14,15,16,17

Conclusion

Our model shows that effective resource allocation in health can indeed be an impactful tool in producing desired socioeconomic outcomes, and suggests that leaders can make proactive, well-informed decisions regarding resource allocation in health systems for optimal health and socioeconomic wellbeing. There are some further considerations required to examine the effect that complex factors like technology and innovation have on health investments and outcomes.