Good Public Health Policies Require Good Data

Anne Zink, M.D., is a lecturer and senior fellow at the Yale School of Public Health. Jeffrey Schiff, M.D., is a senior scholar at the nongovernmental research organization AcademyHealth. Both are former chief medical officers, or CMOs—Zink for the state of Alaska and Schiff for Minnesota’s Medicaid agency—and are now working with The Pew Charitable Trusts to develop a blueprint that can help states create data-driven partnerships focused on improving people’s health.

This interview with them has been edited for clarity and length.

⁠What first drew you to the field of medicine?

Zink: My parents were physicians, and I was an inorganic chemistry major and fine arts minor in college. I was interested in a lot of different things—science, art, communications—and it was really the mystery of the human experience and how it all fits together that drew me to medicine.

Schiff: My mom was a nurse and so proud of the care she provided. She also loved the physiology of health care. I was sort of a geek in high school—and even then, I liked working with kids. Medicine (really pediatrics) was the perfect mix of science and compassion.

How did you then move into health policy work?

Zink: Once I started practicing, I loved it but was also frustrated by the silos within medicine and the barriers to treating the whole patient. My interest in breaking down those silos got me interested in systems of care, and that put me on a path toward public health work. Patients continued to be my “why,” but policy became my “how.”

Schiff: As an emergency room pediatrician, I loved working with kids and families. And I learned pretty fast that the ER is often where you can see—quickly and acutely—the real-world effects of health policy. I started slowly getting involved in policy-related efforts, and one step led to the next. I was drawn to working with systems to have a greater impact.

Zink: The way you describe the emergency department resonates for me. I often tell my emergency medicine residents that they chose public health—they just didn’t know it! 

Can you tell us a little bit about your experience serving as chief medical officer for a state? 

Zink: The COVID-19 pandemic influenced my time as Alaska’s chief medical officer a lot. There were a number of structural changes to the public health department that I made during—and in many ways in response to— the pandemic that I’m proud of and that I think have helped make Alaska’s system work better for patients.

What would be some examples?

Zink: To better serve the people of Alaska, we split the department into two: a department of public health and a department of social services. We developed a more integrated team focused on complex care—meaning care for patients with multiple, significant, and ongoing health issues. That’s important because complex care patients typically account for only about 5% of the Medicaid population in any given state, but about 50% of the Medicaid costs. And, today, Alaska also has a data team in the Commissioner of Health’s office that brings together public health specialists and Medicaid specialists who work side by side to improve people’s health across the health system as a whole. I think these changes helped to make government work for people a bit better, and that was part of my hope when I became chief medical officer.

Dr. Schiff, what about you?

Schiff: I left my role as chief medical officer right before the pandemic started, and I don’t know if I’m happy or sad that I didn’t get to experience what Anne experienced. In any event, I was Minnesota’s first Medicaid CMO. The job was created by the Legislature in 2005, and I started in 2006. And, because it was new, I had the opportunity to shape and define the role. We developed and implemented new models of care, new evidence-based ways of providing health benefits, and new approaches to improving health care quality.

Foundational to everything we did was trust and relationship-building with everyone from Medicaid members and their communities to legislative leaders. This created an environment in which people welcomed and sought out the medical expertise that my team and I had to offer. I think having clinical leaders in government who can credibly bring evidence to government efforts leads to effective and creative solutions. It was both a responsibility and an honor to serve in that role.

Can you describe what you’re working on with Pew? Who are you bringing together and what are you working toward?

Schiff: We’re trying to figure out how to improve the integration of data at the state level—across public health, medical systems, and other sources—so that we have a data infrastructure in place to support better health outcomes. The experts we’re bringing together are an incredible group, including people with significant experience doing this kind of data-driven work in states and nationally.

Zink: It may seem nerdy and wonky, but I can’t think of a more important topic. Increasingly, data is at the heart of any conversation about what can make us healthy and well. The truth is that I simply can’t provide good health care or do good public health work if I don’t have good data.

And that’s the crux of what this work with Pew is focused on: How do we make sure that the good data and information that is already reported, collected, and available to states can be used more easily and effectively to improve people’s health? And what does that look like?

What are you most looking forward to about this work with Pew?

Zink: I’m looking forward to, and grateful for, a nonpartisan discussion of how to tackle this issue. I joke that I belong to the “party of health,” and have always valued nonpartisan approaches to get people to work together toward better health.

Schiff: I’m looking forward to the opportunity to support states in setting up systems that are effective. I feel like public health and the medical community have long suffered from systems that are overly academic, or driven by grants for specific issues, but perhaps not practical or sustainable. This work, on the other hand, is about setting up data-sharing systems and partnerships that are more universal, strategic, and usable.

And what do you anticipate will be most challenging?

Zink: Things are changing so fast on a technology and a policy level that I think it will be hard to lay out a plan that will stay relevant and effective. But sharing information and helping states learn from each other about what’s working well will certainly help mitigate that challenge—and that’s core to the approach that Pew is taking.

Schiff: I guess what I’m looking forward to is also one of the biggest challenges: crafting a blueprint that is flexible and practical enough to be an effective tool that’s adaptable for any state. It won’t be easy, but I’m confident that we have the right people coming together, and we can do it.

What’s the value proposition for states to pursue data-driven partnerships between their Medicaid and public health agencies—particularly at a time when resources are limited? 

Schiff: I think the value proposition is really simple. This is what we expect from our government: to improve people’s ability to live healthy lives. And that requires data. Nobody comes to the legislature in a state and says: “I have an idea that’s going to cost more money and not help anyone.” There are a lot of well-intentioned ideas for how to improve people’s lives. But that’s where data comes in: to help folks at all levels understand what’s cost effective and how to best use resources.

I also think it’s helpful to think of these efforts in the context of research and development. As a percentage of total budget, Medicaid and public health spend a tiny sliver of the amount that a private-sector organization spends on research and development and on understanding its target population. With that in mind, investments in data-driven partnerships and other similar efforts really aren’t that expensive, and the return on investment becomes clear pretty quickly.

Zink: If I were meeting with a governor, I’d say: “You’re building data-driven partnerships because it’s going to save money, it’s going to improve health and potentially save a lot of lives in your state, and you’re going to help make sure that government is working for people versus the other way around.”

I often point to Washington state’s seven best practices for emergency department visits, which started in 2010 and were essentially just recommendations for sharing data between different places where patients received care, and a few guidelines. None of the best practices were mandated, and it saved $32 million in one year. It was a great example of government identifying a problem and partnering with clinicians to find a solution based on data sharing. It saved a ton of money and improved people’s lives.

What do you think are the biggest, most problematic misconceptions about using data to improve people’s health?

Schiff: I wish people better understood that the data doesn’t have to be perfect to be usable. The easiest way to kill an idea is to say, “Well, the data isn’t perfect.” We’re compelled to act based on what we know now. Nobody is saying we have to know everything before we start to make a difference. If we act based on the data we have in the best interests of the people we serve, then we are meeting the moment. We can modify and improve as we learn more.

Zink: In my experience, people think that the government has way more data than it does. In a world where we’re all so used to having information at our fingertips and engaging in prolific information sharing of all different types, I think people are generally shocked and dismayed when they find out how little information clinicians and public health departments actually have access to. And that misconception really hinders our ability to do this data-sharing work because people assume that it’s already happening.

In the midst of what many people have described as a challenging time for public health, what gives you hope? 

Zink: I tend to be an optimistic person. And I think that challenging times help to disrupt silos and the status quo, and to bring together people, players, and different perspectives that, otherwise, may not have worked together. I think that this is actually a remarkable time for envisioning what a unified health system in our country could look like.

Schiff: There are some core ethical principles in health care: beneficence, nonmaleficence (i.e., do no harm), autonomy, and justice. The need for data is consistent with those principles. At the end of the day, I believe all Americans want health care that abides by those principles, and that means they want good data shared for everyone’s benefit.