D A Kindig

University of Wisconsin–Madison, Madison, Wisconsin, United States

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Publications (92)570.04 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Achieving meaningful population health improvements has become a priority for communities across the United States, yet funding to sustain multisector initiatives is frequently not available. One potential source of funding for population health initiatives is the community benefit expenditures that are required of nonprofit hospitals to maintain their tax-exempt status. In this article, we explore the importance of nonprofit hospitals' community benefit dollars as a funding source for population health. Hospitals' community benefit expenditures were obtained from their 2009 IRS (Internal Revenue Service) Form 990 Schedule H and complemented with data on state and local public health spending from the Association of State and Territorial Health Officials and the National Association of County & City Health Officials. Key measures included indicators of hospitals' community health spending and governmental public health spending, all aggregated to the state level. Univariate and bivariate statistics were used to describe how much hospitals spent on programs and activities for the community at large and to understand the relationship between hospitals' spending and the expenditures of state and local health departments. Tax-exempt hospitals spent a median of $130 per capita on community benefit activities, of which almost $11 went toward community health improvement and community-building activities. In comparison, median state and local health department spending amounted to $82 and $48 per capita, respectively. Hospitals' spending thus contributed an additional 9% to the resources available for population health to state and local health departments. Spending, however, varied widely by state and was unrelated to governmental public health spending. Moreover, adding hospitals' spending to the financial resources available to governmental public health agencies did not reduce existing inequalities in population health funding across states. Hospitals' community health investments represent an important source for public health activities, yet inequalities in the availability of funding across communities remain.
    Journal of public health management and practice: JPHMP 03/2015; DOI:10.1097/PHH.0000000000000253 · 1.47 Impact Factor
  • David A Kindig
    Milbank Quarterly 03/2015; 93(1):24-7. DOI:10.1111/1468-0009.12101 · 5.06 Impact Factor
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    ABSTRACT: Achieving meaningful population health improvements has become a priority for many healthcare and public health organizations, yet funding to sustain multi-sector initiatives is frequently not available. One potential source of funding for population health initiatives is the community benefit expenditures that are required of nonprofit hospitals to maintain their tax-exempt status. In this paper, we used data from nonprofit hospitals’ tax filings (IRS Form 990 Schedule H) combined with expenditure information for state and local health departments to explore the importance of hospitals’ community benefit dollars as a funding source for population health. We found that across all 50 states nonprofit hospitals spent an average of $133 per capita on community benefit activities, of which $13 went toward community health initiatives (CHI). State and local health department spent an average of $110 and $50 per capita, respectively. Hospitals’ spending on CHI thus contributed an additional eight percent to the financial resources available for public health activities, with further increases expected as health reform takes full effect. CHI spending, however, varied widely among hospitals and, based on our analyses, was unrelated to state and local health department spending Adding CHI dollars to the financial resources available to public health agencies, however, reduced existing inequalities in governmental public health spending across states as shown by a drop in the Gini coefficient from 0.36 for CHI spending alone to 0.21 for CHI and governmental public health spending combined. Hospitals’ CHI dollars thus play an important role in funding the larger public health system.
    142nd APHA Annual Meeting and Exposition 2014; 11/2014
  • George R. Flores, David Kindig, Alina Baciu
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    ABSTRACT: The Affordable Care Act has created opportunities for health care delivery and public health practice to collaborate in new ways to improve population health, and some of the law’s provisions offer concrete platforms for better interaction between the two fields. These opportunities complement system transformation already undertaken by a number of communities often in partnerships involving health care organizations and one or more of the following: state or local public health agencies, academic institutions, and community or other non-profit organizations. In a June 2013 workshop of the IOM Roundtable on Population Health Improvement, presenters and participants discussed: the emergence of variants of the accountable care organization concept, such as accountable care communities in Ohio and coordinated care communities in Oregon, and the need to create markets for health, drawing investments that keep people from entering the care system. Workshop participants also learned about and discussed: the role of communities in shaping the health system broadly conceived (and not merely health care systems); the ACA-driven or reinforced efforts to change the health care payment system and incentivize primary prevention and a population focus; and the increased involvement of non-profit hospitals in partnership with public health agencies and others to tackle some of the place-based factors (housing quality, educational attainment) that powerfully influence the health of their communities.
    142nd APHA Annual Meeting and Exposition 2014; 11/2014
  • David Kindig, Karen Anderson, Alina Baciu
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    ABSTRACT: The phrase “movement-building” and “we need a movement” arise frequently in gatherings on the topic of population health improvement, in recognition of the fact that healthier communities and healthier, longer lives for all will require collective and transformative action. After all, the public health field emerged in part from the history of the labor movement, and has been both beneficiary of or a partner to other movements over the years. Frameworks, insights, and vocabulary drawn from both sociology and community organizing provide some of the tools needed to determine how social movements can inform individuals, groups, and organizations that strive to alter the social and environmental conditions that shape health in U.S. communities. A June 2013 workshop of the Institute of Medicine Roundtable on Population Health Improvement provided these tools, along with several powerful perspectives from movement experts and movement leaders. The themes that arose from presentations and discussion included: the key ingredients of successful movements; essential distinctions or dichotomies (connect vs. direct); the challenge of movement-building in the absence of a well-defined antagonist and the available alternatives; the history of policies that have led to health inequities and the transformative power of movements in addressing inequity. Specific examples examined for their lessons and impact included: the Healthy Communities movement, the climate change and “green” movement(s), and the tobacco control movement.
    142nd APHA Annual Meeting and Exposition 2014; 11/2014
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    ABSTRACT: Regular reporting of health inequalities is essential to monitoring progress of efforts to reduce health inequalities. While reporting of population health became increasingly common, reporting of a subpopulation group breakdown of each indicator of the health of the population is rarely a standard practice. This study reports education-, sex-, and race-related inequalities in four health outcomes in each of the selected 93 counties in the United States in a systematic and comparable manner.
    International Journal for Equity in Health 06/2014; 13(1):47. DOI:10.1186/1475-9276-13-47 · 1.71 Impact Factor
  • Erik Bakken, David Kindig
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    ABSTRACT: The initial analysis of the revised Internal Revenue Service Schedule H community benefit report revealed that only about 5% of these dollars are allocated for community health improvement activities. These results have prompted suggestions for improved community health via community benefit reform, given the poor performance of the US population health system. However, if such a reform were enacted, it would have differential impacts across states due to variation in nonprofit hospitals, expenditures, and community benefit allocations. We model this variation, indicating that the range in per capita benefit across states would approximately range from $46 to $309. This variation should be taken into account as community benefit reform is considered.
    Journal of public health management and practice: JPHMP 03/2014; 21(1). DOI:10.1097/PHH.0000000000000049 · 1.47 Impact Factor
  • Erik Bakken, David Kindig
    WMJ: official publication of the State Medical Society of Wisconsin 02/2014; 113(1):9-10.
  • David A Kindig, George Isham
    Frontiers of health services management 01/2014; 30(4):56-7.
  • David A Kindig, George Isham
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    ABSTRACT: Because population health improvement requires action on multiple determinants--including medical care, health behaviors, and the social and physical environments--no single entity can be held accountable for achieving improved outcomes. Medical organizations, government, schools, businesses, and community organizations all need to make substantial changes in how they approach health and how they allocate resources. To this end, we suggest the development of multisectoral community health business partnership models. Such collaborative efforts are needed by sectors and actors not accustomed to working together. Healthcare executives can play important leadership roles in fostering or supporting such partnerships in local and national arenas where they have influence. In this article, we develop the following components of this argument: defining a community health business model; defining population health and the Triple Aim concept; reaching beyond core mission to help create the model; discussing the shift for care delivery beyond healthcare organizations to other community sectors; examining who should lead in developing the community business model; discussing where the resources for a community business model might come from; identifying that better evidence is needed to inform where to make cost-effective investments; and proposing some next steps. The approach we have outlined is a departure from much current policy and management practice. But new models are needed as a road map to drive action--not just thinking--to address the enormous challenge of improving population health. While we applaud continuing calls to improve health and reduce disparities, progress will require more robust incentives, strategies, and action than have been in practice to date. Our hope is that ideas presented here will help to catalyze a collective, multisectoral response to this critical social and economic challenge.
    Frontiers of health services management 01/2014; 30(4):3-20.
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    ABSTRACT: Trends in population health outcomes can be monitored to evaluate the performance of population health systems at the national, state, and local levels. The objective of this study was to compare and contrast 4 measures for assessing progress in population health improvement by using age-adjusted premature death rates as a summary measure of the overall health outcomes in the United States and in all 50 states. To evaluate the performance of statewide population health systems during the past 20 years, we used 4 measures of age-adjusted premature (<75 years of age) death rates: current rates (2009), baseline trends (1990s), follow-up trends (2000s), and changes in trends from baseline to the follow-up periods (ie, "bending the curve"). Current premature death rates varied by approximately twofold, with the lowest rate in Minnesota (268 deaths per 100,000) and the highest rate in Mississippi (482 deaths per 100,000). Rates improved the most in New York during the baseline period (-3.05% per year) and in New Jersey during the follow-up period (-2.87% per year), whereas Oklahoma ranked last in trends during both periods (-0.30%/y, baseline; +0.18%/y, follow-up). Trends improved the most in Connecticut, bending the curve downward by -1.03%; trends worsened the most in New Mexico, bending the curve upward by 1.21%. Current premature death rates, recent trends, and changes in trends vary by state in the United States. Policy makers can use these measures to evaluate the long-term population health impact of broad health care, behavioral, social, and economic investments in population health.
    Preventing chronic disease 12/2013; 10:E214. DOI:10.5888/pcd10.130210 · 1.96 Impact Factor
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    ABSTRACT: Clinical care contributes only 20 percent to overall health outcomes, according to a population health model developed at the University of Wisconsin. Factors contributing to the remainder include lifestyle behaviors, the physical environment, and social and economic forces-all generally considered outside the realm of care. In 2010 Minnesota-based HealthPartners decided to target nonclinical community health factors as a formal part of its strategic business plan to improve public health in the Twin Cities area. The strategy included creating partnerships with businesses and institutions that are generally unaccustomed to working together or considering how their actions could help improve community health. This article describes efforts to promote healthy eating in schools, reduce the stigma of mental illness, improve end-of-life decision making, and strengthen an inner-city neighborhood. Although still in their early stages, the partnerships can serve as encouragement for organizations inside and outside health care that are considering undertaking similar efforts in their markets.
    Health Affairs 08/2013; 32(8):1446-52. DOI:10.1377/hlthaff.2011.0567 · 4.64 Impact Factor
  • David A Kindig, Erika R Cheng
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    ABSTRACT: Researchers increasingly track variations in health outcomes across counties in the United States, but current ranking methods do not reflect changes in health outcomes over time. We examined trends in male and female mortality rates from 1992-96 to 2002-06 in 3,140 US counties. We found that female mortality rates increased in 42.8 percent of counties, while male mortality rates increased in only 3.4 percent. Several factors, including higher education levels, not being in the South or West, and low smoking rates, were associated with lower mortality rates. Medical care variables, such as proportions of primary care providers, were not associated with lower rates. These findings suggest that improving health outcomes across the United States will require increased public and private investment in the social and environmental determinants of health-beyond an exclusive focus on access to care or individual health behavior.
    Health Affairs 03/2013; 32(3):451-8. DOI:10.1377/hlthaff.2011.0892 · 4.64 Impact Factor
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    ABSTRACT: There is no well-established mechanism at the local level to discuss or manage the balance of investments in health care and the other social determinants of health. We propose the development of voluntary regional organizations and/or use of current organizations to work with stakeholders of the health system to 1) review local data on health, experience and quality of care, and costs of care (Triple Aim); 2) create shared goals, actions and investments to meet the Triple Aim; and 3) involve citizens in local delivery system reform and stewardship of financial resources. These accountable health communities (AHCos) would contribute to co-creating a sustainable health system.
    Minnesota medicine 11/2012; 95(11):37-9.
  • Erik Bakken, David A Kindig
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    ABSTRACT: The Affordable Care Act is drawing increased attention to the Internal Revenue Service (IRS) Community Benefit policy. To qualify for tax exemption, the IRS requires nonprofit hospitals to allocate a portion of their operating expenses to certain "charitable" activities, such as providing free or reduced care to the indigent. To determine the total amount of community benefit reported by Wisconsin hospitals using official IRS tax return forms (Form 990), and examine the level of allocation across allowable activities. Primary data collection from IRS 990 forms submitted by Wisconsin hospitals for 2009. Community benefit reported in absolute dollars and as percent of overall hospital expenditures, both overall and by activity category. For 2009, Wisconsin hospitals reported $1.064 billion in community benefits, or 7.52% of total hospital expenditures. Of this amount, 9.1% was for charity care, 50% for Medicaid subsidies, 11.4% for other subsidized services, and 4.4% for Community Health Improvement Services. Charity care is not the primary reported activity by Wisconsin hospitals under the IRS Community Benefit requirement. Opportunities may exist for devoting increasing amounts to broader community health improvement activities.
    WMJ: official publication of the State Medical Society of Wisconsin 10/2012; 111(5):215-9.
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    Tim Casper, David A Kindig
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    ABSTRACT: The variation in health outcomes among communities results largely from different levels of financial and nonfinancial policy investments over time; these natural experiments should offer investment and policy guidance for a business model on population health. However, little such guidance exists. We examined the availability of data in a sample of Wisconsin counties for expenditures in selected categories of health care, public health, human services, income support, job development, and education. We found, as predicted by the National Committee on Vital and Health Statistics in 2002, that availability is often limited by the challenges of difficulty in locating useable data, a lack of resources among public agencies to upgrade information technology systems for making data more usable and accessible to the public, and a lack of enterprise-wide coordination and geographic detail in data collection efforts. These challenges must be overcome to provide policy-relevant information for optimal population health resource allocation.
    Preventing chronic disease 08/2012; 9:E136. DOI:10.5888/pcd9.120066 · 1.96 Impact Factor
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    Erika R Cheng, David A Kindig
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    ABSTRACT: Several well-established determinants of health are associated with premature mortality. Using data from the 2010 County Health Rankings, we describe the association of selected determinants of health with premature mortality among counties with broadly differing levels of income. County-level data on 3,139 US counties from the 2010 County Health Rankings were linked to county mortality data from the Centers for Disease Control and Prevention Compressed Mortality database. We divided counties into 3 groups, defined by sample median household income levels: low-income (≤25th percentile, $29,631), mid-income (25th-75th percentile, $29,631-$39,401), and high-income (≥75th percentile, ≥$39,401). We analyzed group differences in geographic, sociodemographic, racial/ethnic, health care, social, and behavioral factors. Stratified multivariable linear regression explored the associations of these health determinants with premature mortality for high- and low-income groups. The association between income and premature mortality was stronger among low-income counties than high-income counties. We found differences in the pattern of risk factors between high- and low-income groups. Significant geographic, sociodemographic, racial/ethnic, health care, social, and behavioral disparities exist among income groups. Geographic location and the percentages of adult smokers and adults with a college education were associated with premature mortality rates in US counties. These relationships varied in magnitude and significance across income groups. Our findings suggest that population health policies aimed at reducing mortality disparities require an understanding of the socioeconomic context within which modifiable variables exist.
    Preventing chronic disease 03/2012; 9:E75. DOI:10.5888/pcd9.110120 · 1.96 Impact Factor
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    ABSTRACT: Successful efforts to reduce obesity will require public policy strategies that target both individuals and external factors such as social conditions, economic circumstances, and physical environments. Public opinion data suggest that many policy changes to reduce obesity are likely to face public resistance. We conducted 4 focus groups involving 33 adults living in or near a midsized Midwestern city in July 2008. Participants were assigned to the focus groups on the basis of self-reported political ideology. We used a semistructured discussion guide to 1) better understand public perceptions of obesity and 2) assess the promise of narratives as a strategy to stimulate meaningful discussion about obesity-related policy change. Participants viewed internal factors as primary causes of obesity. Despite substantial acknowledgment of external causes of obesity, many participants - particularly political conservatives - were resistant to external policy solutions for the problem. Across the political spectrum, participants responded more favorably to a short narrative emphasizing barriers to reducing adult obesity than a story emphasizing barriers to reducing childhood obesity. This study provides a deeper context for understanding public perceptions about obesity. Some types of narratives appear promising for promoting support for policy solutions to reduce obesity.
    Preventing chronic disease 03/2011; 8(2):A39. · 1.96 Impact Factor
  • Timothy E Corden, David A Kindig
    Pediatric Annals 03/2011; 40(3):131-5. DOI:10.3928/00904481-20110217-06 · 0.29 Impact Factor
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    ABSTRACT: In October 2009, authors, staff, and guest experts from the Mobilizing Action Toward Community Health (MATCH) project and the Robert Wood Johnson Foundation, the project's funder, met in Madison, Wisconsin to discuss metrics, incentives, and partnerships for population health improvement. Their essays were published in this and the previous 2 issues of Preventing Chronic Disease (www.cdc.gov/pcd/issues/2010/jul/toc.htm and www.cdc.gov/pcd/issues/2010/sep/toc.htm). The plenary and small-group discussions were provocative and wide ranging. The purpose of this commentary is to 1) summarize key themes from the essays and meeting discussion and 2) present recommendations for future practice and research regarding metrics, incentives, and partnerships to improve population health.
    Preventing chronic disease 11/2010; 7(6):A124. · 1.96 Impact Factor

Publication Stats

988 Citations
570.04 Total Impact Points

Institutions

  • 1991–2014
    • University of Wisconsin–Madison
      • • Department of Population Health Sciences
      • • Department of Medicine
      Madison, Wisconsin, United States
  • 2012
    • Madison College
      Madison, Wisconsin, United States
  • 2011
    • Cornell University
      • Department of Communication
      Ithaca, NY, United States
  • 2006
    • Utah State University
      Logan, Ohio, United States
  • 2004
    • Wisconsin Policy Research Institute
      Hartland, Wisconsin, United States