Transcript Slides
Jeffrey Levi, PhD
Professor of Health Policy &
Management
Residency Fellowship in
Health Policy
October 12, 2016
Bottom line
• Changes in health financing driving the
health system to think beyond their four
walls—this requires new partnerships
• Public health can be the “chief health
strategist,” catalyzing and negotiating
this change using its strengths and
adapting to a new role
Uninsured Rate Among the Nonelderly Population,
1972-2015
20
18
Share of population uninsured:
18.2
17.5
17.2
16.7
16
16.3
14
16.1
13.3
12
12.0
10
10.6
8
6
4
Note: 2015 data is for Q1, Q2 and Q3 only.
Source: CDC/NCHS, National Health Interview Survey, reported in
http://www.cdc.gov/nchs/health_policy/trends_hc_1968_2011.htm#table01 and:
http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201602.pdf.
2015*
2014
2013
2012
2011
2010
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2008
2007
2006
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2001
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1999
1998
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1996
1995
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1991
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1989
1986
1984
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1978
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1974
0
1972
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Population Health: The New
Buzzword
• Means many things to many people
• Fundamentally about thinking more comprehensively
about what care inside the clinic means and linking it to
the conditions outside the clinic
• Spectrum from linkage to social services to provision of
social services to addressing social determinants of
health
– Even CMS now speaks of social determinants
– Ultimate driver: Triple Aim
– Social and behavioral determinants [of health] as cost
drivers
• Requires partnerships; requires targeted and universal
interventions (policy/systems change)
Drivers of change
• The health system is changing only in part
because of the ACA
– Focus on outcomes
– Focus on cost containment
• Expectation of return on investment from both
clinical and public health interventions
– Not whether, but timeframe and extent
– Who shares the savings and how are they used?
Status quo is not an option
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NCD mortality rate (16/17)
CD mortality rate (14/17)
Last in life expectancy
Youth least likely to survive to 50
Highest level of income
inequality; poverty; child poverty
• Third lowest rate of pre-school
education and secondary school
completion
Health and Social Care Spending
Percent of GDP
Percent
Source: E. H. Bradley, L. A. Taylor, and H. V. Fineberg, The American Health Care Paradox:
Why Spending More is Getting Us Less, Public Affairs, 2013.
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From accountable care to
“accountable health”
• Accountable health approaches
integrate (in varying degrees) the health
care and social needs of individuals in
the hope of improving health outcomes,
reducing costs, and resolving upstream
factors that affect health.
It seems overwhelming…what
matters is that we start
• Different communities at different starting
points
• Different motivators – from traditional disease
management to social determinants or
community economic competitiveness
• All paths lead to new partnerships and
collaborations and to broader impact than
imagined
ACA provides a pathway
• Addressing social determinants of health
requires new partnerships
– Moving beyond health in all policies to a
Culture of Health
– Examples abound of new partners across
housing, education, community development
• National Prevention Council/National
Prevention Strategy as a federal base
ACA envisions new partnerships
-- National Prevention Council
Bureau of Indian Affairs
Department of Labor
Corporation for National and Community
Service
Department of Transportation
Department of Agriculture
Department of Veterans Affairs
Department of Defense
Environmental Protection Agency
Department of Education
Federal Trade Commission
Department of Health and Human Services
Office of Management and Budget
Department of Homeland Security
Office of National Drug Control Policy
Department of Housing and Urban
Development
White House Domestic Policy Council
Department of Justice
Department of the Interior
Office of Personnel Management
General Services Administration
National Prevention Strategy:
Goal ∙ Strategic Directions ∙ Priorities
NPS has catalyzed change within
federal government
• Partnership for Sustainable Communities
– HUD, DOT, EPA
– Metrics: active transportation use; access to
healthy food choices; access to open space
• Increased use of Health Impact Assessments
– CDC/NNPHI, Health Impact Project
• Regional “prevention council” in Region 8
Moving NPS into communities
• National Collaborative on Education and Health
– Integrating health-relevant metrics into school report cards
– As health system moves into communities, including schools
as locus for creating health
• Braiding and blending funds to incentivize
partnership in communities
– School Climate Grants
– Performance Partnership Pilots for Disconnected Youth
Levers in the ACA
• Accountable Care
Organizations (and
variants)
• CMMI Innovation
Awards (population
health models that
address social
determinants)
• SIM grants and global
budgets
• Medicaid essential
health benefits rule
• Community benefit
requirements for nonprofit hospitals
• Prevention and Public
Health Fund
A spectrum of approaches
• Upstream approaches with long time horizon
vs. services/changes that have quick impact
• Emphasis on meeting individual (social)
service needs vs. policy, systems, and
environmental change
• Leadership from health system vs. public
health vs. community
Hennepin Health Social Accountable Care Organization
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Creates a link between physical and mental
health, inpatient and outpatient care, and social
services. Members receive tiered care from a
coordinated care delivery team using a common
electronic health record and integrated data
warehouse.
Services include housing and social services
navigation, employment counseling, targeted
case management, access to outreach workers
and community paramedics and to clinics
designed to meet members’ complex needs.
PMPM capitated payment system with shared
risk and members are prospectively enrolled
rather than attributed.
Hennepin Health Social Accountable
Care Organization (2)
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Reduced emergency department visits by more than 20% in year 1. Reduced spending
for some of the program’s top 200 users of medical services. County has reinvested $1
million in savings to fill service gaps and providing even better, cost-saving, care
Improved number of patients receiving optimal use of care for chronic diseases (7.6%
increase in asthma, 10.8% in diabetes, 23.5% increase in patients receiving optimal vascular
care)
Savings have been reinvested in sobering center, vocational services for high-risk behavioral
health patients, leasing transitional housing as an alternative to hospitalization for medically
complex homeless patients
Incorporating public health promotion via smoking cessation initiatives and expanded dental
services
Analyzing data from more than 1,200 Life Style Overview surveys. Identified social
determinant areas that Hennepin Health members perceive as having a high potential of
improving their quality of life, such as food, social support, employment and medications
Oregon CCOs
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Trillium Community Health Plan and Lane County Health and Human Services are
collaborating on the following prevention programs for low income populations:
730 low income elementary school students in 85 schools are playing the PAX
Good Behavior Game for smoking prevention.
Pregnant women are receiving gift cards for staying smoke-free between prenatal
visits.
230 physical and behavioral health providers are now trained in smoking
cessation treatments.
Body mass index research will be done at low income elementary schools.
Schools will be assessed to determine their readiness to meet 2017-2018
mandates for increased physical education in grades K-8.
New tools will help communities advocate for healthy food offerings in recreation
center vending machines.
University Hospitals, Cleveland OH
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Anchor Mission” commitment to stimulating the local
economy
Vision 2010 $1.2 billion strategic expansion set
enduring local standards for including minority
contractors in construction opportunities/building
trades
Buy local vendor preference led to largest supplier
opening local distribution center, other suppliers
locating operations in Cleveland
Evergreen Cooperatives – 4 worker-owned
businesses, created more than 100 jobs
NewBridge Cleveland – non-profit trains
underemployed youth for health care jobs, engages
at-risk youth in afterschool arts program
Truman Medical Center, Kansas
City MO
• Financial literacy program
– Low-wage employees didn’t have banking
relationships
– Recruited commercial bank to open in the hospital
• Access to healthy food
– Developed a farmer’s market, accepts SNAP benefits
– Working on putting a full service grocery in a food
desert
CMMI Investments
• Health Care Innovation Awards
• State Innovation Models
– New partnerships
– An integrator agency
– Coverage of non-clinical interventions
– Thinking beyond the patient population to
the community’s health and well being
• Accountable Health Communities FOA
CMMI Accountable Health
Communities (JAMA)
To accelerate the development of a scalable delivery model for addressing
upstream determinants of health … CMS recently announced a 5-year,
$157 million program to test… whether systematically identifying and
addressing health-related social needs can reduce health care costs and
utilization among community-dwelling Medicare and Medicaid
beneficiaries.
The foundation of the AHC model is universal, comprehensive screening
for health-related social needs — including but not limited to housing
needs (e.g., homelessness, poor housing quality, inability to pay mortgage
or rent), food insecurity, utility needs
(e.g., difficulty paying utility bills), interpersonal safety (e.g., problems of
intimate-partner violence, elder abuse, child maltreatment), and
transportation difficulties.
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California Accountable
Communities for Health Initiative
Accountable Communities for Health
Education
sector
Health care
sector
Public
health
Community
agencies &
residents
Social
Services
Other
govt.
agencies
Business
& Labor
Community Collaborative and Governance
Selected Health Issue:
• Health need
• Chronic condition
• Set of related
conditions
• Community condition
Backbone organization
Sustainability
Plan
Wellness
Fund
Braiding existing funding &
programs for interventions
Portfolio of mutually reinforcing interventions
Clinical
Community-Clinical Linkage
Community Programs
& Social Services
Policy & Systems
Environment
Timeframe of Intervention
Short term
ACH Evaluation Expert
Medium term
Long term
Identify savings across
providers, systems &
sectors for potential
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reinvestment
Tapping resources beyond
health
• Community Reinvestment Act
• Low-Income Investment Fund Social
Impact Calculator
• SPARCC—Strong, Prosperous and
Resilient Communities Challenge
• Innovative financing models
– Social impact bonds
– Solving the “wrong pocket” issue
Who leads? It depends….
How does public health change?
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New leadership role
Convener/integrator/catalyst
New skills within health departments
Assurance vs. delivery of
services/programs
Public Health as Chief Health
Strategist for Communities
• “State and local health departments will be more likely to
design policies than provide direct services; more likely
to convene coalitions than work alone; and be more
likely to access and have real-time data than await the
next annual survey. These new required skills and
abilities characterize a new role for health departments
as the “chief health strategist” for a community.”
– Public Health Leadership Forum http://www.resolv.org/sitehealthleadershipforum/
Programs/Activities Specific to an HD and/or Community Needs
Most of an HD’s Work is “Above the Line”
Foundational
Public
Health
Services
How does the workforce change?
• Foundational
capabilities
• Policy/systems/
community change
– “Health in all policies”
– Coalition building
• Health IT
– Integrated with EHRs
– Technical and analytic
capacity
• Integrator role
– Individuals (CHWs)
– Systems – within health
and outside health
(convening/leadership)
• Direct services vs.
quality assurance
• Health promotion
beyond government
public health
Implementation challenges
• A system that is changing as we try to
partner with it
• Constituency building just beginning
beyond public health
• Scary fiscal times can result in circling
the wagons
• Devil is in the details, to say the least
Can we do it?
• Six years ago we considered the following to be
dreams or too much of a stretch
– Accreditation
– Health reform
• Embracing of population health
– National Prevention Council, Strategy
– Mandatory funding for public health
– Major new prevention programming
• Status quo is not an option