1. The Case for Health System Change
Dan Rahn, M.D.
Chancellor, University of Arkansas for Medical Sciences

2. What is Driving Health System Change?

3. How Does the United States Compare

4. Health Expenditure Per Capita

5. Health Expenditures by Country
Health spending % of GDP in 2011:
United States 17.7%
Netherlands 11.9%
France 11.6%
OECD Average 9.3%

6. Health Expenditures by Country
The United States together with Mexico and Chile are the only OECD countries where less than 50% of health spending is publicly financed.
The overall level of health spending in the United States is so high that public (i.e. government) spending on health per capita is still greater than in all other OECD countries, except Norway and the Netherlands.

7. Health Expenditures by Country
In the United States, life expectancy at birth increased by almost 9 years between 1960 and 2011, but this is less than the increase of over 15 years in Japan and over 11 years on average in OECD countries. As a result, while life expectancy in the United States used to be 1 ½ years above the OECD average in 1960, it is now, at 78.7 years in 2011, almost 1 ½ years below the average of 80.1 years.

8. What is driving health system change?

9. National Research Council/IOM report
What is driving health system change?
National Research Council/IOM report
US males and females in all age groups up to 75 years of age have shorter life expectancies and higher prevalence and mortality from multiple diseases, risk factors and injuries than 16 other developed nations
For 45 of 48 years, health care cost growth has outstripped growth in public funds and GDP

10. Comparison of International Infant
Mortality Rate: 2000
Infant Mortality
2.5
Singapore
Hong Kong
Japan
Sweden
Norway
Finland
Spain
Chech Republic
Germany
Italy
France
Austria
Belgium
Switzerland
Netherlands
Northern Ireland
Australia
Denmark
Canada
Israel
Portugal
England & Wales
Scotland
Greece
Ireland
New Zealand
United States
Cuba
3.0
3.2
3.4
3.8
3.8
3.9
4.1
4.4
4.5
4.5
4.8
4.8
4.9
5.1
5.1
5.2
5.3
5.3
5.4
5.5
5.6
5.7
6.1
6.2
6.3
6.9
7.2
Deaths per 1,000 Live Births

11. Health System Design and Performance Social Determinants of Health
WHY?
Multifunctional
Health System Design and Performance
Social Determinants of Health

12. Social Determinants Side

13. Institute of Medicine Report: Best Care at Lower Cost: The Path to Continuously Learning Health Care in America
“Health Care in America has experienced an explosion in knowledge, innovation, and capacity to manage previously fatal conditions. Yet, paradoxically, it falls short on such fundamentals as quality, outcomes, cost, and equity. Each action that could improve quality-developing knowledge, translating new information into medical evidence, applying the new evidence to patient care-is marred by significant shortcomings and inefficiencies that result in missed opportunities, waste, and harm to patients.”

14. If…
If banking were like health care, automated teller machine (ATM) transactions would take not seconds but perhaps days or longer as a result of unavailable or misplaced records
If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination.
If shopping were like health care, product prices would not be posted, and the price charged would vary widely within the same store, depending on the source of payment.
If automobile manufacturing were like health care, warranties for cars that require manufacturers to pay for defects would not exist. As a result, few factories would seek to monitor and improve production line performance and product quality.
If airline travel were like health care, each pilot would be free to design his or her own preflight safety check, or not perform one at all.

15. Waste estimates
Unnecessary Services $210 billion
Inefficiently delivered services $130 billion
Excess administrative costs $190 billion
Prices that are too high $105 billion
Missed prevention opportunities $55 billion
Fraud $75 billion
Total $765 billion

16. The Vision

17. Categories of the Committee’s Recommendations Foundational Elements Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge. Recommendation 2: The data utility. Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge. Care Improvement Targets Recommendation 3: Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions. Recommendation 4: Patient-centered care. Involve patients and families in decisions regarding health and health care, tailored to fit their preferences. Recommendation 5: Community links. Promote community-clinical partnerships and services aimed at managing and improving health at the community level. Recommendation 6: Care continuity. Improve coordination and communication within and across organizations. Recommendation 7: Optimized operations. Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health. Supportive Policy Environment Recommendation 8: Financial incentives. Structure payment to reward continuous learning and improvement in the provision of best care at lower cost. Recommendation 9: Performance transparency. Increase transparency on health care system performance. Recommendation 10: Broad leadership. Expand commitment to the goals of a continuously learning health care system.

18. Arkansas’ Healthcare Population
What About Arkansas?
Arkansas’ Healthcare Population
45th in Stroke
46th in Occupational Fatalities
43rd in Infant Mortality
43rd in Obesity
45th in Premature Death
50th in Immunization Coverage
49th in per Capita Health Spending
42nd in Lack of Health Insurance
45th in Children in Poverty
45th in Physical Activity
48th in Overall Health
A challenge to us all: health care professionals, public health professionals, policy leaders, community leaders
Complex interrelationships between social issues, economic issues, geographic issues, educational and bilingual (biological?) substructure
Burden of ill health is not evenly distributed in society
45th in Cardiovascular Deaths
41st in Adequacy of Prenatal Care
44th in Poor Physical Health Days
45th in Cancer Deaths
Source: Americas Health Rankings.org 2010

19. What about Arkansas?

20. Infant Mortality by Race in Arkansas
What about Arkansas?

21. Comparison of International Infant
Mortality Rate: 2000
What about Arkansas?
2.5
Singapore
Hong Kong
Japan
Sweden
Norway
Finland
Spain
Chech Republic
Germany
Italy
France
Austria
Belgium
Switzerland
Netherlands
Northern Ireland
Australia
Denmark
Canada
Israel
Portugal
England & Wales
Scotland
Greece
Ireland
New Zealand
United States
Cuba
3.0
3.2
3.4
3.8
3.8
3.9
4.1
4.4
4.5
4.5
4.8
4.8
4.9
5.1
5.1
5.2
5.3
5.3
5.4
5.5
5.6
5.7
6.1
6.2
6.3
6.9
7.2
Deaths per 1,000 Live Births

22. Age-Specific Death Rates from Coronary Heart Disease, Arkansas & U.S.,
What about Arkansas?
Age-Specific Death Rates from Coronary Heart Disease, Arkansas & U.S.,
Aged years,
45-64 age group
, 62%

23. Age-Specific Death Rates from Cancer, Arkansas & U.S.,
What about Arkansas?
, 26%
45-64 age group
Age-Specific Death Rates from Cancer, Arkansas & U.S.,
Aged years,

24. Age-Specific Death Rates from Stroke, Arkansas & U.S.,
What about Arkansas?
, 54%
Age-Specific Death Rates from Stroke, Arkansas & U.S.,
Aged years,

25. Uninsurance

26. Health Outcomes

27. Mortality

28. Morbidity

29. Socio-Economic Factors

30. Educational Factors

31. African American Population

32. What are Social Determinants of Health?
Within countries, cities and communities there are dramatic variations in health among certain groups of people that are closely linked to those groups socioeconomic status
These conditions are the social determinants of health and are defined by the World Health Organization – diet, exercise, tobacco, obesity
These 2 health indices illustrate a reproducible principle

33. Social Determinants Access to Health Care Poverty Education Work
Leisure – diet/exercise
Tobacco
Obesity
Living conditions/environments
Environmental toxins
Access
Insurance status – we may be on the brink of dealing with this
Geographic distribution – distance health network
Workforce – planning in process
Today I’d like to look at some of the evidence for influence of these other determinants

34. Study from England and Wales (Curran, 2009)
Role of Poverty
Study from England and Wales (Curran, 2009)
Between 1972 – 1996 (UK had universal health insurance)
Life expectancy of men in the highest “social class” increased from 72 yrs in the period of to 79 yrs in the period , an increase of 7 years and 8%.
For this same period, life expectancy of men in the lowest social class increased from 66 yrs to 68 yrs an increase of only 3%. The gap widened.
Let’s look at evidence for impact of some of these
I have pulled a few representative studies
Access to care- center for virtual health – workforce vacancies
Impact of insurance

35. Role of Education
Study conducted by Steven Woolf at VCU (published in 2009 in JAMA). Mortality for adults aged varied by education level
Some education beyond high school: 206/100,000
High school education: 478/100,000
Less than high school education: 650/100,000
Annual mortality ranking
National data – us vital statistics
Education – direct effect?
Indirect indicator?
Surrogate for economic impact?
Surrogate for health behavior?

36. Role of Education
Impact of college education on population health - Giving Everyone the Health of the Educated: An examination of whether social change would save more lives than medical advances (Woolf, et. Al., AJPH, 2007)
Using US vital statistics data from
Results: Medical advances averted 178,193 deaths during the study period. Correcting disparities in education – associated mortality rates would have saved 1,369,335 lives, a ratio of 8:1
Woolf looked impact of college education vs health advances
Policy question raised is: what is the relative importance of investing in education vs in biomedical research?
Again, one can methodologically raise all kinds of questions but the fact remains that all along the educational continuum those with more education experience better health

37. Impact of Health Literacy
Health Literacy and Outcomes Among Patients with Heart Failure (Peterson, et. al. JAMA 2011)
Retrospective review of 2156 patients with discharge diagnosis of heart failure identified between
Surveyed by mail with median follow up of 1.2 years
Health literacy assessed with a 3 question screen tool: on a scale of 1-5
How important is health related knowledge?
One study looked CHF???

38. Screening Tool
How often do you have someone help you read hospital material?
How often do you have problems learning about your medical condition because of difficulty reading hospital materials?
How confident are you filling out forms by yourself?

39. Screening Tool Outcomes
Score less than 10 was called low health literacy.
Of 1494 included responders, 262 had low health literacy. Those with LHL had a 17.6% mortality rate during the study period compared with 6.3% for all others, adjusted for other illnesses, age, economic status, etc.
Patient & family centered health
PCMH
Patient Centered Care

40. Overall Impact of Health Literacy of Health Outcomes
Low Health Literacy and Health Outcomes: An Updated Systematic Review (Berkman, et. al., AIM 2011)
Low Health Literacy was consistently associated with:
More hospitalizations
Greater use of emergency care
Lower receipt of mammography screening and influenza vaccine
Poorer ability to demonstrate taking medication appropriately
Poorer ability to interpret labels and health messages
In elderly patients: poorer overall health status, higher mortality rates
This is what PCMH’s and PFCC are all about

41. Race / Ethnicity
Race: inextricably intertwined with economic status and education but infant mortality of black newborns in the US is twice as high as that of white newborns (Woolf, 2009)
If we could eliminate race-based inequalities, five lives would be saved for every life saved by medical advances
JAMA same article I referred to earlier
Center for Health Disparities & the AR Minority health commission were formed to understand these issues and to craft strategies

42. Economic Impact
“If medicine is to fulfill her great test, then she must enter the political and social life. Since disease so often results from poverty, physicians are the natural attorneys of the poor and social problems should largely be solved by them.” Rudolf Virchow, 19th century pathologist
Our system is oriented toward assuring that those with illness receive all available treatment rather than on health promotion and addressing the conditions that produce disease.
In addition to the health and quality of life impact
Inadequate recognition and ineffective strategies – address these issues
Contributes to our health system cost ma…?)
Virchase node – sentinel nodes – sup>>>>

43. Fundamental Change
is Required

44. Strategies for Health System Change
Accelerate the use of health information technology
Health information exchange
Telehealth
Electronic medical records systems
Restructure the health care payment system to improve the quality of medical care and curb rising costs
Arkansas Payment Improvement Initiative
Patient centered medical homes
Episode-based payments

45. Strategies for Health System Change
Reduce the number of uninsured Arkansans
Private health insurance exchanges (ACA)
Arkansas Private Option for Medicaid Population
Plan for a health care work force that provides appropriate access to medical services particularly in underserved areas
Health Work Force Strategic Plan
Forty separate recommendations

46. A time of disruptive change but it’s not the first…
Hill Burton Act: 1946
Medicare/Medicaid: 1965
“We are against forcing all citizens, regardless of need, into a compulsory government program. It is socialized medicine. If it stands, one of these days you and I are going to spend our sunset years telling our children and our children's children, what it once was like in America when men were free.” Ronald Reagan
SCHIP (State Children’s Health Insurance Program) 1997
Medicare Modernization Act: 2003 (Prescription drug coverage and Medicare Advantage Plans)
PPACA: 2011
Arkansas Private Option Insurance Expansion
Arkansas Payment Improvement Initiative

47. All-Cause Mortality for Individuals aged 65+
United States,
3500
2000
2005
2010
Death rate per 100,000 population
7500
6500
5500
4500

48. Triple Aim
Better population and individual health
Better patient experience
Lower cost

49. Patient Protection and Affordable Care Act
Goal: Extend access to insurance for the vast majority of currently uninsured citizens while improving quality and controlling cost growth

50. Patient Protection and Affordable Care Act
Key strategies:
Private Insurance exchanges for individuals and families with income above 138% of federal poverty level
Medicaid Expansion for individuals and families with incomes up to 138% of federal poverty level
Medicaid expansion is funded federally for first three years after which states begin sharing cost up to 10% state share by 2020
Many other provisions for funding the insurance expansion including reductions in:
DSH payments,
Payment for avoidable hospital readmissions
Failure to meet quality targets
Other

51. Patient Protection and Affordable Care Act
Arkansas Plan: Private Option
Rather than expand traditional Medicaid, use federal Medicaid dollars to purchase insurance on the health insurance exchange
Advantages:
Provider networks and Payment rates for providers are the same for individuals above and below 138% of federal poverty level
No churn between coverage at 138% of federal poverty
Expands risk pool
Federal waiver
Cost control and care coordination promoted through linkage with Arkansas Payment Improvement Initiative

52. for Payment Improvement

53. Medical Home: Arkansas multi-payer emerging vision
All Arkansans have access to an advanced PCMH within 2-4 years
PCMHs proactively manage patients on a 24/7 basis
Primary care providers should be rewarded for continuous improvements in quality and efficiency
Primary care providers are stewards of overall system resources and have accountability for total cost of care
PCMHs support and expect patients to actively engage and manage their own health.

54. The model rewards a Principal Accountable Provider (PAP) for leading and coordinating services and ensuring quality of care across providers
PAP role What it means…
Physician, practice, hospital, or other provider in the best position to influence overall quality, cost of care for episode
Leads and coordinates the team of care providers
Helps drive improvement across system (e.g., through care coordination, early intervention, patient education, etc.)
Rewarded for leading high-quality, cost-effective care
Receives performance reports and data to support decision-making
Core provider for episode
PAP selection:
Payers review claims to see which providers patients chose for episode related care
Payers select PAP based main responsibility for the patient’s care
Episode
‘Quarterback’
Performance management

55. Organizational and practice level requirements to successfully transform to meet triple aim and be successful in the new payment environment
Patient engagement and patient centeredness
Avoid waste: “non-value added” services
Transform from volume based to outcome based focus with accountability for patient and population health outcomes
Patient registries: patient activation and disease management focus to achieve targets for major adult diseases, vaccination rates, etc.
Denominator focus

56. Organizational and practice level requirements to successfully transform to meet triple aim and be successful in the new payment environment
EMR infrastructure: information moving with patient through the system
Guideline focus: practice in accord with what is known to be best practice: real time decision support
Organization must be accountable for care outcomes, patient experience and total costs
Structured relationship for collaboration in care across continuum.

57. What we cannot do is keep doing and expect different results.
what we have been doing
and expect different results.