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The Reality and Promise of Health Reform in Minnesota The Case for a Balanced Approach to Health Reform Edward P. Ehlinger, MD, MSPH Commissioner of Health.

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Presentation on theme: "The Reality and Promise of Health Reform in Minnesota The Case for a Balanced Approach to Health Reform Edward P. Ehlinger, MD, MSPH Commissioner of Health."— Presentation transcript:

1 The Reality and Promise of Health Reform in Minnesota The Case for a Balanced Approach to Health Reform Edward P. Ehlinger, MD, MSPH Commissioner of Health Minnesota Department of Health April 12, 2012

2 April 12, 1872 Jesse James gang robbed the bank in Columbia KY of $1, person killed.

3 David Letterman was born on April 12, 1947 “Sometimes something worth doing is worth overdoing.”

4 Health Reform is Worth Doing Need for Health Reform – Nationally and in Minnesota Costs are increasing dramatically Number of uninsured are increasing Quality of care is uneven Health outcomes are not as good as they should be There are great disparities in health status

5 Current U.S. expenditure for healthcare is $8,666/person.

6 Categories of U.S. Health Care Expenditures University of South Carolina, Arnold School of Public Health, Dept. of Health Services Policy and Management, HSPM J712,

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8 Uninsurance Rate Trends in Minnesota 8 *Indicates statistically significant difference (95% level) from prior year shown. Source: 2001, 2004, 2007, 2009, and 2011 Minnesota Health Access Surveys

9 Uninsurance Rates by Age, Select Years Source: Minnesota Health Access Surveys *Indicates statistically significant difference from previous year shown (95% confidence level). # Indicates statistically significant difference from previous year shown (90% confidence level). ^Indicates statistically significant difference from statewide rate (95% confidence level).

10 Minnesota Uninsurance Rates by Income, Select Years 10 *Indicates statistical difference to previous year shown (95% level). ^Indicates statistically significant difference (95% level) from all incomes within year Source: 2001, 2009, and 2011 Minnesota Health Access Surveys

11 Uninsurance Rates by Race/Ethnicity Select Years 11 Source: 2001, 2009, and 2011 Minnesota Health Access Surveys. *Indicates statistically significant difference from previous year shown (95% confidence level). ^Indicates statistically significant difference from statewide rate (95% confidence level).

12 Sources of Insurance Coverage in Minnesota, Select Years 12 *Indicates statistically significant difference to year shown (95% level). Estimates that rely solely on household survey data differ slightly from annual estimates that include both survey and administrative data. Source: Minnesota Health Access Surveys, 2009 and 2011.

13 UC Atlas of Global Inequality

14 Sweden JapanSingaporeHong Kong 2 Netherlands JapanFinlandHong KongSweden 3 Norway FinlandSwedenJapanSingapore 4 Czech Rep.JapanNorwayHong KongSwedenJapan 5 AustraliaFinlandDenmarkSingaporeFinland 6 DenmarkNetherlandsSwitzerlandNorwaySpain 7 Switzerland CanadaSpainNorway 8 DenmarkNew ZealandFranceNorwayCzech Rep.France 9 Eng. & WalesAustraliaCanadaGermany Austria 10 New ZealandFranceAustraliaNetherlandsItalyCzech Republic 11 United States Engl. & WalesIrelandFrance Germany 12 ScotlandCanadaHong KongDenmarkAustriaDenmark 13 N. IrelandIsraelSingaporeN. IrelandBelgiumSwitzerland 14 CanadaHong KongEngl. & WalesSpainSwitzerlandItaly 15 FranceIrelandScotland NetherlandsN. Ireland 16 SlovakiaScotlandBelgiumAustriaN. IrelandBelgium 17 Ireland United States SpainEngl. & WalesAustraliaNetherlands 18 JapanCzech Rep.GermanyBelgiumCanadaAustralia 19 IsraelBelgium United States AustraliaDenmarkPortugal 20 BelgiumSingaporeNew ZealandIrelandIsraelIreland 21 SingaporeGermanyN. IrelandItalyPortugalEngl. & Wales 22 GermanyN. IrelandAustriaNew ZealandEngl. & WalesScotland 23 CubaSlovakiaItaly United States ScotlandCanada 24 Austria IsraelGreece Israel 25 GreeceBulgariaCzech Rep.IsraelIrelandGreece 26 Hong KongPuerto RicoGreeceCubaNew Zealand 27 Puerto RicoSpainPuerto RicoCzech Republic United States Cuba 28 SpainGreeceCubaPortugalCuba United States 29 Italy BulgariaSlovakiaPolandHungary 30 BulgariaHungaryCosta RicaPuerto RicoSlovakiaPoland 31 HungaryPolandSlovakiaBulgariaHungarySlovakia 32 PolandCubaRussian Fed.HungaryPuerto RicoChile 33 Costa RicaRomaniaHungaryCosta Rica Puerto Rico 34 RomaniaPortugal Chile Costa Rica 35 PortugalCosta RicaPolandRussian Fed.BulgariaRussian Fed. Infant Mortality Rankings (Ascending) – ; Selected Countries (Health United States 2005)

15 Infant mortality rates by maternal race and ethnicity, 2007 Source: NCHS linked birth/infant death data set, 2007

16 Minnesota Infant Mortality Rate / Disparity Ratio Comparison Infant Mortality Rate Infant Mortality Disparity Ratio

17 Clara Barton Died at age 90 on April 12, 1912 Organized American Red Cross “An institution or reform movement that is not selfish, must originate in the recognition of some evil that is adding to the sum of human suffering, or diminishing the sum of happiness.” Public Health: Constant redefinition of the unacceptable. Geoffrey Vickers

18 In 2008, Minnesota Passed Landmark Health Reforms These reforms were built on the recognition that we had: – Uneven quality – Poor value – A lack of information – Payment and delivery incentives that were fundamentally misaligned – A system that paid for volume instead of value

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20 Health Reform in Minnesota Minnesota’s Three Reform Goals Healthier communities Better health care Lower costs

21 Minnesota’s Health Reform Act 2008 Redesign Primary Care – Health Care Homes Population Health – Statewide Health Improvement Program Quality and Cost Payment Reform Supporting – Healthcare Reform Review Council, E-health – Statewide Quality Measurement System – Provider Peer Grouping

22 E-Health Minnesota also passed significant e-health measures including: E-prescribing mandate Interoperable health records mandate Office of Health Information Technology

23 Patient Protection and Affordable Care Act (ACA) 2010 Health insurance exchanges Insurance market reforms Expand Medicaid; close Part D “donut hole” in Medicare Information technology Waste and fraud reduction Health care delivery redesign – Accountable Care Organizations Prevention and public health and wellness programs

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25 Major Insurance Reforms No preexisting condition exclusion Guaranteed issue Rating rules – No health status – 3:1 maximum age rating – 1.5:1 tobacco us Single risk pools in individual and small group market Individual mandate Employer responsibility

26 Impact of Affordable Care Act Passage On Minnesota MN Legislature passes 2010 Health Care Delivery System Medicaid Payment Model, which results in DHS ACO project Early Medicaid expansion (March 2011) (DHS) Planning for health insurance exchange (Commerce) Gov. Dayton creates reform structure in 2011 that includes a task force with workgroups around access, health insurance exchange, care integration and payment reform, prevention and public health, workforce, and citizen engagement.

27 Governor’s Healthcare Reform Task Force Commissioners Lucinda Jesson, Mike Rothman, Ed Ehlinger Pete Benner, AFSCME Mary Brainerd, HealthPartners Michael Connelly, Xcel Energy MayKao Hang, Wilder Foundation Jan Malcolm, Courage Center Rolonda Mason, St. Could Area Legal Services Judy Russel-Martin, MN Nurses Association Dale Thompson, Benedictine Health System Doug Wood, MD, Mayo Clinic Therese Zink, MD, U of MN Representatives Steve Gottwalt and Joe Schomacker Senators Sean Nienow and Michelle Benson

28 Healthcare Reform Task Force: Work Groups Care Integration and Payment Reform Access Workforce Prevention and Public Health

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30 Health Insurance Exchange Advisory Task Force Sue Abderholden, MN Alliance on Mental Illness Danette Coleman, Medica Philip Cryan, SEIU Mary Foarde, Allina Dorii Gbolo, Open Cities Health Center Robert Hanlon, Corporate Health Systems Alfred Babington Johnson, Stair Step Foundation Roger Kathol, MD, Cartesian Solutions Phil Norrgard, Fond du Lac Indian Tribe Stephanies Radtke, Dakota County Community Services Daniel Schmidt, Great River Office Products Representatives Joe Atkins and Tom Huntley Senators Tony Lourey and Ann Rest Commissioners Jesson, Rothman, Ehlinger

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32 Health Insurance Exchange Work Groups Governance Navigator Finance Adverse Selection, Market Competition, Value

33 Health Reform (Triple Aim) MN version – Improve health: improve the health of all Minnesotans and reduce disparities – Reduce costs: Improve efficiency and effectiveness – Foster effective and positive community engagement with health care, public health, and insurance

34 Minnesota’s State Health Ranking

35 State Public Health Rankings 1.Infectious Disease 49 th 2.State public health expenditures46 th 3.Binge Drinking44 th 4.Disparities(geographic)24 th (racial/ethnic) Issue dependent

36 Top Causes of Death: U.S Source: National Center for Health Statistics Cause of DeathNumber of Deaths Heart disease710,760 Cancer553,091 Stroke167,661 Chronic lower respiratory disease122,009 Unintentional injuries97,900 Diabetes69,301 Influenza/pneumonia65,313 Alzheimer’s49,558 Kidney disease37,251 Septicemia31,224 All other causes499,283

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39 39 The “Real” Top Causes of Death U.S Cause of DeathNumber of DeathsPercentage Tobacco435,00018% Diet/activity365,00015% Alcohol85,0004% Microbial agents75,0003% Toxic agents55,0002% Motor vehicles43,0001% Firearms29,0001% Sexual behavior20,000<1% Illicit use of drugs17,000<1% Source: Mokdad et al, JAMA 2004 March 10; 291 (10):

40 Social Causes of Death (2000) Less than High School graduation245,000 – (over 1 million deaths could have been avoided between 1996 to 2002 if all adults in US would have had a college education) Racial segregation176,000 Low social support162,000 Individual level poverty133,000 Income inequality 119,000 Community level poverty 39,000 Galea, et.al., American Journal of Public Health August 2011, Vol 101 no. 8

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43 Public Health = Longer Lives Life Expectancy at Birth, United States, of the 30 years of life gained in the 20 th Century resulted from public health accomplishments

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45 Clara Barton died on April 12, 1912 “I have an almost complete disregard of precedent, and a faith in the possibility of something better. It irritates me to be told how things have always been done. I defy the tyranny of precedent. I go for anything new that might improve the past.”

46 Health System Dynamics Presented by: Jeanne F. Ayers, Minnesota Department of Health - Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, Available at:

47 Safer, Healthier Population Becoming Vulnerable Becoming no longer vulnerable Vulnerable Population Becoming Afflicted without Complications Developing Complications Afflicted with Complications Targeted protection Primary prevention Secondary prevention Dying from Complications Tertiary prevention Society's Health Response General protection Adverse Living Conditions World of Providing… Education Screening Disease management Pharmaceuticals Clinical services Physical and financial access Etc… Medical and Public Health Policy DISEASE AND RISK MANAGEMENT World of Transforming… Deprivation Dependency Violence Disconnection Environmental decay Stress Insecurity Etc… By Strengthening… Leaders and institutions Foresight and precaution The meaning of work Mutual accountability Plurality Democracy Freedom Etc… Healthy Public Policy & Public Work DEMOCRATIC SELF-GOVERNANCE Presented by: Jeanne F. Ayers, Minnesota Department of Health - Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, Available at: Areas of Emphasis

48 We need to integrate clinical medicine and public health Health issues of today require prevention and treatment. – Chronic diseases – Injuries (TZD is great example) We can’t afford the cost of just clinical interventions. Social determinants of health are becoming increasingly important We need to maximize the skills of clinical and public health professionals.

49 Deaths Prevented And Change In Health Care Costs Plus Program Spending, Three Intervention Scenarios, At Year 10 And Year 25. Milstein B et al. Health Aff 2011;30:

50 Deaths Prevented And Change In Health Care Costs Plus Program Spending, Three Intervention Scenarios, At Year 10 And Year 25. Milstein B et al. Health Aff 2011;30: ©2011 by Project HOPE - The People-to-People Health Foundation, Inc.

51 Annual Costs (Health Care And Program Spending), Three Layered Intervention Scenarios, Year 0 To Year 25. Milstein B et al. Health Aff 2011;30: ©2011 by Project HOPE - The People-to-People Health Foundation, Inc.

52 Annual Deaths, Three Layered Intervention Scenarios, Year 0 To Year 25. Milstein B et al. Health Aff 2011;30: ©2011 by Project HOPE - The People-to-People Health Foundation, Inc.

53 How our healthcare money is spent

54 University of South Carolina, Arnold School of Public Health, Dept. of Health Services Policy and Management, HSPM J712,

55 Challenges to Achieving Health 46 th in state funding of public health – $249/person in $49/person in 2011 – Lost tobacco endowment – SHIP funding reduced by 70% – Slow degradation in general fund Reduction in local public health funding Budgeting/planning is built around short-term thinking. Changing view on the role of government in health. – Bill to eliminate department of health Mistrust of government – Newborn Screening Lack of understanding about public health

56 Henry Clay Born April 12, 1777 US politician and lawyer. He is remembered as the "Great Pacificator"; he negotiated the Missouri Compromise of 1850 “Government is a trust, and the officers of the government are trustees. And both the trust and the trustees are created for the benefit of the people.”

57 To create a healthy community We need a balance and rational investment in all aspects of our health system. We need to integrate clinical care, public health, social services, and education. We have to think of health in all policies

58 “Public health is what we, as a society, do collectively to assure the conditions in which people can be healthy.” -Institute of Medicine (1988), Future of Public Health Edward P. Ehlinger, MD, MSPH Commissioner, MDH P.O. Box St. Paul, MN

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60 Henry Clay Born April 12, 1777 US "politician, lawyer". "He is remembered as the "Great Pacificator"; negotiated the Missouri Compromise of 1850 Statistics are no substitute for judgment. Of all human powers operating on the affairs of mankind, none is greater than that of competition Government is a trust, and the officers of the government are trustees. And both the trust and the trustees are created for the benefit of the people.

61 You're unhappy. I'm unhappy too. Have you heard of Henry Clay? He was the Great Compromiser. A good compromise is when both parties are dissatisfied, and I think that's what we have here. – Larry David [ Larry David

62 Mortality Disparity Ratios 1 by Race/Ethnicity, Minnesota African American / Best Ratio American Indian / Best Ratio 1- Ratios are calculated by dividing the rate for each racial/ethnic population rate by the Best rate among the populations. *- Best Rate CLRD – Chronic Lower Respiratory Disease Source: Minnesota Center for Health Statistics, Minnesota Department of Health CauseRatio Highest Homicide11.8 Cancer2.6 Heart Disease2.5 Lowest Stroke1.4 Suicide1.2 Motor Vehicle Death*1.0 CauseRatio Highest Unintentional Injury4.2 Diabetes3.6 Heart Disease3.4 Lowest Cancer2.4 Infant Mortality2.1 Stroke1.4

63 Mortality Disparity Ratios 1 by Race/Ethnicity, Minnesota White / Best Ratio CauseRatio Highest Heart Disease2.5 Cancer2.0 CLRD2.0 Lowest Infant Mortality*1.0 Diabetes*1.0 Homicide* Ratios are calculated by dividing the rate for each racial/ethnic population rate by the Best rate among the populations. *- Best Rate CLRD – Chronic Lower Respiratory Disease Source: Minnesota Center for Health Statistics, Minnesota Department of Health

64 Current U.S. expenditure for healthcare is $8,666/person.

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66 County Health Rankings Model Individual health is influenced by the health of the community

67 Place matters Community matters Health Outcomes

68 How our healthcare money is spent


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