5Health Expenditures by Country Health spending % of GDP in 2011:United States 17.7%Netherlands 11.9%France 11.6%OECD Average 9.3%
6Health 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.
7Health 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.
9National Research Council/IOM report What is driving health system change?National Research Council/IOM reportUS 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 nationsFor 45 of 48 years, health care cost growth has outstripped growth in public funds and GDP
10Comparison of International Infant Mortality Rate: 2000Infant Mortality2.5SingaporeHong KongJapanSwedenNorwayFinlandSpainChech RepublicGermanyItalyFranceAustriaBelgiumSwitzerlandNetherlandsNorthern IrelandAustraliaDenmarkCanadaIsraelPortugalEngland & WalesScotlandGreeceIrelandNew ZealandUnited StatesCuba3.03.23.43.22.214.171.124.126.96.36.199.188.8.131.52.184.108.40.206.220.127.116.11.18.104.22.168Deaths per 1,000 Live Births
11Health System Design and Performance Social Determinants of Health WHY?MultifunctionalHealth System Design and PerformanceSocial Determinants of Health
13Institute 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.”
14If…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 recordsIf 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.
15Waste estimatesUnnecessary Services $210 billionInefficiently delivered services $130 billionExcess administrative costs $190 billionPrices that are too high $105 billionMissed prevention opportunities $55 billionFraud $75 billionTotal $765 billion
17Categories 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.
18Arkansas’ Healthcare Population What About Arkansas?Arkansas’ Healthcare Population45th in Stroke46th in Occupational Fatalities43rd in Infant Mortality43rd in Obesity45th in Premature Death50th in Immunization Coverage49th in per Capita Health Spending42nd in Lack of Health Insurance45th in Children in Poverty45th in Physical Activity48th in Overall HealthA challenge to us all: health care professionals, public health professionals, policy leaders, community leadersComplex interrelationships between social issues, economic issues, geographic issues, educational and bilingual (biological?) substructureBurden of ill health is not evenly distributed in society45th in Cardiovascular Deaths41st in Adequacy of Prenatal Care44th in Poor Physical Health Days45th in Cancer DeathsSource: Americas Health Rankings.org 2010
20Infant Mortality by Race in Arkansas What about Arkansas?
21Comparison of International Infant Mortality Rate: 2000What about Arkansas?2.5SingaporeHong KongJapanSwedenNorwayFinlandSpainChech RepublicGermanyItalyFranceAustriaBelgiumSwitzerlandNetherlandsNorthern IrelandAustraliaDenmarkCanadaIsraelPortugalEngland & WalesScotlandGreeceIrelandNew ZealandUnited StatesCuba3.03.23.43.22.214.171.124.126.96.36.199.188.8.131.52.184.108.40.206.220.127.116.11.18.104.22.168Deaths per 1,000 Live Births
22Age-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%
23Age-Specific Death Rates from Cancer, Arkansas & U.S., What about Arkansas?, 26%45-64 age groupAge-Specific Death Rates from Cancer, Arkansas & U.S.,Aged years,
24Age-Specific Death Rates from Stroke, Arkansas & U.S., What about Arkansas?, 54%Age-Specific Death Rates from Stroke, Arkansas & U.S.,Aged years,
32What 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 statusThese conditions are the social determinants of health and are defined by the World Health Organization – diet, exercise, tobacco, obesityThese 2 health indices illustrate a reproducible principle
33Social Determinants Access to Health Care Poverty Education Work Leisure – diet/exerciseTobaccoObesityLiving conditions/environmentsEnvironmental toxinsAccessInsurance status – we may be on the brink of dealing with thisGeographic distribution – distance health networkWorkforce – planning in processToday I’d like to look at some of the evidence for influence of these other determinants
34Study from England and Wales (Curran, 2009) Role of PovertyStudy 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 theseI have pulled a few representative studiesAccess to care- center for virtual health – workforce vacanciesImpact of insurance
35Role of EducationStudy conducted by Steven Woolf at VCU (published in 2009 in JAMA). Mortality for adults aged varied by education levelSome education beyond high school: 206/100,000High school education: 478/100,000Less than high school education: 650/100,000Annual mortality rankingNational data – us vital statisticsEducation – direct effect?Indirect indicator?Surrogate for economic impact?Surrogate for health behavior?
36Role of EducationImpact 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 fromResults: 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 8:1Woolf looked impact of college education vs health advancesPolicy 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
37Impact 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 betweenSurveyed by mail with median follow up of 1.2 yearsHealth literacy assessed with a 3 question screen tool: on a scale of 1-5How important is health related knowledge?One study looked CHF???
38Screening ToolHow 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?
39Screening 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 healthPCMHPatient Centered Care
40Overall 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 hospitalizationsGreater use of emergency careLower receipt of mammography screening and influenza vaccinePoorer ability to demonstrate taking medication appropriatelyPoorer ability to interpret labels and health messagesIn elderly patients: poorer overall health status, higher mortality ratesThis is what PCMH’s and PFCC are all about
41Race / EthnicityRace: 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 advancesJAMA same article I referred to earlierCenter for Health Disparities & the AR Minority health commission were formed to understand these issues and to craft strategies
42Economic 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 pathologistOur 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 impactInadequate recognition and ineffective strategies – address these issuesContributes to our health system cost ma…?)Virchase node – sentinel nodes – sup>>>>
44Strategies for Health System Change Accelerate the use of health information technologyHealth information exchangeTelehealthElectronic medical records systemsRestructure the health care payment system to improve the quality of medical care and curb rising costsArkansas Payment Improvement InitiativePatient centered medical homesEpisode-based payments
45Strategies for Health System Change Reduce the number of uninsured ArkansansPrivate health insurance exchanges (ACA)Arkansas Private Option for Medicaid PopulationPlan for a health care work force that provides appropriate access to medical services particularly in underserved areasHealth Work Force Strategic PlanForty separate recommendations
46A time of disruptive change but it’s not the first… Hill Burton Act: 1946Medicare/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 ReaganSCHIP (State Children’s Health Insurance Program) 1997Medicare Modernization Act: 2003 (Prescription drug coverage and Medicare Advantage Plans)PPACA: 2011Arkansas Private Option Insurance ExpansionArkansas Payment Improvement Initiative
47All-Cause Mortality for Individuals aged 65+ United States,3500200020052010Death rate per 100,000 population7500650055004500
48Triple AimBetter population and individual healthBetter patient experienceLower cost
49Patient 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
50Patient Protection and Affordable Care Act Key strategies:Private Insurance exchanges for individuals and families with income above 138% of federal poverty levelMedicaid Expansion for individuals and families with incomes up to 138% of federal poverty levelMedicaid expansion is funded federally for first three years after which states begin sharing cost up to 10% state share by 2020Many other provisions for funding the insurance expansion including reductions in:DSH payments,Payment for avoidable hospital readmissionsFailure to meet quality targetsOther
51Patient Protection and Affordable Care Act Arkansas Plan: Private OptionRather than expand traditional Medicaid, use federal Medicaid dollars to purchase insurance on the health insurance exchangeAdvantages:Provider networks and Payment rates for providers are the same for individuals above and below 138% of federal poverty levelNo churn between coverage at 138% of federal povertyExpands risk poolFederal waiverCost control and care coordination promoted through linkage with Arkansas Payment Improvement Initiative
53Medical Home: Arkansas multi-payer emerging vision All Arkansans have access to an advanced PCMH within 2-4 yearsPCMHs proactively manage patients on a 24/7 basisPrimary care providers should be rewarded for continuous improvements in quality and efficiencyPrimary care providers are stewards of overall system resources and have accountability for total cost of carePCMHs support and expect patients to actively engage and manage their own health.
54The model rewards a Principal Accountable Provider (PAP) for leading and coordinating services and ensuring quality of care across providersPAP role What it means…Physician, practice, hospital, or other provider in the best position to influence overall quality, cost of care for episodeLeads and coordinates the team of care providersHelps drive improvement across system (e.g., through care coordination, early intervention, patient education, etc.)Rewarded for leading high-quality, cost-effective careReceives performance reports and data to support decision-makingCore provider for episodePAP selection:Payers review claims to see which providers patients chose for episode related carePayers select PAP based main responsibility for the patient’s careEpisode‘Quarterback’Performance management
55Organizational and practice level requirements to successfully transform to meet triple aim and be successful in the new payment environmentPatient engagement and patient centerednessAvoid waste: “non-value added” servicesTransform from volume based to outcome based focus with accountability for patient and population health outcomesPatient registries: patient activation and disease management focus to achieve targets for major adult diseases, vaccination rates, etc.Denominator focus
56Organizational and practice level requirements to successfully transform to meet triple aim and be successful in the new payment environmentEMR infrastructure: information moving with patient through the systemGuideline focus: practice in accord with what is known to be best practice: real time decision supportOrganization must be accountable for care outcomes, patient experience and total costsStructured relationship for collaboration in care across continuum.
57What we cannot do is keep doing and expect different results. what we have been doingand expect different results.