1. LSU HEALTH CARE SERVICES DIVISION QUARTERLY HEALTH EFFECTIVENESS MEETING BATON ROUGE, SEPTEMBER 18, 2007

2. THOUGHTS FROM OKLAHOMA Michael Lapolla, College of Public Health John Gaudet, Bedlam Alliance September 18, 2007 ABOUT MEDICAL HOMES - AND MORE

3. MIKE LAPOLLA OUR THOUGHTS FROM HIGH ALTITUDES

4. OUR HEALTH CARE “DUST BOWL”

5. CAUSES CHALLENGES COMMUNITY RESPONSE

6. THE CAUSES

7. MEDICARE AND MEDICAID Responded well concerning physician production – but poorly concerning Medicaid administration and policy. The state (and the nation) was still learning how to deal with federal programs and how to maximize patient care reimbursements. Emphasis on larger enrollments and smaller payments. Abuse led to PPS and DRG in the 1980’s. 1960’s

8. OIL BOOM MASKS PROBLEMS State DHS (next slide) suffocates all other health policy players. Dedicated state sales tax. State Health Department rendered inert – university (OU) “teaching hospital” a shambles – the concept of a dynamic Health Sciences Center is still a vision. About 170 county commissioners sent to federal prison (there are only 231 in the state), Oil boom is underway full-speed – things “ain’t too bad”. 1970’s

9. + HUEY LONGJ. EDGAR HOOVER

10. OIL BUST EXPOSES PROBLEMS The state is both broke and shocked. LER dies; Medicaid and DHS left disarray with no institutional memory. Academic Health Center Teaching Hospital (now under DHS) “beyond repair”. Any federal (matching) Medicaid opportunities, such as DSH, are foregone. Health policy issues just emerging. Still in generally blissful ignorance - cannot see storm clouds. 1980’s

11. EMERGING FROM DARKNESS Economy recovers. Legislature is starting to change and turnover (term limits/no new taxes). Good ole boys on the way out. State creates a Health Care Authority. Privatizes the only public hospital in the state. Begins to take advantage of Medicaid – but it is way too late. The “uninsured” are noticed – the concept of a “safety net” emerges. Starting to realize we have big problems. 1990’s

12. SEEING THE LIGHT Realized that we missed the boat on Medicaid – “too bad – so sad”. Medicaid DSH frozen. Some states are big winners (Louisiana) – some states are still at the starting gate (Oklahoma). Communities cannot solely rely upon the state and feds. Now what? Let’s review the past 15 years. NOW

13. STATE OF OKLAHOMA Missed FQHC opportunities Missed Medicaid DSH opportunities Ignored State of State Health warnings Dismissed United Health rankings Health Care Authority rises from chaos Privatized state’s only public hospital 1992-2007

14. TULSA COMMUNITY New Medical School identity and leadership Start of the Bedlam Alliance Philanthropy awakened and enabling Good-to-Great philosophy engaged Regional Strategic Health Plan Community responding School of Community Medicine 2002-2007

15. THE CHALLENGES CAUSED BY GENERATIONS OF NEGLECT

16. OKLAHOMA UNINSURED

18. LAOKLAOK Hospital$ 930m$ 407m$ 205$ 117 DSH$ 911m$ 23m$ 201$ 7 Nursing Home$ 594m$ 463m$ 131$ 133 Managed Care$ 0$ 171m$ 0$ 49 Drugs$ 945m$ 417m$ 208$ 120 FQHC$ 9m$ 5m$ 2$ 1 Indian$ 6m$ 62m$ 1$ 18 Other$ 1,700m$ 1,000m$ 372$ 294 TOTAL$ 5.1B$ 2.6B$ 1,120$ 737 MEDICAID 2004 PER CAPITATOTAL DOLLARS

19. Metropolitan Safety Nets Public Hospital Comp Med Sch Medicaid DSH Focused Hospital State FQHC JacksonvilleUniversityYes NoJacksonville RochesterUniversityYes Rochester Grand RapidsNo Yes NoGrand Rapids Oklahoma CityUniversityYes NoOklahoma City LouisvilleUniversityYes Louisville RichmondDistrictYes Richmond GreenvilleDistrictYes NoGreenville DaytonNoYes NoDayton FresnoCountyNoYes Fresno BirminghamStateYes Birmingham HonoluluPublicYesAlternateYes Honolulu AlbanyUniversityYes Albany TucsonUniversityYes NoTucson TulsaNo Tulsa SyracuseStateYes Syracuse OmahaUniversityYes NoOmaha “Tulsa (and Wichita) are the only two major metro areas (of the 80 largest) in the nation lacking all traditional infrastructure, financing mechanisms and organizational tools for providing coordinated and focused safety net services. Both have community-based med schools.” OU College of Public Health study for the Oklahoma Secretary of Health, April 2005

20. 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 346,976 130,494 40,000 Primary 90,000 Specialty 31,199 46,320 101,661 37,300 SERVED BY SAFETY NET UNSERVED ER Other Clinics Major Clinics Free Clinics TULSA METRO

21. OKLAHOMA United Health Foundation America’s Health Rankings – 2006

22. HEART DISEASE

23. MENTAL HEALTH NEEDS

24. National Average 1,029 1,011 1979 AGE ADJUSTED DEATH RATES THE TEN STATES WITH THE HIGHEST RATES Source: Centers for Disease Control. Graphic: OU College of Public Health

25. National Average 946 801 2004 AGE ADJUSTED DEATH RATES THE TEN STATES WITH THE HIGHEST RATES Source: Centers for Disease Control. Graphic: OU College of Public Health

26. Oklahoma A State of Health? “We are the ONLY state where our age- adjusted death rates became WORSE through the 1990s and into this century.” “If we had the same adjusted death rate as the nation, we would have about 3,700 fewer people dying each year.” Oklahoma State Board of Health “2006 State of the State’s Health” Graphic: University of Oklahoma College of Public Health. Data Source: U.S. Centers for Disease Control and Prevention AGE ADJUSTED DEATH RATE U.S OK

27. LA US OK OKLAHOMA FROM THE NATIONAL AVERAGE TO LOUISIANA AGE ADJUSTED DEATH RATES

28. While the death rate of most U.S. residents is declining, that of Tulsans is not – and the trend is going in the wrong direction United States Tulsa County 198019902000 1,000 950 900 850 800 1,100

29. AIMING HIGHER The Commonwealth Fund Results from a State Scorecard on Health System Performance

30. COMMONWEALTH FUND State Scorecard Summary of Health System Performance

31. OUR EMBARASSMENT “When you are 50 th – how do you defend the status quo?” 50 th

32. COMMUNITY RESPONSES

33. KIM HOLLAND OKLAHOMA INSURANCE COMMISSIONER INITIATIVES FOR OKLAHOMA

34. AN OKLAHOMA CHAT CHOOSING HEALTHPLAN ALL TOGETHER © University of Michigan; courtesy of Sacramento Healthcare Decisions (SHD)

35. Oklahoma Employer/Employee Partnership for Insurance Coverage PREMIUM SHARING 15% EMPLOYEE – 25% EMPLOYER – 20% STATE – 40% FEDERAL

37. HI DC

38. HEALTH FOR OKLAHOMANS INFORMATION FOR POLICYMAKERS OHI OKLAHOMA HEALTH INSTITUTE

39. GERRY CLANCY, MD PRESIDENT, OU-TULSA INITIATIVES FOR TULSA

40. THE GOOD TO GREAT STUDY Y-Axis:Ratio of cumulative stock returns to general market. X-Axis: Years from transition. -15-10-50+5+10+15 Good-to-Great Companies Direct Comparison Companies 1.00 Market baseline Transition Point 7.00

41. This begs the question, “what could the University of Oklahoma College of Medicine, Tulsa do to become a great medical school?” One answer is to lead a long-term strategy to successfully improve the health status of the entire Tulsa metropolitan region. COLLEGE OF MEDICINE-TULSA

42. A GREAT MEDICAL SCHOOL WOULD IMPROVE HEALTH A great medical school would lead the long-term effort to bring the Tulsa health status in line with national averages and trends.

43. IMPROVE PRODUCTIVITY A great medical school would lead the long-term effort to increase productivity (reduce years of productive life lost) and work towards eliminating racial disparities in Tulsa. A GREAT MEDICAL SCHOOL WOULD

44. OFFSET POVERTY A great medical school would lead the effort to bring better health status to those in poverty, especially children. A GREAT MEDICAL SCHOOL WOULD

45. CONTINUUM OF HEALTH SERVICES Prenatal Care Live Birth Primary Disease Prevention Treatment of Acute Disease Tertiary Disease Prevention Rehabilitative Care End of LifeHealth Promotion Diagnosis of Disease Secondary Disease Prevention Treatment of Chronic Illness Long Term Care Palliative Care INSTITUTIONS HOSPITALS - NURSING HOMES REHABILTATION CENTERS PRIMARY CARE SAFETY NET CLINICS & PROVIDERS HEALTHPLEX SPECIALTY OUTPATIENT SERVICE BY REFERRAL

46. GERRY CLANCY, MD, PRESIDENT, OU-TULSA MICHAEL LAPOLLA, OU COLLEGE OF PUBLIC HEALTH

47. … will blend the education and practice of public health with medical education to produce community-oriented and jointly credentialed physicians who will influence personal and population health. SCHOOL OF COMMUNITY MEDICINE

48. COMMUNITYPHILANTHROPY

50. NOW - FROM THE TREETOPS THE BEDLAM ALLIANCE John Gaudet