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

What is Driving Health System Change?

How Does the United States Compare

Health Expenditure Per Capita

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

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.

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.

What is driving health system change?

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

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

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

Social Determinants Side

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.”

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.

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

The Vision

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.

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

What about Arkansas?

Infant Mortality by Race in Arkansas What about Arkansas?

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

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 45-64 years, 1968 - 2010 45-64 age group 2005-2010, 62%

Age-Specific Death Rates from Cancer, Arkansas & U.S., What about Arkansas? 2005-2010, 26% 45-64 age group Age-Specific Death Rates from Cancer, Arkansas & U.S., Aged 45-64 years, 1968 - 2010

Age-Specific Death Rates from Stroke, Arkansas & U.S., What about Arkansas? 2005-2010, 54% Age-Specific Death Rates from Stroke, Arkansas & U.S., Aged 45-64 years, 1968 - 2010

Uninsurance

Health Outcomes

Mortality

Morbidity

Socio-Economic Factors

Educational Factors

African American Population

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  

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

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 1972-1976 to 79 yrs in the period 1992-1996, 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

Role of Education Study conducted by Steven Woolf at VCU (published in 2009 in JAMA). Mortality for adults aged 25-64 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?  

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 1996-2002 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 further @ 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

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 2001-2008 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 specifically @ CHF???

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?

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

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

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

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>>>>

Fundamental Change is Required

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

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

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

All-Cause Mortality for Individuals aged 65+ United States, 1950 - 2010 3500 2000 2005 2010 Death rate per 100,000 population 7500 6500 5500 4500

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

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

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

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

for Payment Improvement

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.

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

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

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.

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