Community Leaders’ Blueprint for Health Policy Marcia L Comstock, MD MPH Jon R Comola Wye River Group on Healthcare March 30, 2005

Agenda Provide background on the ‘communities’ project Highlight the common themes that emerged Delineate consensus points around priorities for health policy Share results of a public opinion poll on health care values

Who We Are WRGH/FAHCL: not-for-profit, non-partisan catalysts Bring diverse stakeholders together Create a neutral environment to encourage honest discussion and debate Promote better understanding of different perspectives, through open dialogue that explores shared values and builds trust

Communities Shaping a Vision for America’s 21st Century Health & Healthcare

Background Began July 2002 Involves leaders in 12 very different communities across the country Concept for healthcare leadership roundtables or ‘listening sessions’ proposed by WRGH Model developed together with the White House Planning involved a broad range of sponsoring organizations and political interests

Financial Sponsors American Assn of Health Plans American Cancer Society American Hospital Association American Medical Group Association American Psychological Association Blue Cross Blue Shield Association National Assn of Chain Drug Store National Chamber Foundation PhRMA

Supporting Organizations AARP Center for Evaluative Clinical Sciences, Dartmouth Medical School National Alliance for Hispanic Health National Business Coalition on Health National Committee for Quality Health Care Progressive Policy Institute, an affiliate of the Democratic Leadership Council Washington Business Group on Health White House Council of Economic Advisors

Site Selection Geographic diversity Community size Cultural diversity Competition Regulatory environment Rate of uninsured Medicare costs (Dartmouth Atlas) Quality ranking (HCFA study)

Selected Communities Salt Lake City, UT Chicago, IL Hanover, NH Portland, OR San Diego, CA San Antonio, TX Albuquerque, NM Durham, NC Fort Lauderdale, FL Jackson, MS Spokane, WA Muncie, IN

Participants Physician leaders Hospital executives Insurance/managed care executives Pharmaceutical industry executives Local business leaders White House CEA & Democratic policy staff Consumer representatives Public health commissioners/officials Directors of community health centers Civic thought leaders

Pre-Meeting Site Visit One-on-one & small group meetings 25-30 leaders in each community interviewed Focused on gaining understanding of culture, marketplace dynamics, relationships Identification of ‘case studies’ of successful partnerships at the community level Build support for the process

Leadership Meeting Agenda Identification of two most critical issues Discussion of the social contract for healthcare Attributes of a well-functioning healthcare system Aligning incentives Resource allocation Cultural change Engaging communities

Goals Identify healthcare values that guide the thinking of community leaders and citizens Create mechanisms for this thinking to inform the national policy debate Identify replicable, collaborative community-based initiatives that address healthcare problems Use the power of multi-sector, multi-state support to bring about public policy changes

Process Created ‘ownership’ of results Professional writer developed ‘transcript’ of meeting A report was prepared from the transcript without attribution The report was provided to participants for additions, corrections Changes were incorporated Individual reports incorporated into the final report, along with a summary of values and principles

Findings Community leaders do not gravitate to polarized solutions advanced in Washington There is much agreement at the community level & a sincere interest on the part of all stakeholders to responsibility address health system challenges Universal sense of crisis, but not hopelessness—a ‘window of opportunity’ Strong sense that healthcare leaders are more motivated than they have been to discuss problems and work together on solutions

Findings Recognition that core elements that need to be re-examined comprise both business & social components Great understanding of the realities—where we are, how & why we got here, the serious crisis we face An emerging sense of what we ought to do—create a more a patient-centric system Need to systematically address barriers through reevaluation of organization, financing, & delivery of healthcare, & roles of different stakeholder groups

Common Themes No social contract in health care that is well-articulated and broadly understood People do not know what they should realistically expect from the health care system, nor do they understand their responsibility to contribute The healthcare system has fostered unrealistic expectations General consensus that we should more explicitly define rights and responsibilities “Rather than say health care is a right, call it a privilege to which everyone should have access” Restore a sense of community interdependence Healthcare is both a public and a private good

Common Themes Individuals need to be actively involved in making key choices about health-related behaviors, and healthcare-related decisions But efforts to increase personal responsibility for health and health care must be linked with efforts to educate and actively reach out to patients, particularly those who are underserved We need much more accountability in the health care system for delivering high value care and at the community level to enable people to make good choices and adopt more positive health behaviors

Common Themes Widespread belief that there is a serious void in leadership in the healthcare industry Trust is a critical pillar of a well-functioning healthcare system, but health care institutions have lost a great deal of credibility with the public and skepticism about motives is prevalent There is tremendous fragmentation in healthcare, with each interest group moving forward in whatever direction they feel is appropriate Some policy and financing issues must be addressed at the federal level, but there is great faith in communities’ ability to develop creative approaches

What Do We Do? Decide as a society what we really want from healthcare, beginning with community discussions Shift our thinking-Washington will not solve our problems ‘Top down’ approaches used for 60 years have not worked Reform efforts must recognize the pluralistic nature of this country and our culture The public needs to be involved in discussions of key choices Start by carefully defining problems and priorities from the unique perspective of a community

What Do We Do? Communities are the logical place for initiating change All healthcare is local Policies determined at the community level more likely to be based on the actual conditions in a community Health care leaders are more likely to work together productively within their own backyard Community-based discussion is much more likely to pull in participation from ‘the grassroots’ and reflect a community’s values and priorities.

What Do We Do? To restore trust the public needs to see leaders working collaboratively in their best interest Health care leaders need to stop pointing the finger of blame at each other and cooperate on a common agenda Industry leaders need to systematically think and plan beyond the fire at their feet, collaboratively Collaboration will require that we address clearly mal-aligned financial incentives in our ‘non-system’ Current payment polices hamper providers from focusing on prevention as the right thing to do and from collaborating to improve community health

Development of the Health Policy ‘Blueprint’

Blueprint Inputs Community leaders’ Advisory Board recommendations 150 representatives of diverse communities across the country and across the spectrum of health and healthcare interests Used a methodical combination of electronic brainstorming and facilitated discussions Captured 340 recommendations in 14 areas Ranked and prioritized in Washington session with trade/professional association executives and policy thought leaders Top 84 framed as a series of actionable steps for this administration

Public Awareness We need to increase the awareness of the public about challenges and gain broad agreement on a vision for our healthcare system We need a clear goal and a methodical, aggressive campaign to make healthy lifestyle decisions ‘cool’ Going ‘upstream’, reaching the younger generation with messages and tools for prevention will have the most lasting impact The President should articulate specific, measurable healthcare reform goals with timeframes and develop a national report card which shows progress against national goals

Personal Responsibility Broad support for more individual responsibility, but must take disparities into account Some recommend that individuals who practice good health habits should directly benefit in lower premiums Others feel that the prevalence of poor health habits is a societal problem, and all should share the burden Widespread agreement on need to emphasize education on healthy lifestyles and wellness Numerous financial incentives felt to have potential utility Need transparency of information on price and quality Shared decision-making can effectively engage patients in a healthy open exchange We should look outside the health care field to determine what works to motivate behavioral change

Incentives Incentives currently drive illness treatment, not better health Incentives need to be better aligned to support primary prevention as well as ‘tertiary’ prevention and disability avoidance Emphasis placed on rewarding evidence-based care and outcomes, not services Should develop models where providers, payers, and patients can share in the savings from prevention, early detection and better care management

Access Access to health care is socially desirable and economically beneficial and ensuring access to health care coverage for all was cited as a top priority for the Administration The problem of access encompasses cultural and logistical elements, as well as insurance A strong and sustainable safety net is needed to provide for the medically disenfranchised There was considerable support for the concept of a ‘medical home’ Some recommended we define a ‘baseline’ level of health care coverage; others favored emphasis on access to a ‘baseline’ of quality services irrespective of coverage standards There is a desire for greater flexibility in regulations, in the tax code, and with grants and waivers so communities can craft solutions that meet their unique needs

Affordability The escalating cost of health care services is a top priority, as affordability is seen as a keystone to greater access and a healthier population Recommendations frequently focus on a segment of the cost pie, but overall system inefficiencies need to be addressed Greater transparency of information and accountability for all stakeholders were frequently cited as necessary steps There is broad agreement that we should focus on deriving more VALUE from whatever it is that we as a society decide to spend on healthcare

Coordination of Care With an eye on demographics, there was a strong emphasis on the increasing importance of better integration and coordination of services A greater focus is needed on prevention and primary care, public health, behavioral health, and care management for chronic illness Numerous recommendations related to enhancing the role of allied health professionals, (e.g., advanced practice nurses, pharmacists, etc.) and to f integrating social services in a coordinated care model Health policy should also ensure access to a continuum of care, that includes mental and behavioral health, and oral health care services

Information Technology Promoting and advancing IT is seen as a prerequisite to addressing many healthcare challenges The ultimately utility of information technology will be largely determined by individual behavior The greatest impact of IT is in its application to electronic medical records, elimination of medical errors, inter-linking of rural areas, and reduction of administrative costs Standardization, incentives for investment and adoption, funding of pilots and demonstration projects, cultural adaptation by professionals and their institutions, and training of health professionals seen as critical steps in advancing the use of IT

Public Health There is broad agreement that public health needs to move up on the national agenda; many see it as an untapped asset IOM standards on public health should be adopted as national policy and state and local governments given support and incentives to meet standards A better definition of the appropriate role of public health in today’s society is needed with a consistency of activities Public health should assume a greater role in public awareness, education, and coordination, particularly in the areas of health promotion and wellness Public health should serve as coordinator of population data collection and interpretation

Role of Government Agreement that an appropriately defined role for government is a critical component of a well-functioning healthcare system Few participants advocated for a centralized single-payer approach As purchaser government should leverage its role to promote quality, efficiency and appropriate resource allocation Reward the practice of evidence based medicine, advance quality metrics and fund demonstration projects As public policy maker, government should carefully balance social interests Flexibility should be a hallmark of effective government As a communicator, make a healthy America synonymous with strong a America

National Study on Consumer on Health Values

Purpose Examine consumer attitudes, values, and behaviors related to health care Highlight challenges for employers and policymakers in effectively motivating consumers to become more engaged in their health care, more committed to prevention and healthy lifestyles, and better informed in order to make choices based on cost and quality information Understand how consumers view their role in health care decision-making and what aspects of health care they value most Clarify how they feel about making choices and possibly changing their lifestyles

Involvement in Decision-Making Most Americans say they would be willing to become more involved in their health care decisions if the health care system were easier to navigate. Two in five Americans (40%) agree strongly and an additional quarter (24%) agree somewhat that, if the health care system were easier to navigate, they would be more involved in making health care decisions for themselves and their family. A large minority of Americans would still follow their doctor’s advice, even if it conflicted with reliable information from a knowledgeable source. More than a third (36%) agree somewhat or strongly that they would still follow their doctor’s advice even if it conflicted with reliable information from a knowledgeable source. Less than half (46%) of Americans disagree somewhat or strongly that they would follow their doctor’s advice in this situation.

Covering Healthcare Expenses in Retirement A large majority of Americans say they would be willing work extra years to have enough money to pay for their health care in retirement. Three-quarters (74%) of Americans agree strongly or somewhat that they would be willing to work an extra two or three years in order to ensure they have enough money to pay for their health care in retirement. However, response varies with age. While nine in ten (88%) Americans age 18-24 agree strongly or somewhat that they would be willing to work longer, as the age of the respondent rises, the percentage of those willing to work additional years falls. For example, fewer than eight in ten (77%)of those age 35-44, seven in ten (72%) of those age 45-54, two-thirds (67%) of those age 55-64, and half (50%) of those 65 and older would be willing to work an extra two or three years to ensure they would have enough money to pay for their health care in retirement.

Perception of Quality & Value A large majority of Americans believe that, when getting medical care for a serious medical problem, differences in quality between health care providers may mean the difference between life and death. However, majorities are unwilling to pay more for higher-quality care and think it is unfair to require patients to pay more for better care. More than three-quarters of Americans agree that where they receive medical care for a serious medical problem can influence whether they live or die, with 53% agreeing strongly and an additional 25% agreeing somewhat. Fewer than one in five (16%)American adults would be willing to pay significantly higher premiums for a health insurance plan that provided coverage to go to hospitals and medical groups shown to provide better care. Two-thirds (64%) of Americans think it is unfair for patients to pay more to be treated by medical groups or hospitals that have been shown to provide better care.

Do Cost or Health Plan Limitations Keep Consumers With Current Providers? If money were not an issue, only about two in five Americans would change where they receive their health care. Less than two in five (38%) Americans agree somewhat or strongly that, if they won the lottery, they would change where they get their health care. About half (51%) of Americans disagree somewhat or strongly that winning the lottery would prompt them to change where they get their health care.

Personal Responsibility Though Americans know that a healthy lifestyle can improve and/or prevent many medical problems, they are split on whether they agree that those who practice unhealthy lifestyles should pay more. Almost all (93%) Americans agree strongly or somewhat that, by making healthy lifestyle choices - such as not smoking, exercising frequently, and controlling their weight – they can prevent or improve many serious medical problems.

Personal Responsibility A plurality of 46% say we should not require people with unhealthy lifestyles to pay higher premiums than people with healthy lifestyles, and a virtually identical plurality (47%) feel that we should not require people with unhealthy lifestyles to pay higher deductibles or co-payments for their medical care. However, when questions are asked about different types of health risks, attitudes vary depending on the type of risk involved. Majorities believe that smokers should pay more than non-smokers (58%) and that people who do not wear seat belts should pay more than people who do wear them (53%). On the other hand, only slightly more than a quarter of Americans believe that people who are overweight (27%) or people who do not exercise regularly (also 27%) should pay more. )

Views on Rising Healthcare Costs Americans attribute the rising costs of health care to a variety of factors, with high profits/drug companies and greed and waste in the system being cited most often. More than half of American adults feel that rising health care costs are due to high profits/drug companies (69%), greed and waste in the system (62%), the aging of the population (55%), and malpractice lawsuits (54%.) By contrast, fewer Americans attribute rising costs to the use of expensive medical technologies (46%) or the fact that consumers have little incentive to seek lower cost care (39%.)

What is a Life Worth? On balance, Americans are not willing to put a dollar value on living another year. Only three in ten (31%) Americans agree strongly or somewhat that society should put a dollar value on living another year. About half (48%) of Americans disagree strongly or somewhat with society putting a dollar value on living another year to help decide how much money to spend on prolonging lives. The remaining 21 percent of American adults are undecided on this issue.

Clinics as Catalysts for Collaborative Community-focused Change

CHCs as Change Agents Clinics are in touch with everyday people and their needs Clinics serve as interlocutors to other social services Clinics are supported by and governed by local citizens Clinics are a key component in this administrations strategy to address access issues Clinics are looking at the provision of services as a ‘population health’ proposition Clinics have a vested interest in ensuring services are well coordinated between private and publics sector

CHCs as Change Agents Many CHCs are ahead of the private sector with critical elements needed to address health system weaknesses: Provide a ‘medical home’ Focus on prevention and primary care Excel at community outreach through CHWs and lay educators Are sensitive to diverse populations Effectively integrates medical with social services

WRGH Reports Communities Shaping a Vision for America’s 21st Century Health & Healthcare: Phase I: http://www.wrgh.org/docs/book_shaping.pdf Phase II: http://www.wrgh.org/docs/feat_phase2_report.pdf Community Leaders’ Blueprint for American Health Care Policy: http://www.wrgh.org/docs/blueprintonly.pdf National Study on Consumer Health Values: http://www.wrgh.org/docs/harris.pdf

Marcia L Comstock, MD MPH Contact Information Jon R Comola CEO 512-472-2005 jrcomola@wrgh.org Marcia L Comstock, MD MPH COO 610-687-2320 mlcomstock@wrgh.org