1. Finding The Opportunities In National And New York State Healthcare Reform Dale Jarvis 206-613-3339 dale@djconsult.net

2. Three Simple Topics The Problem The Fix New York’s Opportunity and Challenge Page 2

3. The Problem… Page 3

4. The U.S. Quality and Cost Problems 110 Preventable Deaths per 100,000 $7,285 Per Capita Health Expenditure 4 4 Page 4

5. The U.S. has a Sick Care System not a Health Care System Half of Americans have one or more chronic health conditions (155+ million) Over half of these people receive their care from 3 or more physicians In total, treating chronic health conditions consumes 75%+ of the $2.5 trillion we spend on healthcare each year in the U.S. In large part due to the fact that money doesn’t start flowing in the US healthcare system until after you become sick Page 5

6. Americans with a Serious Mental Illness die, on the average, at age 53 The high prevalence of persons with these disorders, combined with high cost, directly affect the quality and cost problems The Two-Part Problem is Closely Linked to a Third Problem Page 6

7. The Fix… Better Health for the Population Better Care for Individuals Reduced Costs through Improvement (not rationing) Page 7

8. “ Follow the Money” (Deep Throat quote from Bob Woodward’s account of Watergate) Prevention Activities must be funded and widely deployed Primary Care must become a desirable occupation and Mental Health and Substance Use Disorder Assessment & Treatment for all must become the Standard of Care In order to Decrease Demand in the Specialty and Acute Care Systems Page 8

9. We Already Know How to Flip the Resource Triangle (Medical Homes, Accountable Care Organizations, supported by Payment Reform) In Denmark, over the last few decades, the number of hospitals has dropped from 155 to 89 today, a 42% drop. (Sources: Paul Grundy, Director of Healthcare, Technology and Strategic Initiatives for IBM Global Wellbeing Services and Wikipedia) And in the US: “Pilots in the U.S. include Geisinger's, which Grundy says has been remarkably successful, yielding … a 12% reduction in ER utilization, a 20% reduction in hospitalization, and a 48% reduction in rehospitalization. (excerpt from David Harlow’s Health Care Law Blog 9/15/2009) Page 9

10. Vermont Blueprint for Health The Healthcare System of the Future? Key Ingredients: –Medical Homes –Community Health Teams –Mental Health Providers –Public Health Prevention –Accountable Care Organizations 10 Page 10

11. Accountable Care Organizations (ACOs) – the homes for medical homes  ACOs are provider groups that accept responsibility for the cost and quality of care delivered to a group of patients that are cared for by ACO clinicians  With Medical Homes/Healthcare Homes at the center Page 11

12. Harold Miller, Center for Healthcare Quality and Payment Reform, How to Create Accountable Care Organizations, www.chqpr.orgwww.chqpr.org Why Accountable Care Organizations? It takes more than a high performing Healthcare Home to improve quality and bend the cost curve Page 12

13. But what about At-Risk, Vulnerable Populations? Social Determinants of Health –There is a distinct relationship between an individual’s health status and the social and environmental conditions in which he or she lives Page 13

14. But what about At-Risk, Vulnerable Populations? For many children, families, and adults in the safety net, good healthcare is not enough Consider a mom with depression and diabetes Add to this scenario the facts that she is the head of household of a family of three, has lost her job, is experiencing domestic violence and she and her children are on the brink of homelessness Page 14

15. Goal: Create The “Healthcare Neighborhood”, The Next Generation Safety Net Healthcare System The Fulton County Georgia (Atlanta area) Neighborhood Union Primary Care Partnership’s One Stop Shopping: –Well patient care –Sick-patient care –OB/GYN services –Travel immunization services –Communicable disease intervention –WIC/nutrition education –Oral health services –Behavioral health services –A day center for parents receiving services – Employment assistance – Disability and vocation rehabilitation services – Foreclosure prevention services – Housing assistance – A reading room/information center that offers ESL classes – A farmer’s market – A community garden – A walking trail Page 15

16. Which requires the Customization of the Accountable Care Organization Page 16

17. Emerging Idea: Community Care Organizations (ACOs for the Safety Net) A Community Care Organization is an ACO that is designed to focus on the needs of the safety net population in a community, with a special emphasis on addressing the social determinants of health such as poverty, unemployment, homelessness, poor housing, neighborhood violence, etc. Designed by a broad cross-section of community residents and community partners, the core of the CCO is made up of existing community service agencies. Page 17

18. The List Includes… Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) Community Mental Health and Substance Use Disorder Treatment Providers Recovery, Peer and Wellness Organizations Public Health Departments Hospitals Social Service Agencies Child Welfare Providers and Family Resource Centers Housing and Homeless Services Providers Oral Health Providers Pre-Schools and Schools Job Training and Employment Support Organizations Page 18

19. The Purpose of a CCO… …is to organize a Healthcare Neighborhood that will help all community members move toward the Triple Aim of: –Better health for the population, –Better care for individuals and –Reduced costs. A core objective of the CCO is to develop an integrated network of community groups that see themselves as hospital and institution prevention organizations; Helping prevent admission and readmission to acute care and psychiatric hospitals; nursing homes; youth residential treatment facilities; jails prisons, and juvenile justice facilities; and other restrictive, high cost, non-community based institutions. Page 19

20. One important measure of success … …will be the creation of the cycle of resilience and recovery in communities From Comas, a Scottish community development organization working to promote recovery and resilience amongst individuals and communities Page 20

21. New York’s Opportunity And Challenge Page 21

22. A Compressed Period of Change US timeline compared with China Other States’ timeline compared with NY Page 22

23. We Know How To Fix The Healthcare System But How Will It Unfold Across The Country? Some states will fight “ObamaCare” at the risk of destroying their economies Some states will leverage many of the healthcare reform tools but be tone deaf to the importance of the healthcare neighborhood for the safety net Other states will “get it” and set the pace for the rest of the country Page 23