Finding The Opportunities In National And New York State Healthcare Reform

Dale Jarvis206-613-3339dale@djconsult.net

Three Simple Topics

• The Problem

• The Fix

• New York’s Opportunity and Challenge

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The Problem…

Page 3

The U.S. Quality and Cost Problems

$2,471 $2,658

$2,687

$2,701 $2,729

$2,900 $2,990

$3,349 $3,353

$3,361 $3,540

$3,593 $3,619

$3,792 $3,853

$3,867

$4,791

$7,285

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Per Capital Health Expenditures, 2007 (US $)18 Industrialized Nations, OECD Health Data, 2010

Note: US Spending is 52% above Norway and 88% above Cana

60

70

80

90

100

110

65

71 7174 74

7780 82 82 84 84

9093

96101 103 103 104

110

Preventable Deaths* per 100,000 Populationin 2002-2003 (19 Industrialized Nations,

Commonwealth Fund)(* by conditions such as diabetes, epilepsy, stroke, influenza,

ulcers, pneumonia, infant mortality and appendicitis)

110 Preventable Deathsper 100,000

$7,285 Per Capita Health Expenditure

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4

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The U.S. has a Sick Care Systemnot 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

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• 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

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The Fix…

• Better Health for the Population

• Better Care for Individuals

• Reduced Costs through Improvement (not rationing)

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“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

Prevention, Early Intervention,

Primary Care, and Behavioral Health

Inpatient & Institutional

Needed Resource Allocation

All things Inpatient and Institutional

Prevention, Primary Care, BH

Current Resource Allocation

Page 8

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)

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Vermont Blueprint for HealthThe Healthcare System of the Future?

• Key Ingredients:– Medical Homes– Community Health

Teams– Mental Health

Providers– Public Health

Prevention– Accountable Care

Organizations

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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

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Harold Miller, Center for Healthcare Quality and Payment Reform, How to Create Accountable Care Organizations, www.chqpr.org

Why Accountable Care Organizations?

• It takes more than a high performing Healthcare Home to improve quality and bend the cost curve

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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

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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

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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

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Which requires the Customization of the Accountable Care Organization

Healthcare Neighborhood

Accountable Care Organization

Accountable Care Organization

Health Home

(MH/SU Agency with PC)

Hospital

Food Mart

Medical Specialty Clinic

Food Mart

MH/SU Specialty Clinic

Health Home

(PC Clinic with MH/

SU)

Hospital

Clinic

Clinic

Social Service Agencies

Employment,Education Public Health,Housing Oral Health, Long Term Care, etc.

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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.

Community Care Organization

Person Centered

Health Care

Homes

Hospitals

Food Mart

Specialty Medical Clinics

Food Mart

Specialty Behavioral Health Clinics

Person Centered

Health Care

Homes

Hospitals

Clinic

Clinic

Social Service Agencies

Employment/Education Child Welfare, Housing Public Health, Oral Health, Etc.

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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

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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.

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One important measure of success…• …will be the creation of the cycle of

resilience and recovery in communitiesIndividuals

develop resilience

Resiliencesupportsrecovery

Recovery isassisted by social

support

Social supportcreates a

community

Catalysts defineand energizecommunities

Communitydevelopment

increasessupports for more

individuals

From Comas, a Scottish community development organization working to promote recovery and resilience amongst individuals and communities Page 20

New York’s Opportunity And Challenge

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A Compressed Period of Change

• US timeline compared with China

• Other States’ timeline compared with NY

Pre-Managed

Care

Managed Behavioral Healthcare Carve-Out

Clinical-Financial-Structural Integration

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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 thepace for the restof the country

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