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Access to Health 2008 Texas Indigent Health Care Association Conference. Eduardo Sanchez, M.D., MPH VP and Chief Medical Office, Blue Cross and Blue Shield of Texas Former, Texas Commissioner of Health. A “Transformed” Health System. The objective is optimal population-health

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access to health 2008 texas indigent health care association conference

Access to Health2008 Texas Indigent Health Care Association Conference

Eduardo Sanchez, M.D., MPH

VP and Chief Medical Office, Blue Cross and Blue Shield of Texas

Former, Texas Commissioner of Health

a transformed health system
A “Transformed” Health System
  • The objective is optimal population-health
  • Redesigned to prevent and manage chronic diseases
  • Better integration of public health and medical care
  • Evidence-based intervention and practice
  • Prioritization and adequate funding/reimbursement of interventions that optimize health
  • Best use of health information and health information technology
our health care system
Our health care system

“an expensive plethora of uncoordinated, unlinked, economically segregated, operationally limited microsystems each performing in ways that too often lead to suboptimal performance”

(Halvorson, 2007)

our health care system4
Our health care system
  • 54% of Americans with chronic disease skip pills and appointments because of cost
    • Diabetes
    • Heart disease
    • Cancer
    • depression
  • 42% spent > $1000 on out of pocket medical costs
    • 4% in the U.K.
    • 8% in the Netherlands
  • More likely to have suffered from a lack of coordination of care

Commonwealth Fund, Health Affairs on line

blue cross blue shield association thinking about health care reform
Blue Cross Blue Shield AssociationThinking About Health Care Reform
  • Employer-based Health Insurance System
    • 59% US
    • 50% Texas
  • Variations in Cost and Quality
    • 30 percent of care rendered today, according to some studies, is unnecessary, redundant and, in some cases, even harmful.
  • Cost Impact of Chronic Disease
    • Cut the prevalence of diabetes in half
      • obesity, weight management, nutrition, fitness and health risk assessment
  • Overview of the Uninsured
    • Higher mortality rate for the uninsured
indigent health care needs
Indigent Health Care Needs
  • Screening and early detection services
  • Health education
  • Immunizations, management of other communicable diseases
  • Reproductive care, including prenatal and family planning services
  • Diagnosis and management of chronic health conditions (diabetes, hypertension, etc.)
  • Primary care
  • Additional medical care
who are the uninsured in texas
Who are the Uninsured in Texas?
  • They are of all ages
  • They are from all income groups
  • They live all over Texas
  • Most of them work
  • Most of them are legal, US citizens
  • Their population is growing
the uninsured
The Uninsured
  • United States = 15.0%
  • Texas (6,000,000) = 25.0%
    • 70% of whom are at <200% FPL
  • Texas children (1,500,000) = 22.0%
    • 1/3 < FPL
    • 1/3 100-200% FPL
    • 1/3 >200% FPL

CPPP, 2008

determinant of diabetes
Determinant of Diabetes?

Persons living in low income communitiesare 80% more likely to be hospitalizedfor diabetes or related complications compared with those living in affluent areas

(AHRQ)

vicious circle of health cost increases with high numbers of uninsured12
Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured

Uninsured utilize higher than necessary levels of care

Many uninsured

vicious circle of health cost increases with high numbers of uninsured13
Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured

Uninsured utilize higher than necessary levels of care

Many uninsured

Higher

uncompensated costs

vicious circle of health cost increases with high numbers of uninsured14
Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured

Uninsured utilize higher than necessary levels of care

Many uninsured

Higher

uncompensated costs

Increased charges

to paying customers

vicious circle of health cost increases with high numbers of uninsured15
Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured

Uninsured utilize higher than necessary levels of care

Many uninsured

Higher

uncompensated costs

Increased charges

to paying customers

Insurance companies

raise premiums for insured

vicious circle of health cost increases with high numbers of uninsured16
Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured

Uninsured utilize higher than necessary levels of care

Many uninsured

Higher

uncompensated costs

More employers drop coverage

because of high premiums

Increased charges

to paying customers

Insurance companies

Raise premiums for insured

health care spending in the united states
Health Care Spending in the United States

$2.1 trillion per year

$7,000 per person per year

slide19

*

%GDP spent on health care

estimated health care spending in texas
Estimated Health Care Spendingin Texas

$100 billion is spent on health care annually (conservative estimate)

$70 billion, physician and hospital care

$15 billion, drugs and other professional health services

$85 billion, direct client care

$13 billion (15%) spent on indigent care

the real problem
The Real Problem:

The Full Cost of Poor Employee Health

Personal Health Costs

Medical Care

Pharmacy

Medical & Pharmacy Costs

$3,376 PEPY

25%

Productivity Costs

Absenteeism

Short-term Disability Long-term Disability

Health-RelatedProductivity Costs

$10,128 PEPY

75%

Presenteeism

Overtime

Turnover

Temporary Staffing

Administrative Costs

Replacement Training

Off-Site Travel for Care

Customer Dissatisfaction

Variable Product Quality

Total Costs = $13,504 PEPY

Sources: Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: 40-152 and Loeppke, R., et al. Health and Productivity as a Business Strategy. Journal of Occupational and Environmental Medicine. Vol 49, No. 7, July, 2007. Pages 712-721 and the 2006 Mercer Employer Annual Survey;

23

f as in fat 2008 trust for america s health
F as in Fat 2008; Trust forAmerica’s Health

Texas

  • Obesity #15
  • Diabetes #11
  • Physical inactivity #8
aiming higher results from a state scorecard on health system performance
Aiming Higher: Results from a State Scorecard on Health System Performance

Texas #49

  • Access #51
  • Quality #46
  • Avoidable hospital use & costs #48
  • Healthy lives #24

Commonwealth Fund

determinants of health
Determinants of Health

Biological

Socioeconomic

Behavioral

Environmental

what drives health status and health care costs
What Drives Health Status and Health Care Costs?

How Can We Encourage and Support Behavior Change?

Source: IFTF and Center for Disease Control and Prevention, Health and Healthcare 2010, January 2000

29

scrimping on medical care
Scrimping on Medical Care
  • “The economic crisis is exposing further weaknesses in this country’s healthcare system. …many Americans are skimping on medications, physician visits and preventive screening in order to pay other household bills…
  • Some evidence suggests that many people are cutting back on drugs that fight chronic conditions like high cholesterol, high blood pressure, osteoporosis, and diabetes”

(New York Times, 10/26/08)

health care are we getting our money s worth
Health Care: Are We Getting Our Money’s Worth?

People of the U.S.

Medical Care

Public Health

Dollars Expended

changing health systems to improve health status
Changing Health Systems to Improve Health Status
  • The health and disease paradigm has been shifting in the United States from an acute, infectious disease model of morbidity and mortality to a chronic, non-infectious model. 
  • The systems and interventions that helped prevent and treat infectious diseases at the individual and population level must be transformed to prevent and treat chronic diseases.
  • The United States needs a population-based, prevention-centered health system that interrelates public health and medical care.
the health care equation is out of balance
Demand

Older

Heavier

More Sedentary

Un & Underinsured

Health Illiterate

Supply

Increasing Access

Increasing Workforce

System Redesign

Improving Quality of Care

Improving Technology

Improving Meds

The Health Care Equation is Out of Balance

Demand Reduction Is Imperative

how to achieve balance

Health promotion

and

Disease prevention

How to achieve balance

Supply

  • Increasing Access
  • Increasing Workforce
  • System Redesign
  • Improving Quality of Care
  • Improving Technology
  • Improving Meds

Demand Reduction Is Imperative

slide35
"Healthy choices need to bethe easy choices”

– World Health Organization\'s Ottawa charter

slide36
Framework on Population Health . . .(adapted from CDC, Public Health Action Plan to Prevent Heart Disease and Stroke)

A Vision of the Future

Social and

Environmental

Conditions

Favorable to

Health

Health

Promoting

Behavioral

Patterns

Low

Population

Risk

Low

Disease

Occurrence

Good Quality

Of Life Until

Death

Full Functional

Capacity

Policy and

Environmental

Change

Behavior

Change

Risk Factor

Detection

And Control

Acute Case

Management/

Treatment

Chronic disease

Management/

Rehabilitation

End-of-Life

Care

Approaches to Intervention

The Present Reality

Unfavorable

Social and

Environmental

Conditions

Adverse

Behavioral

Patterns

Disease

Occurrence

1st Event

Fatal

Complications/

Decompensation

Major Risk

Factors

Poor Health

Status/Disability

Target Population

Large and general

Small and specific

the consequences of misplaced priorities
The Consequences of Misplaced Priorities

To maximize health, we should pursue interventions in proportion to their ability to improve outcomes

Woolf, JAMA, V.297,#5

the consequences of misplaced priorities38
The Consequences of Misplaced Priorities
  • Choosing effective services (appropriate use of things that work vs. overuse of things that don’t )

To maximize health, we should pursue interventions in proportion to their ability to improve outcomes

Woolf, JAMA, V.297,#5

the consequences of misplaced priorities39
The Consequences of Misplaced Priorities
  • Choosing effective services (appropriate use of things that work vs. overuse of things that don’t )
  • Delivering care (services delivery system improvements vs. biomedical advances)

To maximize health, we should pursue interventions in proportion to their ability to improve outcomes

Woolf, JAMA, V.297,#5

the consequences of misplaced priorities40
The Consequences of Misplaced Priorities
  • Choosing effective services (appropriate use of things that work vs. overuse of things that don’t )
  • Delivering care (services delivery system improvements vs. biomedical advances)
  • Preventing disease (tobacco cessation versus b-blockers)

To maximize health, we should pursue interventions in proportion to their ability to improve outcomes

Woolf, JAMA, V.297,#5

the consequences of misplaced priorities41
The Consequences of Misplaced Priorities
  • Choosing effective services (appropriate use of things that work vs. overuse of things that don’t )
  • Delivering care (services delivery system improvements vs. biomedical advances)
  • Preventing disease (tobacco cessation versus b-blockers)
  • Fostering social change (educational attainment versus medical advances)

To maximize health, we should pursue interventions in proportion to their ability to improve outcomes

Woolf, JAMA, V.297,#5

education the greatest predictor of longevity
Education: The Greatest Predictorof Longevity
  • Lower education = unhealthy behaviors
  • Lower education = higher death rate
    • < 12 years of education: 615.6 deaths per 100,000 foradults 18-65
    • >13 years of education: 207.9 deaths per 100,000 foradults 18-65

CDC National Center for Health Statistics, Vital Statistics Vol. 53, #5, Deaths, 2002

the primary solution mending texas fractured health care system
The Primary Solution Mending Texas’ Fractured Health Care System
  • Grow Texas’ primary care physician base
    • Create a consolidated loan repayment program for Texas’ primary care physicians and other qualified health care professionals who agree to serve in medically underserved areas
    • Increase funding for family medicine residency programs and primary care residency programs
    • Fully fund primary care pre-ceptorship programs
  • Invest in health information technology
    • Create a matching investment fund to provide HIT infrastructure for residency programs and primary care physician practices

©2008, Primary Care Coalition

the primary solution mending texas fractured health care system44
The Primary Solution Mending Texas’ Fractured Health Care System
  • Ensure Texans have access to affordable healthinsurance options
  • Pursue innovative, market-based approaches to reduce the ranks of the uninsured
    • Build upon the reforms initiated by Senate Bill 10 to use Medicaid dollars to extend private coverage for low-income parents and adults
    • Support funding for local public-private collaborations such as the three-share model designed to extend affordable health care and coverage for the uninsured

©2008, Primary Care Coalition

the primary solution mending texas fractured health care system45
The Primary Solution Mending Texas’Fractured Health Care System
  • Reinvest in Medicaid and CHIP
    • Support competitive physician reimbursement rates that keep pace with the amount it costs to provide the services, and include rewards for physicians who implement after-hours care, open-access scheduling and other features of the patient-centered medical home
    • Enact 12 months continuous coverage for children enrolled in Medicaid and CHIP; strengthen outreach initiatives to enroll children who are eligible but not enrolled in CHIP or Medicaid
    • Reduce the Medicaid “hassle factor” to entice more physiciansto participate, modernize outdated information technology, andsupport extended use of HIT such as electronic medical recordsand e-prescribing

©2008, Primary Care Coalition

the primary solution mending texas fractured health care system46
The Primary Solution Mending Texas’Fractured Health Care System
  • Support a patient-centered primary care medical home forall Texans
    • Assure that patients receive the right care at the right time, every time by supporting and nurturing the establishment of a medical home for every Texan
    • Provide incentives to physicians who adopt components of the medical home model into their practices such as after-hours care, open-access scheduling and health information technology
    • To provide the best care at the lowest price for their patients

©2008, Primary Care Coalition

another consideration to improve the health of texans
Another consideration toImprove the Health of Texans

An investment of $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking and other tobaccouse could save the country more than $16 billion annually(and Texas more than $1.3 billion annually) within five years.This is a return of $5.60 for every $1

  • Invest $240 million on population health measures

Blueprint for a Healthier America:

MODERNIZING THE FEDERAL PUBLIC HEALTH SYSTEM

TO FOCUS ON PREVENTION AND PREPAREDNESS

america s health insurance plans ahip a vision for reform
America’s Health Insurance Plans (AHIP) A Vision for Reform

A Vision to Assure Health Coverage for All Americans

  • SCHIP reauthorization
  • Medicaid eligibility for adults < 100% FPL
community oriented primary care health system
Community-oriented Primary-care Health System

Medical Care

Public Health

Specialty/Tertiary Care

Access to

Healthy Foods &

Activities

Specialty Care

Diagnostic

Testing

Primary Care

  • Patient Centered
  • Medical Home
  • (mental/dental/medical)
  • Easy access
  • Continuity of care
  • Comprehensive care
  • Coordination of all care
  • (Clinical preventive services
  • and disease management)

Coordinated

School Heath

&

Worker wellness

Hospital Based

Care

Inpatient Care

Emergency and

trauma care

Comprehensive

Tobacco

Control

= Optimal Communication (Integrated Virtual System)

Including best use of health informational technology

Concept

slide50

“One of the first duties of thephysician is to educate the masses not to take medicine”

Sir William Osler (1849-1919)

slide51

“Healthy choices need to

be the easy choices”.

World Health Organization’s Ottawa charter

healthy living tips
Healthy Living Tips
  • Eat smart
  • Be active
  • Avoid tobacco
  • Stay connected
  • Sleep plenty
  • Learn to learn
access to health 2008 texas indigent health care association conference53

Access to Health2008 Texas Indigent Health Care Association Conference

Eduardo Sanchez, M.D., MPH

VP and Chief Medical Office, Blue Cross and Blue Shield of Texas

Former, Texas Commissioner of Health

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