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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 l.jpg

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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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


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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)


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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


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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


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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


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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


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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


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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)


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Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured


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Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured

Many uninsured


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Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured

Uninsured utilize higher than necessary levels of care

Many uninsured


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Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured

Uninsured utilize higher than necessary levels of care

Many uninsured

Higher

uncompensated costs


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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


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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


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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


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Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured

Even more uninsured


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Health Care Spending in the United States

$2.1 trillion per year

$7,000 per person per year


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*

%GDP spent on health care


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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


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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


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F as in Fat 2008; Trust forAmerica’s Health

Texas

  • Obesity #15

  • Diabetes #11

  • Physical inactivity #8


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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


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Determinants of Health System Performance

Biological

Socioeconomic

Behavioral

Environmental


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What Drives System PerformanceHealth 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


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Scrimping on Medical Care System Performance

  • “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)


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Health Care: Are We Getting Our Money’s Worth? System Performance

People of the U.S.

Medical Care

Public Health

Dollars Expended


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Changing Health Systems to System PerformanceImprove 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.


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Demand System Performance

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


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Health promotion System Performance

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


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"Healthy choices need to be System Performancethe easy choices”

– World Health Organization's Ottawa charter


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Framework on Population Health . . . System Performance(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


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The Consequences of Misplaced Priorities System Performance

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

Woolf, JAMA, V.297,#5


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The Consequences of Misplaced Priorities System Performance

  • 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


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The Consequences of Misplaced Priorities System Performance

  • 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


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The Consequences of Misplaced Priorities System Performance

  • 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


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The Consequences of Misplaced Priorities System Performance

  • 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


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Education: The Greatest Predictor System Performanceof 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


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The Primary Solution Mending Texas’ System Performance 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


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The Primary Solution Mending Texas’ System Performance 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


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The Primary Solution Mending Texas’ System PerformanceFractured 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


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The Primary Solution Mending Texas’ System PerformanceFractured 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


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Another consideration to System PerformanceImprove 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


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America’s Health Insurance Plans (AHIP) System PerformanceA Vision for Reform

A Vision to Assure Health Coverage for All Americans

  • SCHIP reauthorization

  • Medicaid eligibility for adults < 100% FPL


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Community-oriented Primary-care System PerformanceHealth 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


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

Sir William Osler (1849-1919)


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“Healthy choices need to System Performance

be the easy choices”.

World Health Organization’s Ottawa charter


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Healthy Living Tips System Performance

  • Eat smart

  • Be active

  • Avoid tobacco

  • Stay connected

  • Sleep plenty

  • Learn to learn


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Access to Health System Performance2008 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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