The Case for Health System Change

1. The Case for Health System Change Dan Rahn, M.D. Chancellor, University of Arkansas for Medical Sciences

2. What is Driving Health System Change?

3. How Does the United States Compare

4. Health Expenditure Per Capita

5. Health Expenditures by Country • Health spending % of GDP in 2011: • United States 17.7% • Netherlands 11.9% • France 11.6% • OECD Average 9.3%

6. Health Expenditures by Country • The United States together with Mexico and Chile are the only OECD countries where less than 50% of health spending is publicly financed. • The overall level of health spending in the United States is so high that public (i.e. government) spending on health per capita is still greater than in all other OECD countries, except Norway and the Netherlands.

7. Health Expenditures by Country • In the United States, life expectancy at birth increased by almost 9 years between 1960 and 2011, but this is less than the increase of over 15 years in Japan and over 11 years on average in OECD countries. As a result, while life expectancy in the United States used to be 1 ½ years above the OECD average in 1960, it is now, at 78.7 years in 2011, almost 1 ½ years below the average of 80.1 years.

8. What is driving health system change?

9. What is driving health system change? • National Research Council/IOM report • US males and females in all age groups up to 75 years of age have shorter life expectancies and higher prevalence and mortality from multiple diseases, risk factors and injuries than 16 other developed nations • For 45 of 48 years, health care cost growth has outstripped growth in public funds and GDP

10. Comparison of International Infant Mortality Rate: 2000 Infant Mortality 2.5 Singapore Hong Kong Japan Sweden Norway Finland Spain Chech Republic Germany Italy France Austria Belgium Switzerland Netherlands Northern Ireland Australia Denmark Canada Israel Portugal England & Wales Scotland Greece Ireland New Zealand United States Cuba 3.0 3.2 3.4 3.8 3.8 3.9 4.1 4.4 4.5 4.5 4.8 4.8 4.9 5.1 5.1 5.2 5.3 5.3 5.4 5.5 5.6 5.7 6.1 6.2 6.3 6.9 7.2 Deaths per 1,000 Live Births

11. WHY? Multifunctional • Health System Design and Performance • Social Determinants of Health

12. Social Determinants Side

13. Institute of Medicine Report: Best Care at Lower Cost: The Path to Continuously Learning Health Care in America “Health Care in America has experienced an explosion in knowledge, innovation, and capacity to manage previously fatal conditions. Yet, paradoxically, it falls short on such fundamentals as quality, outcomes, cost, and equity. Each action that could improve quality-developing knowledge, translating new information into medical evidence, applying the new evidence to patient care-is marred by significant shortcomings and inefficiencies that result in missed opportunities, waste, and harm to patients.”

14. If… • If banking were like health care, automated teller machine (ATM) transactions would take not seconds but perhaps days or longer as a result of unavailable or misplaced records • If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination. • If shopping were like health care, product prices would not be posted, and the price charged would vary widely within the same store, depending on the source of payment. • If automobile manufacturing were like health care, warranties for cars that require manufacturers to pay for defects would not exist. As a result, few factories would seek to monitor and improve production line performance and product quality. • If airline travel were like health care, each pilot would be free to design his or her own preflight safety check, or not perform one at all.

15. Waste estimates • Unnecessary Services $210 billion • Inefficiently delivered services $130 billion • Excess administrative costs $190 billion • Prices that are too high $105 billion • Missed prevention opportunities $55 billion • Fraud $75 billion Total $765 billion

16. The Vision

17. Categories of the Committee’s Recommendations Foundational Elements Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge. Recommendation 2: The data utility. Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge. Care Improvement Targets Recommendation 3: Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions. Recommendation 4: Patient-centered care. Involve patients and families in decisions regarding health and health care, tailored to fit their preferences. Recommendation 5: Community links. Promote community-clinical partnerships and services aimed at managing and improving health at the community level. Recommendation 6: Care continuity. Improve coordination and communication within and across organizations. Recommendation 7: Optimized operations. Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health. Supportive Policy Environment Recommendation 8: Financial incentives. Structure payment to reward continuous learning and improvement in the provision of best care at lower cost. Recommendation 9: Performance transparency. Increase transparency on health care system performance. Recommendation 10: Broad leadership. Expand commitment to the goals of a continuously learning health care system.

18. Arkansas’ Healthcare Population What About Arkansas? 45th in Stroke 46th in Occupational Fatalities 43rd in Infant Mortality 43rd in Obesity 45th in Premature Death 50th in Immunization Coverage 49th in per Capita Health Spending 42nd in Lack of Health Insurance 45th in Children in Poverty 45th in Physical Activity 48th in Overall Health 45th in Cardiovascular Deaths 41st in Adequacy of Prenatal Care 44th in Poor Physical Health Days 45th in Cancer Deaths Source: Americas Health Rankings.org 2010

19. What about Arkansas?

20. What about Arkansas? Infant Mortality by Race in Arkansas

21. Comparison of International Infant Mortality Rate: 2000 What about Arkansas? 2.5 Singapore Hong Kong Japan Sweden Norway Finland Spain Chech Republic Germany Italy France Austria Belgium Switzerland Netherlands Northern Ireland Australia Denmark Canada Israel Portugal England & Wales Scotland Greece Ireland New Zealand United States Cuba 3.0 3.2 3.4 3.8 3.8 3.9 4.1 4.4 4.5 4.5 4.8 4.8 4.9 5.1 5.1 5.2 5.3 5.3 5.4 5.5 5.6 5.7 6.1 6.2 6.3 6.9 7.2 Deaths per 1,000 Live Births

22. What about Arkansas? Age-Specific Death Rates from Coronary Heart Disease, Arkansas & U.S., Aged 45-64 years, 1968 - 2010 45-64age group 2005-2010, 62%

23. What about Arkansas? Age-Specific Death Rates from Cancer, Arkansas & U.S., Aged 45-64 years, 1968 - 2010 45-64age group 2005-2010, 26%

24. Age-Specific Death Rates from Stroke, Arkansas & U.S., Aged 45-64 years, 1968 - 2010 What about Arkansas? 2005-2010, 54%

25. Uninsurance

26. Health Outcomes

27. Mortality

28. Morbidity

29. Socio-Economic Factors

30. Educational Factors

31. African American Population

32. What are Social Determinants of Health? • Within countries, cities and communities there are dramatic variations in health among certain groups of people that are closely linked to those groups socioeconomic status • These conditions are the social determinants of health and are defined by the World Health Organization – diet, exercise, tobacco, obesity

33. Social Determinants • Access to Health Care • Poverty • Education • Work • Leisure – diet/exercise • Tobacco • Obesity • Living conditions/environments • Environmental toxins

34. Role of Poverty • Study from England and Wales (Curran, 2009) • Between 1972 – 1996 (UK had universal health insurance) • Life expectancy of men in the highest “social class” increased from 72 yrs in the period of 1972-1976 to 79 yrs in the period 1992-1996, an increase of 7 years and 8%. • For this same period, life expectancy of men in the lowest social class increased from 66 yrs to 68 yrs an increase of only 3%. The gap widened.

35. Role of Education • Study conducted by Steven Woolf at VCU (published in 2009 in JAMA). Mortality for adults aged 25-64 varied by education level • Some education beyond high school: 206/100,000 • High school education: 478/100,000 • Less than high school education: 650/100,000

36. Role of Education • Impact of college education on population health - Giving Everyone the Health of the Educated: An examination of whether social change would save more lives than medical advances (Woolf, et. Al., AJPH, 2007) • Using US vital statistics data from 1996-2002 • Results: Medical advances averted 178,193 deaths during the study period. Correcting disparities in education – associated mortality rates would have saved 1,369,335 lives, a ratio of 8:1

37. Impact of Health Literacy • Health Literacy and Outcomes Among Patients with Heart Failure (Peterson, et. al. JAMA 2011) • Retrospective review of 2156 patients with discharge diagnosis of heart failure identified between 2001-2008 • Surveyed by mail with median follow up of 1.2 years • Health literacy assessed with a 3 question screen tool: on a scale of 1-5

38. Screening Tool • How often do you have someone help you read hospital material? • How often do you have problems learning about your medical condition because of difficulty reading hospital materials? • How confident are you filling out forms by yourself?

39. Screening Tool Outcomes • Score less than 10 was called low health literacy. • Of 1494 included responders, 262 had low health literacy. Those with LHL had a 17.6% mortality rate during the study period compared with 6.3% for all others, adjusted for other illnesses, age, economic status, etc.

40. Overall Impact of Health Literacy of Health Outcomes • Low Health Literacy and Health Outcomes: An Updated Systematic Review (Berkman, et. al., AIM 2011) • Low Health Literacy was consistently associated with: • More hospitalizations • Greater use of emergency care • Lower receipt of mammography screening and influenza vaccine • Poorer ability to demonstrate taking medication appropriately • Poorer ability to interpret labels and health messages • In elderly patients: poorer overall health status, higher mortality rates

41. Race / Ethnicity • Race: inextricably intertwined with economic status and education but infant mortality of black newborns in the US is twice as high as that of white newborns (Woolf, 2009) • If we could eliminate race-based inequalities, five lives would be saved for every life saved by medical advances

42. Economic Impact • “If medicine is to fulfill her great test, then she must enter the political and social life. Since disease so often results from poverty, physicians are the natural attorneys of the poor and social problems should largely be solved by them.” Rudolf Virchow, 19th century pathologist • Our system is oriented toward assuring that those with illness receive all available treatment rather than on health promotion and addressing the conditions that produce disease.

43. Fundamental Change is Required

44. Strategies for Health System Change • Accelerate the use of health information technology • Health information exchange • Telehealth • Electronic medical records systems • Restructure the health care payment system to improve the quality of medical care and curb rising costs • Arkansas Payment Improvement Initiative • Patient centered medical homes • Episode-based payments

45. Strategies for Health System Change • Reduce the number of uninsured Arkansans • Private health insurance exchanges (ACA) • Arkansas Private Option for Medicaid Population • Plan for a health care work force that provides appropriate access to medical services particularly in underserved areas • Health Work Force Strategic Plan • Forty separate recommendations

46. A time of disruptive change but it’s not the first… • Hill Burton Act: 1946 • Medicare/Medicaid: 1965 “We are against forcing all citizens, regardless of need, into a compulsory government program. It is socialized medicine. If it stands, one of these days you and I are going to spend our sunset years telling our children and our children's children, what it once was like in America when men were free.” Ronald Reagan • SCHIP (State Children’s Health Insurance Program) 1997 • Medicare Modernization Act: 2003 (Prescription drug coverage and Medicare Advantage Plans) • PPACA: 2011 • Arkansas Private Option Insurance Expansion • Arkansas Payment Improvement Initiative

47. All-Cause Mortality for Individuals aged 65+ United States, 1950 - 2010 7500 6500 Death rate per 100,000 population 5500 4500 3500 2005 2000 2010

48. Triple Aim • Better population and individual health • Better patient experience • Lower cost

49. Patient Protection and Affordable Care Act Goal: Extend access to insurance for the vast majority of currently uninsured citizens while improving quality and controlling cost growth

50. Patient Protection and Affordable Care Act • Key strategies: • Private Insurance exchanges for individuals and families with income above 138% of federal poverty level • Medicaid Expansion for individuals and families with incomes up to 138% of federal poverty level • Medicaid expansion is funded federally for first three years after which states begin sharing cost up to 10% state share by 2020 • Many other provisions for funding the insurance expansion including reductions in: • DSH payments, • Payment for avoidable hospital readmissions • Failure to meet quality targets • Other