Health Care Reform in the Northwest: Part 1 Lillian Shirley, BSN, MPH, MPA Patrick F. Luedtke, MD, MPH www.nwcphp.org/hot-topics
Integrating Population Health within a Health System Delivery to Achieve the Triple Aim Lillian Shirley, BSN, MPH, MPA Director, Public Health Division Vice Chair, Oregon Health Policy Board
Oregon - the Big Picture
Triple Aim Better quality care for individuals (safety, effectiveness, patientcenteredness, timeliness, efficiency, equity) Better health for populations, (addressing upstream causes such as poor nutrition, physical inactivity, and substance abuse) Reducing per-capita costs
Definitions of Population Health Population served by an individual provider or payer Insuring that patients are assigned correctly to Primary Care Provider Population served by the entire delivery system Primary care patients Population residing in the broader community Geographic area, membership in a category of persons that share specific attributes
Behaviors Associated With Premature Death Smoking Unhealthy diet Physical inactivity Risky alcohol and drug use
Transforming the Health System Payers, Insurers, and ACOS Community Prevention/ Social Determinants of Health, Education Public Health Health Care System/Primary Care Improved Population Health, Health Outcomes & Lower Costs (Triple Aim) Thanks to TFAH & California Endowment & Kresge Foundation
Differing Views of Population Health Health Care (Clinical View) Panel of patients High risk patients Patients with specific conditions or utilization Public Health View Defined by geography Indicators are community indicators Population within geography may change over time
Integrating Outcomes and Funding for Populations Examples of Early Efforts Diabetes prevention Medically high risk children Liver disease
Multnomah County Diabetes Prevention through Care Multnomah County adult population Interventions at the Intersections with other sectors 584,651 Multnomah County adults at high risk for diabetes 323,312 Adults diagnosed with diabetes 35,079 Total Receiving Care Privately insured adults 23,324 20,992 Adults on OHP/Medicaid 6,388 5,749 Uninsured/self pay adults 5,367 4,830
Multnomah County Diabetes Prevention Total adult population 584,651 Tertiary Secondary Primary Individual Health education Health literacy Community Health Retail Initiative School-based healthy eating Safe routes to school Policy Health in built environment decisions Health Impact Assessments
Multnomah County Diabetes Prevention Total adult population 584,651 Tertiary Secondary Individual Health education Health screening Community & Policy Same as primary Primary Individual Health education Health literacy Community Health Retail Initiative School-based healthy eating Safe routes to school Policy Health in built environment decisions Health Impact Assessments
Multnomah County Diabetes Prevention Total adult population 584,651 Tertiary Individual Chronic disease self-management education Medical homes for diabetes care and case management Secondary Individual Health education Health screening Community & Policy Same as primary Primary Individual Health education Health literacy Community Health Retail Initiative School-based healthy eating Safe routes to school Policy Health in built environment decisions Health Impact Assessments
Multnomah County Diabetes (cont.) Adults diagnosed with diabetes: 35,079 Total Receiving Care Privately insured adults 23,324 20,992 Adults on OHP/Medicaid 6,388 5,749 Uninsured/self pay adults 5,367 4,830
Pilot for Medically High Risk Children New Model: Coordination Center Children s Hospitals (Inpatient units) Community Providers (Outpatient clinics, public health and social services) Community -Based Staff Monitor Public Health and Community- Based (Healthy Homes, WIC, Healthy Start, etc.) Outcomes (Reduced cost, improved population health) Outputs (Reports on usage, coordinated services)
Leading Causes of Death Liver Disease: Tied for 9th Payers, Insurers, and ACOS Community Prevention/ Social Determinants of Health, Education Public Health Health Care System/Primary Care Improved Population Health, Health Outcomes & Lower Costs (Triple Aim)
Moving Forward
Causes of Health Inequities Root Factors Poverty Discrimination Oppression Environmental Factors Toxic contaminants Joblessness Unequal education Medical Services Lack of access Unequal quality of care Disparities in treatment Behavioral Factors Nutrition Physical activity Tobacco use Violence Health Inequities Adapted from: Prevention Institute. The Imperative of Reducing Health Disparities through Prevention: Challenges, Implications, and Opportunities.
Changing Behavior is Hard Multi-sector, multi-component approach Consistent reminders and messages (include social media) Shared accountability approach from all sectors Consider social determinants of health Data for ongoing monitoring and improvement
The Public Health System Academia Transportation Governmental Public Health Infrastructure Housing Health Care Delivery System Media Community Members and Organizations Schools Environment Employment Parks Public Health
Public Health Synergy Community Population CCO Clients Increased Health Impact
What Public Health Can Do Meet and align with health delivery systems Provide the following in collaboration Collect and provide data at the community level Know, effective, scalable interventions with potential large impact on population health Participate in collective and focused efforts Identify optimal strategies at all levels across all sectors Rally resources and partnerships beyond company boundaries Communicate about successes/challenges along the way Accelerate efforts to make measurable impact on health
Public health and CCOs Know where patients reside and what the overlap is of CCO and community populations Compare the health of CCO and community populations Decide what level of overlap merits collaboration Engage in collaboration with public health and key community agencies
Public health and CCOs (cont.) Collaboratively select health outcomes both within and outside CCO Set up a formal agreement with public health authorities to share data and monitor progress Identify population health indicators for the CCO local dashboard Use a portion of global payment fee to support community public health activities Hacker, K., & Walker, D.K. (2013). Achieving population health in accountable care organizations. American Journal of Public Health, 103 (7), 1163-7.
Tobacco Cessation Strategies Public/Community Health Smoke Free Restaurants and Bars Tobacco-free Hospital Campus Non-Smoking Parks Smoke Free Public Housing Retail Licensure Restrict Youth Access Delivery System and Payers Tobacco as vital sign Assessment and Education Inpatient Mapping Smokers Work with Housing Authority Tobacco Cessation Programs
Getting There Social Determinants of Health Geographic Analysis (morbidity and mortality where clients are from) Covered Lives in CCO Analysis by profile of individuals in CCO (age, race, income, etc.)
The Road Ahead Clinical care public health integration can be built Partner and collaborate across clinical, community and public health settings Advocate and share accountability for population health
But it s about the people
For more information: health.oregon.gov
Primary Care and Public Health Integration Patrick F. Luedtke, MD, MPH Senior Public Health Officer and Medical Director Lane County, Oregon
Lane County, Oregon
Lane County: The View From Space 1. CCO: ~71,000 lives, Board of 21, Prevention dollars per member per month 2. Public Health Health Officer, Federally Qualified Health Center Medical Director, CCO Board member Medicaid Behavioral Health payer Federally Qualified Health Centers and County Mental Health clinics
Working Together: PH - CCO CCO Board Clinical Advisory Panel Community Advisory Council Community Health Improvement Plan AFIX and immunization program Shared Behavioral Health/Mental Health, Epidemiology, MPH staff
Tobacco Cessation Incentive Program We have too many preemies and pre-term labor cases. Obstetrics/Gynecology (OB/GYN) Vital statistics birth data review. Federally qualified health centers pregnant patient chart review. Public Health (PH) Claims data review for preemie/pre-term labor costs. (CCO) All my pregnant patients smoke! Primary Care Physicians (PCP) PH-PCP-OB/GYN steering committee Nicotine testing & incentive $$ for pregnant smokers
Smoking in Pregnancy 25 Prenatal Smoking By Trimester, Oregon vs. Lane County, 2009 Prenatal Smoking (%) 20 15 10 5 Lane County Oregon 0 1st Trimester 2nd Trimester 3rd Trimester Data Sources: Oregon Health Authority and Lane County Public Health
Lane County: Smoking in Pregnancy Age Smoking Rate Patient Number <20 27% 294 20 24 25% 860 25 29 16% 1,147 30 34 11% 843 35 39 9% 348 >/= 40 11% 81 NOTE: Survey of current use rates: FQHC, PeaceHealth hospitals/clinics, Douglas county. Data Source: Lane County Vital Statistics: 2009
Clinical Expectations Prenatal smoking is associated with: 30% of small for gestational age (SGA) infants 10% of preterm infants 5% of infant deaths* Expected quit rate, without incentives is ~37%** Decreased ear infections and asthma attacks in child *MMWR 58(ss04);1-29 May 26, 2009 ** PRAMS 2005
Medicaid Savings Preventing 1 SGA birth = $45,000 savings $1 spent on cessation = $3.50 in neonatal savings Data Source: CDC, Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC)
Fiscal Data Lane County Medicaid Neonatology Costs (2012) Line item cost $7,643,967 # of Episodes 1,773 Cost/Episode $4,311 Unique members 1,715 Monetary goal: 10% cost reduction/yr (ROI = 7.6)
Tobacco Cessation Incentive Program Program goal: Tobacco cessation in 30% of program participants Participation goal: 80% of pregnant Medicaid patients
Tobacco Cessation Incentive Program Program started August 2013 34 women enrolled (through December 2013) Testing: 3x during pregnancy 1x at six weeks post pregnancy Total possible incentive = $200 (Budget: $100,000/yr)
Results So Far Confirmed quit rate of those retested = 57% Total of 90 person-months of enrollment Program funded for two years This data is incomplete!
Many Thanks to Jennifer Webster MPH, CHES CDC: a.) Division of Reproductive Health b.) Office on Smoking and Health c.) Pregnancy Risk Assessment Monitoring System staff Holly Jo Hodges MD, Trillium CCO NW Center for PH Practice staff
Questions?