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A Framework for Engagement or Perhaps Inclusion?
Jay Bhatt, DO, MPH, MPAPresident of Health Research & Educational Trust of the AHAChief Medical Officer, American Hospital Association
August 10, 2017
THE REDWOODS
Consumers: Americans are spending more money on healthcare today than ten years ago
2,664 2,766 2,8532,976
3,126 3,1573,313
3,556 3,631
4,290
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
U.S. healthcare spending by household
Mean expenditure ($)
Source: Bureau of Labor Statistics Annual Consumer Expenditure Survey
Draft
Government: …but has worse health outcomes
Source: OECD
Draft
Executive summary
The AHA Path Forward advocates for “access to affordable, equitable health, behavioral, and social services”
Affordability can be measured in many different ways
– Different stakeholders care about different metrics
Ultimately, stakeholders must work together to tackle this challenge
– Systemic, societal, and operational drivers must all be addressed
– Consumers, government, employers, payers, health & hospital systems, pharma companies, and community partners all roles to play
Health & hospital systems are pursuing value-based strategies that make care more affordable
– These include redesigning the delivery system; improving quality & outcomes of care; reforming payment & managing risk; and implementing operational solutions
Draft
Consumers
Government
Payers
Employers
• Spending on premiums, deductibles, co-pays (% change)
• Per capita spending on healthcare ($, % change over time)• Return on investment (life expectancy vs. $ spent)
• Healthcare expenditures ($, % change over time)
• Health care premiums per worker ($, % change over time)
Hospitals & health systems
• Hospital prices (% change over time)
Pharmaceutical companies
• Per capita spending on drugs ($, % change over time)
Community partners
• Spending on social services, e.g. housing, food, etc. ($, % change over time)
Views of affordability vary by stakeholder
Draft
Societal
• Determinants of health
• Prevalence of chronic conditions
• Aging population & related end-of-life care
• Consumer behaviors & preferences
Operational
• Workforce shortages
• Drug & device innovation
• IT systems
• Regulatory & compliance burden
• Inefficiency
Systemic
• Access/coverage
• Plan design
• Payment & reimbursement models
• Prevention & wellbeing
• Quality & safety
• Variation in quality, cost, & care delivery
Drivers of affordability
1 2 3
Draft
The Path Forward
Clinical care is only one component of health
Source: University of Wisconsin Population Health Institute. County Health Rankings & Roadmaps 2016. www.countyhealthrankings.org.
20% 20% 60%
Health care Genetics Social, Environmental and Behavioral Factors
What Makes People Healthy?
Determinants of Health
Source: HRET 2017
Source: Institute for Health Metrics and Evaluation, University of Washington, 2014
Place Matters
Source: Institute for Health Metrics and Evaluation, University of Washington, 2014
Place Matters: ND
Hospital Engagement
Network
Advancing higher reliability
1500 hospitals –reduce harm in 11 areas (HEN
2.0)
HIIN has 1630 hospitals
Reduce early elective deliveries by 44%
Post-Op Thrombosis reduced by 34%
Reduced surgical site infections by 21%
Prevent more than 34,000 incidents
Cost Savings of nearly 300 million
Reduce Hospital Acquired conditions by 40% and readmissions
by 20%
AHRQ National Scorecard Data
Advancing High Reliability
Source: AHRQ National Scorecard Estimates from Medicare Patient Safety Monitoring System, National Healthcare Safety Network, and Healthcare Cost and Utilization Project.
AHRQ Data 2010-2014
Advancing High Reliability
Source: AHRQ National Scorecard Estimates from Medicare Patient Safety Monitoring System, National Healthcare Safety Network, and Healthcare Cost and Utilization Project.
Reductions in Hospital Acquired
Conditions (2011-2015)
Advancing Higher Reliability
Source: AHRQ National Scorecard Estimates from Medicare Patient Safety Monitoring System, National Healthcare Safety Network, and Healthcare Cost and Utilization Project.
Total Annual and Cumulative Deaths Avoided
Advancing Higher Reliability
Cumulative deaths averted from 2010 through 2015 are estimated at nearly 125,000. As shown in Exhibit B2, there is variation across types of HACs in the cost savings per HAC averted and in the level of increased mortality associated with the HAC. Due to this variation, costs associated and deaths averted by HAC type are not directly proportional to the HAC reductions shown in Exhibit 4.
Total Annual and Cumulative Cost
Savings
Advancing Higher Reliability
Preliminary 2015 estimates indicate that the decline in HACs resulted in estimated cost savings of approximately $8.3 billion in 2015. Estimated cumulative savings for 2011, 2012, 2013, 2014, and 2015 are approximately $28.2 billion (Exhibit 6).
Including Stakeholders
Patients & Families
PayersHealth Care
Delivery
Communities
Visioning Activity
An adaptive challenge has no known
solution and no available expert for the
current context
ADAPTIVE CHARACTERISTICS
EmotionalMessy Risky
A B
C
How Do Hospitals Partner?
Not involvedNo current partnerships with this type of organization
NetworkingExchange ideas and information
Alliance Formalized partnership (i.e., binding agreement) among multiple organizations with merged initiatives, common goals and metrics
CollaborationExchange information and share resources to alter activities and enhance the capacity of the other partner
FundingGrant-making capacity only
Source: Health Research & Educational Trust, 2015.
Partnerships
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Other hospitals
Public health department
Public safety
Housing/community development
Transportation
Not involved Funding Networking Collaboration Alliance
Source: Health Research & Educational Trust, 2015.
Patient-Level Health Care Organization Population-Level
General Population-Level
PrimaryPrevention
Financial literacy, support, & nutrition programs for low-income families with strong family history of DM
Provide on-site Farmers’ Market, gym, walking trails or financial counseling for families at risk for DM
Advocate for local increase in minimum wage and supports for low-income families, particularly those at risk of DM
SecondaryPrevention
Poverty screening & financial assistance for DM patients at-risk of end-of-month hypoglycemia
Subsidize vouchers to local Farmer’s Market or hire a financial counselor for low-income DM patients
Change timing and content WIC & school food programs to avoid food insecurity among DM
Tertiary Prevention Reduce ED use among high-utilizer severe diabetics using food and income support referrals
Coordinate with local banks, collectors, lenders, to reduce debt burden for utilizer diabetics
Support legislation/ regulations to provide financial and “hotspotter” services to severe diabetics
From Engagement to Inclusion
Engagement = involving others
Inclusion = valuing others
Collaboration = working with others
From Engagement to Inclusion
ParticipantsParticipants have one-time involvement.
AdvisorsOngoing participants act as sources for feedback or community liaisons.
PartnersParticipants serve as co-leaders and are involved in all planning and decision-making
Source: HRET, 2016
So
urc
e:
Inte
ract
ion
In
stit
ute
/An
dre
w W
eiz
ma
n,
20
16
Equity is necessary for a healthy population
Equality vs. Equity
Inclusion
Sour
ce:
Cent
er f
or S
tory
-bas
ed S
trat
egy
, 20
16
Health, Equity and Quality
AHA Task Force on Ensuring Access for Vulnerable Communities in Vulnerable Communities
Characteristics of vulnerable communities are similar for rural and urban areas
Source: AHA 2017
Emerging Strategies for Vulnerable Communities
Virtual Care Strategies
Social Determinants
Inpatient/Outpatient Transformation
Urgent Care Center
Rural Hospital-Health Clinic
Emergency Medical Center
Global Budgets
Frontier Health System
Indian Health Services
Source: AHA 2017
Inclusion in Practice
Patients and Families
Patients and Families: Examples
Communities
Source: ACHI, 2016
Communities: Example
Common language for leadership and decision-making
Nurses and other clinicians
CFOs
CEOs
Physicians
Trustees
Health Care Stakeholders and a Common Language
Payers
Example: Multisector Innovative Care Measures for Desired Health Outcomes
July 24, 2017 I 21
July24,2017
I44
July24,2017
I45
July 24, 2017 I 24
July24,2017
I
25
July 24, 2017 I 26
Finding Short Term Wins…July24,2017
I
27
July 24, 2017 I 28
July24,2017
I51
NEW RESOURCES
What’s your story?
Sour
ce: F
ocus
for
Hea
lth,
2015
Bringing Inclusion Home
Bringing Inclusion Home
Bringing Inclusion Home
Bringing Inclusion Home
The Journey to Population Health Health: health care
Level 1: Patient physical and mental health
Level 2: Patient social and spiritual wellbeing
Level 3: Community health and wellbeing
Level 4: Communities of solution
Optimizing the physical and behavioral health ofyour patients; reducing cost
Addressing socialand spiritual drivers ofhealth and wellbeing
Being active partners in improving health,wellbeing and equityof the community
Leaders across sectors work together to createsustainable and dynamic change
The capacity of peopleis unlocked to improve their health and the wellbeing of their communities
Debrief
• Which groups were the most challenging and why?
• What are some lessons learned?
• Can some engagement strategies be replicated for other stakeholder groups?
Breakthrough Idea
Thank You
Jay Bhatt, DO, MPHPresident of Health Research & Educational Trust
Chief Medical Officer, American Hospital Association
jbhatt@aha.org
@bhangrajay
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