The Rules May Be Changing but the Games Is the Same
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The proposed federal budget would significantly cut funding to major public health agencies and programs like the CDC, NIH, Medicaid, and EPA. The CDC budget would be cut by 17% which a former CDC director said would force them to fight epidemics and health threats with both hands tied behind their back while wearing a blindfold. The budget also cuts Medicaid by $800 billion over 10 years which could impact access to care. Several state marketplaces also proposed substantial premium increases for plans purchased under the Affordable Care Act.
![42nd
TN #1
11.2*
20.4*
* Percentage of adults who self-reported either binge drinking
(consuming more than 4 [women] or more than 5 [men] alcoholic
beverages on a single occasion in the last month) or chronic
drinking (consuming 8 or more [women[ or 15 or more [men[
alcoholic beverages per week) Source: American’s Health Ranking, 2015 http://www.americashealthrankings.org/
Binge Drinking](https://image.slidesharecdn.com/thurs845amalikhanopeningkeynote06-170613200556/85/The-Rules-May-Be-Changing-but-the-Games-Is-the-Same-23-320.jpg)
The Rules May Be Changing but the Games Is the Same
- 1. The Rules May be Changing but the Game is the Same Ali S. Khan, MD, MPH Professor and Dean, College of Public Health, UNMC Assistant Surgeon General (Ret.), USPHS
- 2. • Health and Human Services: - $12.7 billion (16.2%) • Center of Disease Control and Prevention: - $1.2 billion (17%) • National Institutes of Health: - $ 5.7 billion (17.5%)- among the hardest-hit research agencies • Medicaid: - $800 billion over 10 years • Environmental Protection Agency: - $2.6 billion (31.4%) - among the hardest-hit public health agencies • Labor: - $2.5 billion (21%)- includes elimination of some training grants for occupational safety and health FY18 President’s Budget for Major Public Health Agencies “The proposed budget would force CDC to fight epidemics and health threats with both hands tied behind their back while wearing blindfold” http://files.constantcontact.com/6ce74d4e301/cec81ce7-67da-492f-8b01-903827035f93.pdf https://www.hhs.gov/sites/default/files/fy2018-budget-in-brief.pdf
- 3. • Describe: The public and private sectors changes that are impacting bringing together healthcare and primary care • Advocate: Engage academic public health as a core new partner • Challenge: Create new multi-sector partnerships that leverage aligned financial incentives Learning Objectives
- 4. The State of our Health Academic-private partnerships Changing landscape of health Successful new models Call to Action
- 5. The State of our Health Academic-private partnerships Changing landscape of health Successful new models Call to Action
- 6. What do we pay for health care ? 6
- 7. Healthcare Premium • Connecticut marketplace, Anthem, covers 35,000, wants to raise premiums 33.8% • Maryland marketplace, BluChoice, covers 160,000, wants to raise premiums 53.4% • Virginia marketplace covers 295,000, on track for an ave. increase of 30.6% • Requested rate increases, not the final numbers • May change after negotiations between states and insurers Source: State Insurance Departments Credit: Sarah KliffKliff, Sarah (2017) “Insurers want to raise Obamacare rates as much as 53 percent”. Vox.com Retrieved from May 22, 2017
- 8. • National Health Expenditure Projections for 2015-2025: o health spending will grow at average rate of 5.8% annually (or 4.8% per capita) o annual growth 1.3% faster than (GDP) – health share of GDP is expected to rise from 17.5% 2014 to 20.1% by 2025 o initial impacts of Affordable Care Act’s coverage expansions will fade o growth in health spending expected to respond to changes in economic growth faster growth in medical prices population aging o By 2025, Federal, state, and local governments projected to finance 47% of all national health spending (45% in 2014) • In 2015, U.S. health care spending reached $3.2 trillion o a 5.8% annual increase o $9,990 per person o 17.8% of Gross Domestic Product (GDP)
- 9. Health care costs now approaching 20% of GDP and still rising almost as fast as before (slight deceleration for 2014-2015) Source: McKinsey, “Accounting for the Cost of U.S. Health Care.” (2011). Center for American Progress. 9
- 10. Size of “bubble” reflects amount of private contribution to total health care expenditures. 10
- 11. Percentages Uninsured For Adults Ages 18–64, By Race And Ethnicity, 2012–14 Stacey McMorrow et al. Health Aff doi:10.1377/hlthaff.2015.0757 ©2015 by Project HOPE - The People-to-People Health Foundation, Inc. Access to Care
- 12. © 2016 Arcadia Healthcare Solutions 12
- 13. Health Disparity, Omaha, NE
- 14. Zip Code as Predictor of Health Source: City of Portland, Oregon, Office of Health Equity and Human Rightswww.calendow.org
- 15. Estimated annual percentage change in all-cause mortality by age and sex in (A) Canada, (B) England and Wales, (C) the USA, and (D– H) various racial and ethnic groups in the USA, 1999–2014 Shiels et al(2017) . Trends in premature mortality in the USA by sex, race, and ethnicity from 1999 to 2014: an analysis of death certificate data. http://dx.doi.org/10.1016/ S0140-6736(17)30187-3
- 17. Source: BMJ Quality & Safety. Health and social services expenditures: associations with health outcomes, EH Bradley, BR Elkins, J Herrin, B Elbel, March 2011 Ratio of Social to Health Services: Spending by Country 17
- 18. Social Determinants of Health Race/Ethnicity Culture Education Social Economic Status Neighborhood Geographic Location Occupation Gender Sexual Orientation
- 20. The State of our Health Academic-private partnerships Changing landscape of health Successful new models Call to Action
- 21. 12th Source: American’s Health Ranking, 2016 http://www.americashealthrankings.org/ America’s Health Rankings 2016
- 22. Strengths: • Low rate of drug deaths • Low prevalence of low birthweight • Low prevalence of frequent mental distress Challenges: • High prevalence of excessive drinking • High prevalence of obesity • High incidence of pertussis Highlights: • In the past year, immunizations among children aged 19 to 35 months decreased 8% from 80.2% to 73.8% • In the past four years, the percentage of the population without health insurance decreased 30% from 12.8% to 9.0%. • In the past five years, preventable hospitalizations decreased 29% from 65.7 to 46.9 discharges per 1,000 Medicare enrollees. • In the past five years, preventable hospitalizations decreased 29% from 65.7 to 46.9 discharges per 1,000 Medicare enrollees. • In the past year, premature death increased 7% from 6,125 to 6,529 years lost per 100,000 population. • In the past year, health disparity status improved (43rd to 32nd). State Findings: Nebraska, 2016
- 23. 42nd TN #1 11.2* 20.4* * Percentage of adults who self-reported either binge drinking (consuming more than 4 [women] or more than 5 [men] alcoholic beverages on a single occasion in the last month) or chronic drinking (consuming 8 or more [women[ or 15 or more [men[ alcoholic beverages per week) Source: American’s Health Ranking, 2015 http://www.americashealthrankings.org/ Binge Drinking
- 24. 14% of high school students reported binge drinking during the past 30 days (2014/2015 Nebraska Youth Risk Behavioral Survey) 20% of adults (18+) reported binge drinking during the past 30 days (CDC, 2014) Nebraska jumped from 8th to 5th worst in terms of its binge drinking rates among the 50 states and D.C. in 2014 (CDC, 2014) Four of Nebraska’s communities (Omaha, Lincoln, Grand Island, and Norfolk) ranked in the top 15 of nearly 200 cities indexed for binge drinking rates across the country (CDC, 2012) Binge Drinking in Nebraska
- 25. Screening, Brief Intervention, and Referral to Treatment: An evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. Screening – a healthcare professional assesses a patient for risky substance use behaviors using standardized screening tools in any health care setting Brief Intervention – a healthcare professional engages a patient showing risky substance use behaviors in a short conversation, providing feedback and advice Referral to Treatment – a healthcare professional provides a referral to brief therapy or additional treatment to patients who screen in need of additional services (SAMHSA) What is SBIRT?
- 26. Between June 6, 2016-August 31, 2016 screened 536 patients 19 and older were eligible to be screened and 369 were screened 86 of the 369 (23%) scored positive on the AUDIT –C for some level of risk (4 or higher on AUDIT C) for their alcohol use. Next Steps—Improve Brief Intervention Work through Integrated Care and Roll out to 30+ clinics as we implement Patient Centered Medical Home. In addition CRAAFT has been added for adolescents. SBIRT Pilot- CHI Health Family Practice Pilot
- 28. Nebraska ranks 12th overall but… It ranks 41st in Colorectal Cancer Screening compared to other states A Case for CRC Screening Sources: America’s Health Rankings 2016 Nebraska Department of Health and Human Services (N/A) “Nebraska Colon Cancer Screening Program”. http://dhhs.ne.gov/PublicHealth/NCP/Pages/Home.aspx
- 29. Achieving 80% by 2018 in Nebraska means, fewer people will be diagnosed with colorectal cancer and lives will be saved by 2030. Robinson, Tamara and et al (N/A) “Nebraska 20/20: An Academic-Practice Partnerships Model for Health- A Community Based Approach to Increasing Colorectal Screening Rates” American Cancer Society Improving CRC Screening Rates
- 30. Strategic Planning – Work Groups WG #1 – Develop Business Case for State Funding and Private/Donated Services WG #2 – Identify Data Silos and Establish Data Sharing to Benchmark WG #3 - Establish/Recommend Guidelines for Donated Colonoscopy Services & Streamline Process for Every Woman Matters (EWM) WG #4 - Develop a Unified Message and Distribution System for CRC WG #5 - Develop NeHII Data Analytics for CRC Data Collection Strategic Planning- Work Groups
- 31. Healthy Lincoln CRC Project 27 clinics Round 1- Early 2016 (between Feb. and May) Round 2- Summer (June/July) Round 3- November 2016
- 32. Model how population health can be advanced through collaborative, multi- institutional efforts to improve health and health systems on a community basis. Accountable Health Community (AHC) Bridge to Accountable Health State
- 33. llll11111D 9 SOCIOECONOMIC FACTORS Access to health foods Access to preventive care Employment Equality Connected/Accessible transportation Livable median wage Quality Education Relationships/support network Safe/affordable housing Safe Community THESE SOCIOECONOMIC FACTORS , HEALTH BEHAVIORS AND CHRONIC DISEASES IMPACT OUR QUALITY OF LIFE 94,000 OR 1 IN 6 Douglas county residents report having to limit their daily activity due to emotional, physical or mental health 41% of these residents live in NE and in SE Douglas County Source: Live Well Omaha 4 HEALTH BEHAVIORS Lack of physical activity Poor diet Substance use and binge drinking Tobacco use INFLUENCE 4 CHRONIC DISEASES Cancer Heart disease and stroke Lung disease Type 2 diabetes 78% OF EARLY DEATHS IN DOUGLAS COUNTY Leading cause of death linked to chronic diseases socioeconomic factors 40% Clinical Factors 20% Behavi oral Factor s 30% Physical Environment… THE CASE FOR AN ACCOUNTABLE HEALTH COMMUNITY There are multiple factors that impact our health. By working together to address them, we can improve quality of life and reduce the number of deaths linked to chronic disease in our community LEAD TO CAUSING
- 35. The State of our Health Academic-private partnerships Changing landscape of health Successful new models Call to Action
- 36. American Health Care Act (AHCA)
- 37. Modified Source: PwC Health Research Institute Source: http://healthyamericans.org/assets/files/TFAH-2017-FundingCrisisRpt-FINAL.pdf Public Health: $100 billion (3% of $3.36 trillion) Shift the focus to preventative health protecting the entire populations through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious diseases
- 39. Proposed: CMS Accountable Health Communities Core Health-Related Social Needs Screening Questions Housing Instability 1. What is your housing situation today? 2. Think about the place you live. Do you have problems with any of the following? (check all that apply) Food Insecurity 3. Within the past 12 months, you worried that your food would run out before you got money to buy more. 4. Within the past 12 months, the food you bought just didn’t last and you didn’t have money to get more. Transportation Needs 5. In the past 12 months, has lack of transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? (Check all that apply) Utility Needs 6. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home? Interpersonal Safety 7. How often does anyone, including family, physically hurt you? 8. How often does anyone, including family, insult or talk down to you? 9. How often does anyone, including family, threaten you with harm? 10. How often does anyone, including family, scream or curse at you?
- 40. Precision Prevention Medicine Geisinger Fresh Food Pharmacy: • Participants meet one-on-one with a registered dietitian • Receive recipes and hands-on instruction on how to prepare healthy meals • Go home with different kind of prescription consisted of five days’ worth of free, fresh food Aubrey, Allison (2017) “Fresh Food by Prescription: This Health Care Firm is Trimming Costs- And Waistlines”. http://www.npr.org/sections/thesalt/2017/05/08/526952657/fresh-food-by-prescription- this-health-care-firm-is-trimming-costs-and-waistline?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20170508
- 41. AHCos Moving to Healthcare 3.0 Halfon, Neal et al (2014) “Applying a 3.0 Transformation Framework to Guide a Large- Scale Health System Reform” Health Affairs http://content.healthaffairs.org/content/33/11/2003.full
- 42. PUBLIC HEALTH 3.0 TIMELINE Public Health 3.0 www.heathypeople.gov/ph3
- 44. The State of our Health Academic-private partnerships Changing landscape of health Successful new models Call to Action
- 45. • Multi-sectoral partnerships • Backbone organizations • Data and metric • Leadership • Practical evidence-based interventions Aligned Financial Incentives Secret Sauce
- 47. Differences in county mortality rates associated with comprehensive population health system capital, 2014. Glen P. Mays et al. Health Aff 2016;35:2005-2013 ©2016 by Project HOPE - The People-to-People Health Foundation, Inc.
- 48. All Costs $ All Outcomes Your Activities Here Shared Savings
- 49. YOUR CHALLENGE CONVINCE THEM TO PROMOTE FRUITS AND VEGETABLES
- 50. Acknowledgements Trang K Hoang, MPH Matt Bosley, MD, MPH-Candidate Bob Rauner, MD, MPH
Editor's Notes
- #12: A health system problem in access to care
- #14: The distance between Millard West and North Omaha is about 20 miles, but life expectancy differs by 12 years.
- #15: Health disparity- “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion” The child represents in the picture on the left may experience difference social, economic, and environmental disadvantages based on where he lives which leads to reduced life expectancy Framing health disparity in terms of race and gender alone is inadequate. Looking at life expectancy based on where one lives isn’t enough.
- #18: Maybe because we spend relatively little on social services. Other developed countries invest less in health care and relatively more in social services, and they are becoming healthier, faster, than the U.S. We live shorter lives, have higher prevalence of chronic diseases, etc. And these differences are seen among advantaged Americans when compared to residents of comparable SES in other countries.
- #19: Societal issues, personal experience, environmental exposures and biology play an interrelated role in the health of an individual Race/ethnicity Culture Education Socioeconomic status (income) Neighborhood (built environment) Geographic Location (urban/rural) Occupation Gender Sexual Orientation
- #22: Overall rank 12th, was 109th in 2015. Nebraska ranks 20th for senior health and 17th for the health of women and children
- #32: Preliminary screening rates for some clinics were >65% 4 clinics highlighted in yellow did not participate in CME/Part IV MOC components or designate a lead physician Much of the overall improvement in screening rates occurred as the results of clinics cleaning up their messy EHRs (e.g. the most dramatic improvement in clinic 23 for CRC screening happened after they realized many of the screening results had been placed in the wrong place in the chart). Clinic 5 did the same thing after Round 2 and continued to work on it through Round 3( result- screening rates went up to 75%)
- #34: City of Omaha decides to adopt the ACO model
- #38: The five forces shaping the US health ecosystem Rise of consumerism Cosumer access and ownership of health data Consumer cost-sharing Price transparency and shopping 2) Shift from volume to value Federal drive toward value-based purchasing Insurer push for value-based contracts Pharmaceutical and life sciences company push toward value-based contracts 3) March of technological advances and digitalization Use of electronic medical records and other health data 3D printing The emergence of blockchain technology Development of omics Spread of machine learning and artificial intelligence 4) Decentralization Spread of virtual care and remote patient monitoring Embrace of alternative venues and resources for care Increased use of extenders Seamless sharing of data among stakeholders 5) Surge in interest in wellness Consumer internet in wellness Insurer incentives for wellness Employer interest in wellness Source: PwC Health Research Institute
- #48: Differences in county mortality rates associated with comprehensive population health system capital, 2014