Bridging Hospitals and Community Health:

Community Benefit and Health Reform

2010 NNPHI ConferenceNavigating Emerging Opportunities

June 8, 2010

Kevin Barnett, Dr.P.H., M.C.P.Senior Investigator

Public Health Institute

Outline

• Evolution of CB practices and policies

• Health reform – Emerging opportunities

• The case for hospital – public health collaboration

• A sampling of exemplary practices

Evolution of National/State Policies• IRS redefinition of charity 1969/83• Local class actions in 70s• Intermountain Health Care – 1985• National congressional initiative (Roybal-Donnelly – 1990)• State statutes: UT, NY, TX, MA, CA, PN, NH

– Commonalities and distinctions

• Yale-New Haven case (2005) – the game changer• Congressional hearings (2006-2009)• Illinois Supreme Court ruling on Provena

– Next chapter - Grassley and Rush

• IRS 990 Schedule H• National Health Reform and the coming change

Imperative for PH Engagement• National / State Policy Development

– Narrow interpretation of CB by IRS and Finance Committee

– Lack of understanding of implications and opportunities in community needs assessment requirement.

• Regional / Local Innovation– Integrate utilization data, social determinants into

assessment process to regionalize care coordination– Focus on expanded care management with uninsured

populations helps build population health capacity and demonstrates commitment to optimal stewardship.

– Significant potential for transformation of traditional relationships - increased efficiency and effectiveness

Near Term Potential Savings

• In 2002, half of Medicare beneficiaries treated for 5+ conditions, and accounted for 75% of Medicare spending. Thorpe, KE, Howard, DHl, “The rise in spending among Medicare beneficiaries: the role of chronic disease prevalence and changes in treatment intensity,” Health Affairs (Millwood), 2006:25(5): 378 – 388

• Estimated costs for preventable hospitalizations for 2004 were $29 billion, approximately 10% of total hospital expenditures.Russo, Allison, et al, “Trends in Potentially Preventable Hospitalizations among Adults and Children, 1997-2004,” Statistical Brief #36, Healthcare Cost and Utilization Project, AHRQ, August 2007

• Readmissions on 18% of all hospital stays - $12B (80%) of which are potentially avoidable.Miller, M., Executive Director, Medicare Payment Advisory Commission, Report to Congress: Reforming the Delivery System, Testimony to Senate Finance Committee, September 16, 2008

Community Benefit and Health Reform

Primary Prevention Community Problem

Solving

Community-Based

Preventive Services

Clinical Service Delivery

PAYMENT MODELSFee for Service Episode-Based Partial---Full Risk Global Budgeting

Reimbursement CapitationINCENTIVESConduct Evidence-Based Expanded Care Reduce Obstacles toProcedures Medicine Management Behavior ChangeFill Beds Clinical PFP Risk-adjusted PFP Address Root Causes

METRICSNet Revenue Improved Reduced PreventableAggregate Improvement

Clinical Outcomes Hospitalizations/ED in HS and QOLReduced Readmits Reduced Disparities Reduced HC Costs

Opportunities for Hospital – PH Collaboration

Community needs assessment

Analysis/mapping of data to reduce preventable ED/inpatient utilization

Community-based health education programs/campaigns

Comprehensive community initiatives

Influence local policy development to reinforce/sustain efforts

Monitor health status to ID community health problems.

Diagnose and investigate health problems and health hazards in the community.

Inform, educate, and empower people about health issues.

Mobilize community partnerships to ID and solve health problems.

Develop policies and plans that support individual and community health efforts.

PH 10 Essential Functions Hospital Community Benefit

Opportunities for Hospital – PH Collaboration

Enforce laws and regulations that protect health and ensure safety.

Link people to health services and assure access to health care

Assure a competent public health and health care workforce.

Evaluate effectiveness, accessibility, and quality of HC and population health services.

Research for new insights and innovative solutions to health problems.

Tobacco/alcohol sales to minors; neighborhood watch groups

CHOWs / partnerships with CHCs

Youth mentoring / pipeline programs; engagement of academic affiliates

Expanded care management strategies with un/underinsured populations

Research demonstrations to reduce health disparities

PH 10 Essential Functions Hospital Community Benefit

Strategy for Hospital Engagement• Focus on problem solving – ID issues relevant to

utilization and cost, and gradually move upstream

• Emphasize shared accountability (over “watchdog” orientation)

• Bring positive examples of desired institutional behavior to the table (sources of exemplary practices: ACHI, CHA, CDC, PHI)

• Demonstrate understanding of practical challenges

A Sampling of Exemplary Practices

• Backyard Initiative (Allina Hospitals and Clinics)– 10 yr, $100 million investment in south Minneapolis

neighborhoods around flagship medical center – Central focus on social determinants, e.g., environmental

and policy change around tobacco, nutrition and obesity.– Safety net insurance program to link primary care and

community-based preventive services.

• Bell Hill Initiative (UMASS Memorial Health System)– Problem solving approach to health improvement in

diverse low income neighborhood adjacent to flagship medical center.

– Central focus on affordable housing, youth leadership development, strengthening social support systems, and environmental improvements

• Diabetes Wellness Center (Baylor HC System)– $15 million investment to renovate and expand historical

youth development center in South Dallas.– Primary focus on creating opportunities for physical activity

and nutritional knowledge and access.– 13% of residents diagnosed with diabetes; diabetes

hospitalization 30% higher than citywide rate

• Bread of Healing Free Clinic (Aurora Health System)– Developed urban health curriculum with med student

rotations– Provide administrative/clinical staffing, lab and radiology

svs.– Established a collaborative of free clinics and created

MedShare program for pooled purchase of pharmaceuticals

• Healthy Start Program (St. Charles Health System)– Partnership with Deschutes County PHD to provide

prenatal services for uninsured women– Co-location of medical services, WIC, and family

planning.– Secured change in public transportation services.– Provide administrative/clinical staffing, lab and

pharmacy svs.– Secured SAMHSA grant to link services for children and

mothers.

• Regional Research Demonstration Taking CB to Scale (SF/Dallas)– Establish regional clearinghouse for detailed analysis and

mapping of hospital utilization data* and social determinants

– Engage FT Epidemiologist in SF DPH– Institute established at Dallas Hospital Council– Use evidence base as mechanism for shared, strategic

investment by hospitals. – Supplement care management strategies with place-

based collaborative investments in impacted neighborhoods * With unique patient identifiers, by diagnosis, payer source, and institution

• Minnesota GAMC– Fairview HS, HCMC, Health Partners– Global payment from State– Coordinated system of services beyond health care

• Orange County (CA) Mgd Care Plan– Partnership between CalOptima and hospitals– Shared investment in capitated model of enrollment– Focus on medically indigent population

• Project Access (Dallas)– Voluntary model involving hospitals, providers, CHCs– Coordinated through Medical Society– Focus on medically indigent with chronic conditions

CDC – NNPHI Partnership

• Convene regional and/or statewide community benefit roundtables with hospital and public health leadership.

• Review accomplishments to date, review ASACB standards, and secure commitments to deepen engagement

• Colorado• Florida• Georgia• Louisiana• North Carolina

NNPHI Roundtables – Next steps• North Carolina Institute for Public Health

(March 8-9)– Integrate CB elements into statewide PH-hospital master plan – Explore regional initiatives (ACS-Readmissions)– Cross fertilization of local/regional meetings/content

• Georgia Health Policy Center (March 11)– Invited PH community to serve on state CB committee– Explore replication of innovations (e.g., rural model)– Explore data mapping, regional CB initiative (Atlanta)

• Florida Public Health Institute (June 3)– Document positive examples of hospital-PH collaboration– Examine current use of data (incl. utilization data)– Mapping with common indicators

Emerging Funding Opportunities• ARRA stimulus package

– $650 million for wellness and prevention– $1.1 billion for comparative effectiveness research ($300M to

AHRQ)

• National Health Reform– Prevention and public health fund ($2b/yr)– CDC TA on workplace wellness (TBD)

• CMS Center for Innovation ($10b through 2019)– Five year demonstration to improve quality, outcomes, and reduce

costs through patient-centered strategies, care coordination

• Private foundations – Expanding focus on prevention, care coordination

Contact Information

• Kevin Barnett, Dr.P.H., M.C.P.Public Health Institute555 12th Street, 10th FloorOakland, CA 94607Tel: 925-939-3417 Mobile: 510-917-0820Email: kevinpb@pacbell.net

• ASACB standards, tools, and model programs available on website @ www.asacb.org

WE BUILD A BRIGHTER FUTURE

kp.org/communitybenefit

together

Health Systems and Public Health:Spreading Health to Build Healthy Communities Raymond J. Baxter, PhDSenior Vice President, Community Benefit, Research and Health Policy

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What: Kaiser Permanente’s Community Benefit Strategy

Make a Measurable Impacton Health

Fulfill Our Charitable Mission

Be the Model for Community Benefit in the

Field

Build a Performance Culture to Ensure Operational

Excellence

Embed Community Benefit as a Core Principle of Kaiser

Permanente

Health Knowledge

Health Access

Healthy Environments

Community Health Initiatives Environmental Stewardship Educational Theater Program

Medicaid and CHIP Charitable Care and

Coverage Safety Net Partnerships

Research Workforce Development Public Education U.S. and International Policy

Elim

inate

Health

Dis

paritie

s

together

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Why: Behavior and Environment Drive Health

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Why: Place and Race Shape Health

Source: KP Utility for Care Data Analysis, 2009

Obesity and Park Access

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Why: Environment and Behavior Shape Health

County Health Rankings Model

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How: Working in Partnership

Our Community Work Our National Work

Safety net partners

PHIs

State and local

health departments

CommunityCoalitions

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Why PHIs must Engage the Delivery System

• The reality: public health is crumbling• State deficits• Local deficits• Retirement and replenishment• Bunker mentality

• The opportunity: Willie Sutton• $30 billion in community benefit

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• Community-based prevention• Environmental Stewardship• Policy change as a tool• Becoming Accountable Organizations

The Opportunity: Going Upstream