LSU HEALTH CARE SERVICES DIVISIONQUARTERLY HEALTH EFFECTIVENESS MEETING

BATON ROUGE, SEPTEMBER 18, 2007

THOUGHTS FROM

OKLAHOMA

Michael Lapolla, College of Public HealthJohn Gaudet, Bedlam Alliance

September 18, 2007

ABOUT MEDICAL HOMES - AND MORE

MIKE LAPOLLA

OUR THOUGHTSFROM HIGH ALTITUDES

OUR HEALTH CARE “DUST BOWL”

CAUSES

CHALLENGES

COMMUNITY RESPONSE

THECAUSES

MEDICARE AND MEDICAIDResponded well concerning physician production – but poorly concerning Medicaid administration and policy. The state (and the nation) was still learning how to deal with federal programs and how to maximize patient care reimbursements. Emphasis on larger enrollments and smaller payments. Abuse led to PPS and DRG in the 1980’s.

1960’s

OIL BOOM MASKS PROBLEMSState DHS (next slide) suffocates all other health policy players. Dedicated state sales tax. State Health Department rendered inert – university (OU) “teaching hospital” a shambles – the concept of a dynamic Health Sciences Center is still a vision. About 170 county commissioners sent to federal prison (there are only 231 in the state), Oil boom is underway full-speed – things “ain’t too bad”.

1970’s

+

HUEY LONG J. EDGAR HOOVER

OIL BUST EXPOSES PROBLEMSThe state is both broke and shocked. LER dies; Medicaid and DHS left disarray with no institutional memory. Academic Health Center Teaching Hospital (now under DHS) “beyond repair”. Any federal (matching) Medicaid opportunities, such as DSH, are foregone. Health policy issues just emerging. Still in generally blissful ignorance - cannot see storm clouds.

1980’s

EMERGING FROM DARKNESSEconomy recovers. Legislature is starting to change and turnover (term limits/no new taxes). Good ole boys on the way out. State creates a Health Care Authority. Privatizes the only public hospital in the state. Begins to take advantage of Medicaid – but it is way too late. The “uninsured” are noticed – the concept of a “safety net” emerges. Starting to realize we have big problems.

1990’s

SEEING THE LIGHTRealized that we missed the boat on Medicaid – “too bad – so sad”. Medicaid DSH frozen. Some states are big winners (Louisiana) – some states are still at the starting gate (Oklahoma). Communities cannot solely rely upon the state and feds. Now what?

Let’s review the past 15 years.

NOW

STATE OF OKLAHOMAMissed FQHC opportunitiesMissed Medicaid DSH opportunitiesIgnored State of State Health warningsDismissed United Health rankings

Health Care Authority rises from chaosPrivatized state’s only public hospital

1992-2007

TULSA COMMUNITYNew Medical School identity and leadershipStart of the Bedlam AlliancePhilanthropy awakened and enablingGood-to-Great philosophy engagedRegional Strategic Health PlanCommunity respondingSchool of Community Medicine

2002-2007

THECHALLENGES

CAUSED BY GENERATIONS OF NEGLECT

OKLAHOMA AND NATIONAL

18.1

19.9

20.1

18.6

18.2

22.0

23.6

17.8

19.2

17.0

17.7

18.3

16.4

18.9

18.3

17.3

20.4

19.9

18.5

12.9

13.4

13.6

13.9

14.1

15.0

15.315.2

15.4

15.6

16.1

16.3

14.5

14.2

14.6

15.2

15.615.7

15.9

10

15

20

25

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

25%

20%

15%

10%

OKLAHOMA UNINSURED

$0

$20

$40

$60

$80

$100

$120

$140

$160

$180

$200

AL AK AZ AR CA CO CN DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

2004 MedicaidDSH Payments Per Capita

U.S. average is $45.01 per capita; Oklahoma is $6.67

LA OK LA OK

Hospital $ 930m $ 407m $ 205 $ 117

DSH $ 911m $ 23m $ 201 $ 7

Nursing Home $ 594m $ 463m $ 131 $ 133

Managed Care $ 0 $ 171m $ 0 $ 49

Drugs $ 945m $ 417m $ 208 $ 120

FQHC $ 9m $ 5m $ 2 $ 1

Indian $ 6m $ 62m $ 1 $ 18

Other $ 1,700m $ 1,000m $ 372 $ 294

TOTAL $ 5.1B $ 2.6B $ 1,120 $ 737

MEDICAID 2004

PER CAPITATOTAL DOLLARS

Metropolitan Safety NetsPublicHospital

Comp Med Sch

MedicaidDSH

FocusedHospital

State FQHC

Jacksonville University Yes Yes Yes No Jacksonville

Rochester University Yes Yes Yes Yes Rochester

Grand Rapids No No Yes Yes No Grand Rapids

Oklahoma City University Yes Yes Yes No Oklahoma City

Louisville University Yes Yes Yes Yes Louisville

Richmond District Yes Yes Yes Yes Richmond

Greenville District Yes Yes Yes No Greenville

Dayton No Yes Yes Yes No Dayton

Fresno County No Yes Yes Yes Fresno

Birmingham State Yes Yes Yes Yes Birmingham

Honolulu Public Yes Alternate Yes Yes Honolulu

Albany University Yes Yes Yes Yes Albany

Tucson University Yes Yes Yes No Tucson

Tulsa No No No No No Tulsa

Syracuse State Yes Yes Yes Yes Syracuse

Omaha University Yes Yes Yes No Omaha

“Tulsa (and Wichita) are the only two major metro areas (of the 80 largest) in the nation lacking all traditional infrastructure, financing mechanisms and organizational tools for providing coordinated and focused safety net services. Both have community-based med schools.”

OU College of Public Health study for the Oklahoma Secretary of Health, April 2005

350,000

300,000

250,000

200,000

150,000

100,000

50,000

0

346,976

130,494

40,000 Primary90,000 Specialty

31,199

46,320

101,661

37,300

SE

RV

ED

BY

SA

FE

TY

NE

TU

NS

ER

VE

D

ER

Oth

erC

linic

sM

ajor

Clin

ics

Fre

eC

linic

s

TU

LS

A M

ET

RO

4444

40

4546

44

4140

4141

383939

3231

3030

0

5

10

15

20

25

30

35

40

45

50

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

OKLAHOMAUnited Health Foundation

America’s Health Rankings – 2006

HEART DISEASE

MENTAL HEALTH NEEDS

National Average

1,029

1,011

1979AGE ADJUSTED DEATH RATES

THE TEN STATES WITH THE HIGHEST RATES Source: Centers for Disease Control. Graphic: OU College of Public Health

National Average

946

801

2004AGE ADJUSTED DEATH RATES

THE TEN STATES WITH THE HIGHEST RATES Source: Centers for Disease Control. Graphic: OU College of Public Health

OklahomaA State of Health?

“We are the ONLY state where our age-adjusted death rates became WORSE through the 1990s and into this century.”

“If we had the same adjusted death rate as the nation, we would have about 3,700 fewer people dying each year.”

Oklahoma State Board of Health “2006 State of the State’s Health” Graphic: University of Oklahoma College of Public Health. Data Source: U.S. Centers for Disease Control and Prevention

AGE ADJUSTED DEATH RATE

U.S

OK

700

800

900

1,000

1,100

1,200

1979 1984 1989 1994 1999 2004

LA

US

OKOKLAHOMAFROM THE NATIONAL AVERAGE TO LOUISIANA

AGE ADJUSTED DEATH RATES

While the death rate of most U.S. residents is declining, that of Tulsans is not – and the trend is going in the wrong directionUnited States

Tulsa County

1980 1990 2000

1,000

950

900

850

800

1,100

AIMING HIGHERThe Commonwealth Fund

Results from a State Scorecard on Health System Performance

OK

COMMONWEALTH FUND State Scorecard Summary of Health System Performance

OUR EMBARASSMENT

“When you are 50th – how do you defend the status quo?”

50th

COMMUNITYRESPONSES

KIM HOLLANDOKLAHOMA INSURANCE COMMISSIONER

INITIATIVES FOR OKLAHOMA

AN OKLAHOMA CHATCHOOSING HEALTHPLAN ALL TOGETHER

© University of Michigan; courtesy of Sacramento Healthcare Decisions (SHD)

Oklahoma Employer/EmployeePartnership for Insurance Coverage

PREMIUM SHARING15% EMPLOYEE – 25% EMPLOYER – 20% STATE – 40% FEDERAL

HIDC

HEALTH FOR OKLAHOMANS INFORMATION FOR POLICYMAKERSOHI

OKLAHOMA HEALTH INSTITUTE

GERRY CLANCY, MDPRESIDENT, OU-TULSA

INITIATIVES FOR TULSA

THE GOOD TO GREAT STUDYY-Axis:Ratio of cumulative stock returns to general market.X-Axis: Years from transition.

-15 -10 -5 0 +5 +10 +15

Good-to-GreatCompanies

DirectComparisonCompanies

1.00Market baseline Transition Point

7.00

This begs the question, “what could the University of Oklahoma College of Medicine, Tulsa do to become a great medical school?”

One answer is to lead a long-term strategy to successfully improve the health status of the entire Tulsa metropolitan region.

COLLEGE OFMEDICINE-TULSA

TulsaCounty

198019902000201020202030

DEATH RATES AGE ADJUSTED

UnitedStates800

1,100

RATE

1,000

850

A GREAT MEDICAL SCHOOL WOULD

IMPROVE HEALTHA great medical school would lead the long-term effort to bring the Tulsa health status in line with national averages and trends.

All Races19901995200020052010201510

30YPLL IN TULSA COUNTY YEARS OF PRODUCTIVE LIFE LOST PER DEATH

YEARSAfrican-American

26

14

IMPROVE PRODUCTIVITYA great medical school would lead the long-term effort to increase productivity (reduce years of productive life lost) and work towards eliminating racial disparities in Tulsa.

A GREAT MEDICAL SCHOOL WOULD

925989 995

1,486

HIGHESTMID-HIGHMID-LOWLOWESTHOUSEHOLD INCOMES

AGE-ADJUSTED DEATH RATES

OFFSET POVERTY

A great medical school would lead the effort to bring better health status to those in poverty, especially children.

A GREAT MEDICAL SCHOOL WOULD

CONTINUUM OF HEALTH SERVICES

Prenatal CareLive Birth

PrimaryDisease

PreventionTreatment of

Acute Disease

TertiaryDisease

PreventionRehabilitative

Care

End of LifeHealthPromotion

Diagnosisof Disease

SecondaryDisease

Prevention

Treatment ofChronic Illness

Long TermCare

PalliativeCare

INSTITUTIONSHOSPITALS - NURSING HOMES

REHABILTATION CENTERS

PRIMARY CARESAFETY NET CLINICS & PROVIDERS

HEALTHPLEXSPECIALTY OUTPATIENT SERVICE

BY REFERRAL

CREATING THE NATION’S FIRST

SCHOOL OFCOMMUNITY MEDICINEA PLATFORM TO IMPROVE THE HEALTH STATUS OF THE TULSA REGION

GERRY CLANCY, MD, PRESIDENT, OU-TULSAMICHAEL LAPOLLA, OU COLLEGE OF PUBLIC HEALTH

… will blend the education and practice of public health with medical education to produce community-oriented and jointly credentialed physicians who will influence personal and population health.

SCHOOL OFCOMMUNITY MEDICINE

COMMUNITY PHILANTHROPY

NOW - FROM THE TREETOPS

THE BEDLAM ALLIANCEJohn Gaudet