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REBUILDING THE HEALTH CARE SYSTEM IN NEW ORLEANS, AND THE US AN APPLICATION OF JEWISH PRINCIPLES
<ul><li>Structural and process changes to improve the health system </li></ul><ul><li>Post-Katrina  NO health care  </li><...
Participants <ul><li>Rick Streiffer, MD - Moderator   </li></ul><ul><ul><li>Professor of Family and Community Medicine, Tu...
Pre-Katrina Context
AMERICA’S HEALTH: STATE HEALTH RANKINGS, 2008 “Louisiana is 50th this year”
WHY?
Racial/Ethnic Health Disparities Cardiovascular Disease Mortality Rate U.S. White 275 deaths per 100,000 people U.S. Black...
More rural then average People are sicker, older, poorer Lack Medical Access
Poverty =>  Lack of insurance =>  Poor access to care
Pre-Katrina <ul><li>Living in  poverty  ($16,090 for a family of three) </li></ul><ul><ul><li>22% Louisiana residents, 23%...
90%+ of state is Primary Care Health Professional Shortage Areas (HPSA)
AMERICA’S HEALTH: STATE HEALTH RANKINGS, 2008 “Louisiana is 50th this year”
<ul><li>10 state-funded, -run hospitals, 350 clinics </li></ul><ul><li>State mandate: all residents have access to health ...
 
<ul><li>“ In Louisiana, the uninsured have little choice when it comes to medical care.” </li></ul><ul><li>Perpetual under...
<ul><li>10 state-funded, -run hospitals, 350 clinics </li></ul><ul><li>State mandate: all residents have access to health ...
<ul><li>“ In Louisiana, the uninsured have little choice when it comes to medical care.”  – PAR 2007 </li></ul><ul><li>Acc...
<ul><li>NO was served by only two FQHCs </li></ul><ul><ul><li>Together: only 57,000 visits. </li></ul></ul><ul><ul><li>Cha...
“ Louisiana is 50th this year”
Is US Health Really the Best in the World? <ul><li>13 th  (last) for low-birth-weight percentages </li></ul><ul><li>13 th ...
<ul><li>State, & New Orleans: High costs, low quality </li></ul><ul><ul><li>1 st  in Medicare spending per capita  </li></...
25th Percentile Quality $6800 per year 75th Percentile Quality $5200 per year On average, there are 40% more family physic...
Health Care Spending per capita  ($US PPP) Purchasing Power Parity 2008 OECD Data United States  $7538 Germany  $3737 HIGH...
LACK OF ACCESS
DISPARITIES
<ul><li>“ Despite documented benefits of timely preventive care,  barely half of adults (49%) received preventive and scre...
“ Every country starts at the base of the pyramid with primary care, and they work their way up until the money runs out.”...
Health System Characteristics  Associated With Improved Outcomes & Lower Cost <ul><li>Equitable distribution of health ser...
Health System & Policy Characteristics Associated With Improved Outcomes & Lower Cost <ul><li>Equitable distribution of he...
Why Is Primary Care Important? Better health outcomes Lower costs Greater equity in health Starfield 09/04 PC 2945
Characteristics Associated with  Improved Health Outcomes, Better Equity, and Lower Costs  <ul><li>First Contact Access  p...
Primary care is the provision of  first contact ,  person-focused   ongoing  care over time that meets the health-related ...
<ul><li>ECOLOGY: The science of the relationships between organisms & their environments.  Source: N England Journal of Me...
Post-Katrina Context
August 29, 2005
80% of New Orleans Flooded
200,000 Households flooded,  along with the surrounding social infrastructure of churches…schools…friends…family... 1900 l...
Only 1 of 23 hospitals operating, 6 of 53 nursing homes operational,  35 mental health beds (vs about 300 beds) Prevalence...
 
Options <ul><li>Rebuild Charity Hospital System? </li></ul><ul><li>Something different? </li></ul><ul><li>What about your ...
Characteristics of Practices of Personal Physicians Associated with  Improved Health Outcomes, Better Equity, and Lower Co...
The Patient-Centered Medical Home Legislative Definition of AOA, ACP, AAP & AAFP <ul><li>Personal Physician </li></ul><ul>...
<ul><li>Any place that does not have a doctor, whether one is healthy or sick, is not worthy of moving to… for every perso...
Participants <ul><li>Rick Streiffer, MD - Moderator   </li></ul><ul><ul><li>Professor of Family and Community Medicine, Tu...
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Rebuilding the Health Care System in New Orleans and the US

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Dr. Richard Streiffer; An Application of Jewish Principles. CCAR NOLA 2011

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Rebuilding the Health Care System in New Orleans and the US

  1. 1. REBUILDING THE HEALTH CARE SYSTEM IN NEW ORLEANS, AND THE US AN APPLICATION OF JEWISH PRINCIPLES
  2. 2. <ul><li>Structural and process changes to improve the health system </li></ul><ul><li>Post-Katrina NO health care </li></ul><ul><li>Application of Jewish values and principles to health system improvement </li></ul><ul><li>Role of the Jewish community </li></ul>
  3. 3. Participants <ul><li>Rick Streiffer, MD - Moderator </li></ul><ul><ul><li>Professor of Family and Community Medicine, Tulane University School of Medicine </li></ul></ul><ul><li>Rabbi Micah Streiffer </li></ul><ul><ul><li>Temple Beth El- Charlotte, NC </li></ul></ul><ul><li>Robert Post, MD </li></ul><ul><ul><li>Medical Director, Daughters of Charity Health Services of New Orleans </li></ul></ul><ul><li>Elmore F. Rigamer, MD, MPA </li></ul><ul><ul><li>Medical Director, Catholic Charities </li></ul></ul><ul><li>Anne Mulle, BSN, MS, FNP </li></ul><ul><ul><li>Clinic Manager and Nurse Practitioner, Common Ground Health Clinic </li></ul></ul>
  4. 4. Pre-Katrina Context
  5. 5. AMERICA’S HEALTH: STATE HEALTH RANKINGS, 2008 “Louisiana is 50th this year”
  6. 6. WHY?
  7. 7. Racial/Ethnic Health Disparities Cardiovascular Disease Mortality Rate U.S. White 275 deaths per 100,000 people U.S. Black 375 deaths per 100,000 people LA White 285 deaths per 100,000 people LA Black 375 deaths per 100,000 people National Statistics State Statistics
  8. 8. More rural then average People are sicker, older, poorer Lack Medical Access
  9. 9. Poverty => Lack of insurance => Poor access to care
  10. 10. Pre-Katrina <ul><li>Living in poverty ($16,090 for a family of three) </li></ul><ul><ul><li>22% Louisiana residents, 23% New Orleans residents </li></ul></ul><ul><li>No Health Insurance </li></ul><ul><ul><li>>900,000 people (21%) of La residents </li></ul></ul><ul><li>Medicaid </li></ul><ul><ul><li>19% of La population </li></ul></ul><ul><ul><li>Childless adults, working poor: not eligible </li></ul></ul>
  11. 11. 90%+ of state is Primary Care Health Professional Shortage Areas (HPSA)
  12. 12. AMERICA’S HEALTH: STATE HEALTH RANKINGS, 2008 “Louisiana is 50th this year”
  13. 13. <ul><li>10 state-funded, -run hospitals, 350 clinics </li></ul><ul><li>State mandate: all residents have access to health care services </li></ul><ul><li>Primarily individuals without insurance </li></ul><ul><ul><li>50,000 acute care inpatient admissions </li></ul></ul><ul><ul><li>900,000 clinic visits </li></ul></ul><ul><ul><li>400,000 emergency room </li></ul></ul><ul><ul><li>85% of uncompensated care costs for state </li></ul></ul>
  14. 15. <ul><li>“ In Louisiana, the uninsured have little choice when it comes to medical care.” </li></ul><ul><li>Perpetual under-funding </li></ul><ul><li>Poorly maintained buildings </li></ul><ul><li>Overcrowded ERs and clinics </li></ul><ul><li>Waiting times “in months” for appointments </li></ul><ul><li>Long drives from rural areas </li></ul><ul><li>Inability to utilize nearby private doctors, facilities </li></ul><ul><li>Lack of diagnostic and treatment equipment </li></ul><ul><li>Realigning Charity Health Care and Medical Education in Louisiana </li></ul><ul><li>- PAR 2007 </li></ul><ul><ul><li>Access to primary care limited for uninsured </li></ul></ul><ul><ul><li>Heavy dependence on residents, students </li></ul></ul><ul><ul><li>Lack of continuity, coordination </li></ul></ul><ul><ul><li>No electronic record </li></ul></ul><ul><ul><li>“ Silo” oriented (not comprehensive) </li></ul></ul><ul><ul><li>Long waits for appointments </li></ul></ul>
  15. 16. <ul><li>10 state-funded, -run hospitals, 350 clinics </li></ul><ul><li>State mandate: all residents have access to health care services </li></ul><ul><li>Primarily individuals without insurance </li></ul><ul><ul><li>50,000 acute care inpatient admissions </li></ul></ul><ul><ul><li>900,000 clinic visits </li></ul></ul><ul><ul><li>400,000 emergency room </li></ul></ul><ul><ul><li>85% of uncompensated care costs for state </li></ul></ul>
  16. 17. <ul><li>“ In Louisiana, the uninsured have little choice when it comes to medical care.” – PAR 2007 </li></ul><ul><li>Access to primary care limited for uninsured </li></ul><ul><ul><li>Long Drives for rural citizens </li></ul></ul><ul><ul><li>Heavy dependence on residents, students </li></ul></ul><ul><ul><li>Lack of continuity, coordination </li></ul></ul><ul><ul><li>“ Silo” oriented (not comprehensive) </li></ul></ul><ul><ul><li>Long waits for appointments </li></ul></ul><ul><ul><li>No electronic record </li></ul></ul>
  17. 18. <ul><li>NO was served by only two FQHCs </li></ul><ul><ul><li>Together: only 57,000 visits. </li></ul></ul><ul><ul><li>Charity: 350,000 outpatient visits at 150 primary care and specialty clinics </li></ul></ul>
  18. 19. “ Louisiana is 50th this year”
  19. 20. Is US Health Really the Best in the World? <ul><li>13 th (last) for low-birth-weight percentages </li></ul><ul><li>13 th for neonatal mortality and infant mortality overall </li></ul><ul><li>11 th for postneonatal mortality </li></ul><ul><li>13 th for years of potential life lost (excluding external causes) </li></ul><ul><li>11 th for life expectancy at 1 year for females, 12 th for males </li></ul><ul><li>10 th for life expectancy at 15 years for females, 12 th for males </li></ul><ul><li>10 th for life expectancy at 40 years for females, 9 th for males </li></ul><ul><li>7 th for life expectancy at 65 years for females, 7 th for males </li></ul><ul><li>3 rd for life expectancy at 80 years for females, 3 rd for males </li></ul><ul><li>10 th for age-adjusted mortality </li></ul><ul><li>12 th of 13 overall for 16 health indicators </li></ul>In a comparison of 13 countries,* the US rankings were: *Australia, Belgium, Canada, Denmark, Finland, France, Germany, Japan, Netherlands, Spain, Sweden, United Kingdom, United States Source: Starfield, JAMA 2000; 284:483-5.
  20. 21. <ul><li>State, & New Orleans: High costs, low quality </li></ul><ul><ul><li>1 st in Medicare spending per capita </li></ul></ul><ul><ul><li>Last in Medicare quality </li></ul></ul>
  21. 22. 25th Percentile Quality $6800 per year 75th Percentile Quality $5200 per year On average, there are 40% more family physicians per capita at the 75%tile level than at the 25%tile level.
  22. 23. Health Care Spending per capita ($US PPP) Purchasing Power Parity 2008 OECD Data United States $7538 Germany $3737 HIGH COST
  23. 24. LACK OF ACCESS
  24. 25. DISPARITIES
  25. 26. <ul><li>“ Despite documented benefits of timely preventive care, barely half of adults (49%) received preventive and screening tests according to guidelines for their age and sex.” </li></ul><ul><ul><li>Why Not the Best - Commonwealth Fund Commission, 9/06 </li></ul></ul>POOR PREVENTION
  26. 27. “ Every country starts at the base of the pyramid with primary care, and they work their way up until the money runs out.” - Senator Daschle, Jan 8, 2008 … “ We start at the top of the pyramid, and we work our way down until the money runs out…And so we have to change the pyramid. We have to start at the base.” Most of the World The US
  27. 28. Health System Characteristics Associated With Improved Outcomes & Lower Cost <ul><li>Equitable distribution of health services ( access ) </li></ul><ul><li>Universal or near-universal financial assistance guaranteed by a publicly accountable body </li></ul><ul><li>Low or no co-pay for primary care health services </li></ul><ul><li>High percentage of physicians who are generalists (with respect to the population & to all physicians) </li></ul><ul><li>Relationship with a usual source of comprehensive , longitudinal medical care ( the Patient-Centered Medical Home ) </li></ul><ul><li>Narrow range of physician incomes </li></ul>Starfield, Shi, Macinko . The Milbank Quarterly 2005:83(3);457-502 and The Dartmouth Atlas
  28. 29. Health System & Policy Characteristics Associated With Improved Outcomes & Lower Cost <ul><li>Equitable distribution of health services ( access ) </li></ul><ul><li>Universal or near-universal financial assistance guaranteed by a publicly accountable body </li></ul><ul><li>Low or no co-pay for primary care health services </li></ul><ul><li>High percentage of physicians who are generalists (with respect to the population & to all physicians) </li></ul><ul><li>Relationship with a usual source of comprehensive , longitudinal medical care ( the Patient-Centered Medical Home ) </li></ul><ul><li>Narrow range of physician incomes </li></ul>Starfield, Shi, Macinko . The Milbank Quarterly 2005:83(3);457-502 and The Dartmouth Atlas <ul><li>Health outcomes are optimized in nations/regions where 40-50% of the physician workforce are Primary care physicians </li></ul>
  29. 30. Why Is Primary Care Important? Better health outcomes Lower costs Greater equity in health Starfield 09/04 PC 2945
  30. 31. Characteristics Associated with Improved Health Outcomes, Better Equity, and Lower Costs <ul><li>First Contact Access patients seek advice and care first at the practice of the personal physician, </li></ul><ul><li>Patient-focused Care Over Time patient-focused care, including prevention, rather than disease-focused care; and longitudinal care, rather than episodic care </li></ul><ul><li>Comprehensive Care whole person oriented, a broad range of health services </li></ul><ul><li>Coordinated (Integrated) Care integration of care among health professionals including outside organizations and consultants, and optimal participation by members of the team </li></ul>The Patient-Centered Medical Home 4 Essential Functions of Primary Care
  31. 32. Primary care is the provision of first contact , person-focused ongoing care over time that meets the health-related needs of people , referring only those too uncommon to maintain competence, and coordinates care when people receive services at other levels of care. Starfield 09/04 04-132 Starfield 09/04 PC 2943
  32. 33. <ul><li>ECOLOGY: The science of the relationships between organisms & their environments. Source: N England Journal of Medicine 2001;344:2021-25 </li></ul>A typical month of health care in the United States
  33. 34. Post-Katrina Context
  34. 35. August 29, 2005
  35. 36. 80% of New Orleans Flooded
  36. 37. 200,000 Households flooded, along with the surrounding social infrastructure of churches…schools…friends…family... 1900 lives lost, 780,000 people displaced, 850 schools damaged, 18,700 businesses destroyed, and 220,000 jobs lost
  37. 38. Only 1 of 23 hospitals operating, 6 of 53 nursing homes operational, 35 mental health beds (vs about 300 beds) Prevalence of SMI doubled (6.1% to 11.3%) Thousands of physicians, MH professionals, health care workers gone
  38. 40. Options <ul><li>Rebuild Charity Hospital System? </li></ul><ul><li>Something different? </li></ul><ul><li>What about your community? </li></ul>
  39. 41. Characteristics of Practices of Personal Physicians Associated with Improved Health Outcomes, Better Equity, and Lower Costs (Effective, Equitable, Efficient) <ul><li>Family Orientation The degree to which medical services are provided to family members by the same personal physician </li></ul><ul><li>Community Orientation The degree to which the practice assesses the needs of the community, designs interventions, and measures outcomes </li></ul><ul><li>Cultural Competence The degree to which the biopsychosocial model is employed and health beliefs are addressed </li></ul>The Patient-Centered Medical Home Starfield, et al: The Milbank Quarterly 83(3), 2005; 457-502 Starfield & Shi: Pediatrics, 2004;113:1493-99 A critical evaluation of the scientific evidence for each of these characteristics: Rosenthal T: J Am Board Fam Med 2008;21:427-440 3 Corollary Functions of Primary Care 20 th Report, Page 28 Prepared by Jerry Kruse, MD, MSPH
  40. 42. The Patient-Centered Medical Home Legislative Definition of AOA, ACP, AAP & AAFP <ul><li>Personal Physician </li></ul><ul><li>Physician Directed Medical Practice </li></ul><ul><li>Whole Person Orientation </li></ul><ul><li>Coordinated and Integrated Care </li></ul><ul><li>Quality and Safety Measures Evident </li></ul><ul><ul><ul><li>Evidence Based Medicine and Clinical Decision Support </li></ul></ul></ul><ul><ul><ul><li>Voluntary Continuous Quality Improvement (CQI) </li></ul></ul></ul><ul><ul><ul><li>Patient’s Expectation Met </li></ul></ul></ul><ul><ul><ul><li>Health Information Technology used effectively </li></ul></ul></ul><ul><ul><ul><li>Voluntary Recognition Process </li></ul></ul></ul><ul><li>Enhanced Access </li></ul><ul><li>Appropriate Payment </li></ul>COGME 20 th Report, Page 29 Joint Principles of the PCMH
  41. 43. <ul><li>Any place that does not have a doctor, whether one is healthy or sick, is not worthy of moving to… for every person has responsibility for good health </li></ul><ul><li>Maimonides, Mishneh Torah, Law Concerning Beliefs 4:22 </li></ul>
  42. 44. Participants <ul><li>Rick Streiffer, MD - Moderator </li></ul><ul><ul><li>Professor of Family and Community Medicine, Tulane University School of Medicine </li></ul></ul><ul><li>Rabbi Micah Streiffer </li></ul><ul><ul><li>Temple Beth El, Charlotte, NC </li></ul></ul><ul><li>Robert Post, MD </li></ul><ul><ul><li>Medical Director, Daughters of Charity Health Services of New Orleans </li></ul></ul><ul><li>Elmore F. Rigamer, MD, MPA </li></ul><ul><ul><li>Medical Director, Catholic Charities </li></ul></ul><ul><li>Anne Mulle, BSN, MS, FNP </li></ul><ul><ul><li>Clinic Manager and Nurse Practitioner, Common Ground Health Clinic </li></ul></ul>

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