![“Savings generated from improved
[clinical] practice and performance could
also be reinvested in the community,
creating a reinforcing loop.”
-- Sanne Magnan, Elliott Fisher, David Kindig,
George Isham, Doug Wood, Mark Eustis,
Carol Backstrom, Scott Leitz
Magnan S, Fisher E, Kindig D, et al. Achieving Accountability for Health and
Health Care Minneapolis, MN; 2012 July 10. Available at
http://tinyurl.com/icsi-AHC](https://image.slidesharecdn.com/milsteingr-beyondreformandreboundv6-131107125941-phpapp01/85/Dr-Bobby-Milstein-Beyond-Reform-and-Rebound-36-320.jpg)
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Dr. Bobby Milstein | Beyond Reform and Rebound
- 1. Beyond Reform &Rebound: Frontiers for Rethinking and Redirecting Health System Performance Bobby Milstein Director, ReThink Health Visiting Scientist, MIT Sloan School of Management bmilstein@rethinkhealth.org Columbia University, Mailman School of Public Health, Grand Rounds on the Future of Public Health New York, NY October 9, 2013
- 2. More Money forShorter Lives Commission to Build a Healthier America. America is not getting good value for its health dollar. Robert Wood Johnson Foundation 2008. Institute of Medicine. U.S. Health in International Perspective: Shorter Lives, Poorer Health. Washington, DC: National Academies Press; 2013. 2
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- 4. “Sad History ofHealth Care Cost Containment: 1961-2001” Altman DE, Levitt L. The sad history of health care cost containment as told in one chart. Health Affairs 2002;Web Exclusive:hlthaff.w2.83. 4
- 5. “The tendency forinterventions to be delayed, diluted, or defeated by the response of the system to the intervention itself.” -- Meadows, Richardson & Bruckmann Caused by… • Tunnel vision • Narrow mental models • Neglected data • Defensive routines • Failure to foresee • Inability to enact higher leverage policies Meadows DH, Richardson J, Bruckmann G. Groping in the Dark: The First Decade of Global Modelling. Wiley: New York, 1985. Sterman JD. Learning from evidence in a complex world. American Journal of Public Health 2006;96(3):505-514. Forrester JW. Counterintuitive behavior of social systems. Technology Review 1971;73(3):53-68. 5
- 6. Forces Under Debate Cutlerand Sahni, Health Affairs 2013 32(5): 841-850 Chandra, Holmes, Skinner. Brookings Sept 2013. Ryu et.al., Health Affairs 2013 32(5):835-840 Holahan and McMorrow. Urban Institute May 2013 Cuckler et.al., Health Affairs 2013 32(10) Recession Business cycles Uninsurance Payment rate cuts Cost sharing Efficiency and waste Patient demand Health sector stock prices Legislation and regulation Technology Aging (only one) Epidemiology (none) Risk and vulnerability (none) Power and social policy (none) 6
- 7. September 26, 2013 September27, 2013 Seigal Bernard T. A Guide to the New Exchanges for Health Insurance. New York Times 2014 September 27. Abelson R. As Some Companies Turn to Health Exchanges, G.E. Seeks a New Path. New York Times 2013 September 26. 7
- 8. General Electric. BuildingBetter Healthcare Value in Cincinnati: How Employers are Collaborating with Other Healthcare Stakeholders to Improve Health and Reduce Costs in the Queen City. Fairfield, CT: Healthymagination; 2013. Available at http://www.ge.com/globalimpact/pdf/Building_Better_Healthcare_Value_in_Cincinnati.pdf 8
- 9. Anytown, USA Action Regional Pilots (2010-2013) FormalModels (N=8) Results ReActing Thinking ReThinking 9
- 10.
- 11. Variations in Healthand Risks The County Health Rankings Variations in Practice and Spending The Dartmouth Atlas of Health Care 2013 Variations in Care for Advanced Cancer 11
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- 13. Core Members (N=15) •Health Department and Board of Health • Community Health Center • Medical Centers and Hospitals • Mental Health Center • Kaiser Permanente Wider Area Stakeholders (N=30+) • Commerce, Schools, University, Local Government, Philanthropy, Community Organizations Population = 160,000 Uninsured = 15% Poverty = 40% County Health Rank = 57th out of 59 Primary Care Providers = 7 per 10,000 Healthcare expenditures = $1B/year
- 14. “Most Triple Aimprojects start with a project and build up from there.” “We have been thinking big picture and ReThink Healthspecific projects yet.” haven't selected Dynamics Triple Aim Collective Impact Pueblo’s Health System • How is the health system structured? “We are building governance, structure, andHow and first becauseit change our • strategy when does we believe work will change)? (or resist be more successful and sustainable with this approach.” • Where is the greatest leverage? -- Donald Moore, • What trade-offs are involved? CEO Pueblo Community Health Center Milstein B, Hirsch G, Minyard K. County Officials Embark on New, Collective Endeavors to ReThink Their Local Health Systems. Journal of County Administration, March – April 2013. Available at http://tinyurl.com/RTH-County-Officials Milstein B. ReThinking Health in Pueblo, Colorado: A Stewardship Strategy to Advance the Triple Aim. Improving Population Health. August 21, 2012. Available at http://tinyurl.com/RTH-Pueblo-Story Kindig D, Milstein B. From ACOs to Accountable Health Communities: Delivering on Population Health in the Triple Aim. Institute for Clinical Systems Improvement Reinertsen Lecture. October 25, 2012; Minneapolis, MN. Available at https://www.icsi.org/education__services/reinertsen_lecture/ 14
- 15. Planning for System-wideImpact Draft Business Plan • Strategic Priorities • Coordinate care • Post-discharge planning • Support adherence • Recruit safety net PCPs • Healthier behaviors • Pathways to advantage • Capture and reinvest savings • Share savings with providers Favorite • Backbone Organization • Shared Measurement System • Sustainable Funding • Governance & Communications $742,000 investment
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- 17. Atlanta Regional Collaborativefor Health Improvement. Who we are. Atlanta, GA; 2013 June 5. Available at http://www.archicollaborative.org/
- 18. Form a seriousregional collaborative Gather and assess quantitative data Gather and assess qualitative data • Set priorities with diverse stakeholders? • Enact high-leverage strategies • Etc…. 18
- 19. …Raising Many Practical, Strategic,Ethical Questions • • • • • Which to prioritize? How to pay…and sustain? Consequences and tradeoffs? Who decides? Etc… Relevant Methodologies • Many innovators want to play out and pursue Decision science bold• system-change strategies. • Comparative effectiveness research • New teams, new tools, new ways of thinking • Health impact assessment are often required& implementation scale and • Integration to succeed at this sciences in context • Dynamic policy modeling
- 20. • Realistic yetsimplified representations of a local health system (N=8 to date) • Place-based, wide-angle view; diverse scenario options; scores of metrics to trace changes over decades • Anchored to evidence from dozens of datasets, rendered in a common—testable—framework • Tool for open, experiential learning with diverse stakeholders www.ReThinkHealth.org/Dynamics 20
- 21. • 2008-2011: HealthBound US healthreform strategy Sponsor: CDC Publications: HA 2011; AJPH 2010 • Multiple chronic diseases, US & 60+ sites Sponsors: CDC and NIH Publications: HPP 2012; PCD 2010; AJPH 2010; PCD 2008; PCD 2007; AJPH 2006 Selected Awards • 2013 Society for Health Education, Article of the Year • 2011 System Dynamics Society Best Application of SD Modeling • 2008 ASysT Institute, Applied Systems Thinking Prize Refs: http://tinyurl.com/RTH-Related-Models 2005-2006: US Health Economy Growth of US health sector, 1960-2010 Sponsor: CDC Publications: SDR 2006 2009; CDC Honor Awards for 2005 Excellence in Innovation • • 2012 AcademyHealth, Public Health Systems Research Article of the Year • 2003-present: Diabetes; Obesity; PRISM • 1995-1997: Health Care Microworld Local health, health care, social policy Sponsors: NEHA and Innovation Associates, Dartmouth-Hitchcock Publications: SDR 1999 • 1993: Transition to Capitation Local healthcare financing Sponsor: Healthcare Forum Publication: Health Forum J 1994
- 22. Selected Geographic Focus Productivity& Equity Aging Risk Health Care Cost Capacity Other Trends Initiatives Payment Scheme Innovation Funds Captured Savings • Insurance eligibility • Economic conditions • Health care inflation • Primary care slots Population tracked separately in 10 segments by age, insurance, and income 22
- 23. Atlanta sources •US Census andAmerican Community Survey •Vital Statistics •Behavioral Risk Factor Surveillance Survey (BRFSS) •National Survey of Children’s Health (NSCH) •Georgia Hospital Discharge Data •Georgia Department of Public Health •Dartmouth Atlas •Area Resource Files •Georgia Department of Community Health Small-area estimates based on national sources •National Health and Nutrition Examination Survey (NHANES) •National (Hospital) Ambulatory Medical Care Survey (NAMCS, NHAMCS) •National Hospital Discharge Survey (NHDS) •National Nursing Home Survey (NNHS) and Home Health Care Survey (NHHS) •Medical Expenditure Panel Survey (MEPS) •National Health Expenditures (NHE) 23
- 24. In 2010, abouthow much did Atlanta spend on personal health care services? 1. $700 million 2. $3 billion 3. $11 billion 4. $6 billion * Atlanta = Fulton + Dekalb county 24
- 25. In 2010, abouthow much did Atlanta spend on personal health care services? 1. $700 million 2. $3 billion What could we accomplish by devoting just 1% to system change initiatives? 3. $11 billion 4. $6 billion * Atlanta = Fulton + Dekalb county 25
- 26. Challenge: Craft yourfavorite scenario to improve performance of the regional health system over the next several decades (2012-2040) ReThink Health Atlanta ◦ ◦ ◦ ◦ ◦ Improve health Enhance care Lower health care costs Achieve equity Boost productivity 26
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- 28. Under what conditionsis it possible to alter • Direction? • Timing? • Magnitude? 28
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- 32. 1% of 2010spend $100M x 5 = $500M
- 33. Beginning in 2012,what will be the • Direction? • Timing? • Magnitude? 33
- 35. Savings O Initial Innovation Fund R Capture&Reinvest Health Care Savings Costs O Funds Available for Investment O B Fund Depletion Spending on Programs Program Investments A common predicament for costly investments that must be sustained: • • • • • • • Healthier Behaviors Family & Student Pathways Mental Illness Self-Care Cut the program effort Find more funding Reinvest savings
- 36. “Savings generated fromimproved [clinical] practice and performance could also be reinvested in the community, creating a reinforcing loop.” -- Sanne Magnan, Elliott Fisher, David Kindig, George Isham, Doug Wood, Mark Eustis, Carol Backstrom, Scott Leitz Magnan S, Fisher E, Kindig D, et al. Achieving Accountability for Health and Health Care Minneapolis, MN; 2012 July 10. Available at http://tinyurl.com/icsi-AHC
- 37. 50/50 Split withInsurers
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- 40. Peak = $53 Low= - $519
- 41. Challenge: Craft ascenario that ought to work well: a vision for Atlanta you might be proud to enact Some Tips Discuss what you value and how to achieve it Consider both actions and funding Limit = 5 initiatives + any financing options 41
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- 43. 1. 2. 3. 4. 87% Far-Reaching Atlanta Transformation Better HealthAtlanta Promote Health Today 6% 4% 1 2 3 2% 4 N = 70 respondents at ARCHI Workshop (November 14, 2012) 43
- 44. Enabling Healthy Behaviors FamilyPathways Atlanta Transformation Coordinated Care Global Payment Capture and Reinvest Expand Insurance Innovation Fund
- 45. Atlanta Regional Collaborativefor Health Improvement. ARCHI Playbook; 2013 Draft May. Available at http://www.archicollaborative.org/archi_playbook.pdf
- 46.
- 47. Challenge: Fragmented, short-terminvestments—prone to reform and rebound—are unable to alter trends in health system performance - Workforce Productivity - Temporary Investment Fund + Disadvantage + Illness Prevalence and Severity + Utilization of Care + Health Care Costs Funds Available for Investment 47
- 48. Challenge: Fragmented, short-terminvestments—prone to reform and rebound—are unable to alter trends in health system performance - Workforce Productivity - Temporary Investment Fund + Disadvantage - Illness + Prevalence - and Severity - + Utilization of Care + Funds Available for Investment + Health Care Costs - B1 Create Pathways to Advantage + Enable Healthier Behaviors + Improve Routine Care + Coordinate Care + Intervention Initially Reduces Funds Program Investments + + Intervention Decisions + Pay for Value Not Volume (CGP) 48
- 49. Challenge: Fragmented, short-terminvestments—prone to reform and rebound—are unable to alter trends in health system performance - Workforce Productivity - Temporary Investment Fund Cost Benchmarks + + Disadvantage - Illness + Prevalence - and Severity - + Utilization of Care + + Health Care Costs - - Savings to Reinvest + Funds Available for Investment B1 Create Pathways to Advantage + Enable Healthier Behaviors + Improve Routine Care + Coordinate Care + Intervention Initially Reduces Funds Program Investments + + Intervention Decisions + Pay for Value Not Volume (CGP) 49
- 50. Challenge: Fragmented, short-terminvestments—prone to reform and rebound—are unable to alter trends in health system performance - Workforce Productivity - Temporary Investment Fund Cost Benchmarks + + Disadvantage R4 Equity Reduces Vulnerability Create Pathways to Advantage + Illness + Prevalence - and Severity R3 Healthier Behavior Reduces Illness Routine Care Reduces Illness Enable Healthier Behaviors + + Utilization + Health Care of Care Costs + B2 R2 Routine Care Increases Visits & Meds Improve Routine Care + - Savings to Reinvest + Funds Available for Investment - R1 Cutting Waste Lowers Cost Coordinate Care + B1 Intervention Initially Reduces Funds Program Investments + + Intervention Decisions + Pay for Value Not Volume (CGP) 50
- 51. Established and EmergingFinancing Options Challenge: Few innovators appreciate the variety and potential stakes involved when deciding among financing options • Government grants/agreements • Investment portfolio re-allocation • Foundation grants • Operating budget re-allocation • Hospital Community Benefit • Co-op insurance plans • Social Impact Bonds (Pay for Success) • • Population Health Trusts • Insurance alignment and investment, particularly self-insured employers and Medicaid support for community prevention and non-clinicians Tax Credits and Incentives • • Business investment in worksites and region Community Development Financing • • Accountable Care Organizations Venture capital investment to open and establish new markets • Accountable Care Communities • Prizes (X-Prize) • Collective Impact Organizing • Others, as appropriate • Health Care Payment Reform (Getting to Global Payment)
- 52. Challenge: Few regionshave sturdy multi-stakeholder teams to negotiate agreements and serve as stewards of their common health system Ostrom E. Beyond Markets and States: Polycentric Governance of Complex Economic Systems. The Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel; Stockholm; 2009 December 8. Available at http://www.nobelprize.org/nobel_prizes/economic-sciences/laureates/2009/ostrom-lecture.html McGinnis MD. Caring for the Health Commons: What it is and Who's Responsible for it: Social Science Research Network; 2013 February 20. Available at http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2221413 52
- 53. Ostrom’s Design Principles 1. Clearlydefined boundaries 2. Rules adapted to local conditions 3. Collective-choice arrangements that allow participation in the decision-making process 4. Effective monitoring by those related to the monitored 5. Graduated sanctions for violating community rules 6. Mechanisms of conflict resolution that are cheap and easy 7. Self-determination recognized by higher-level authorities 8. Organization in multiple layers of nested enterprises Ostrom E. Governing the commons: the evolution of institutions for collective action. New York, NY: Cambridge University Press; 1990. Ostrom E. Beyond Markets and States: Polycentric Governance of Complex Economic Systems. The Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel; Stockholm; 2009 December 8. Available at http://www.nobelprize.org/nobel_prizes/economic-sciences/laureates/2009/ostrom-lecture.html 53
- 54. Three Central Challenges • Fragmented,short-term investments—prone to reform and rebound—are unable to alter trends in health system performance • Few innovators appreciate the variety and potential stakes involved when deciding among financing options • Few regions have multi-stakeholder teams to negotiate agreements and serve as stewards of their common health system 54
- 55. Learn with leadersin context • How are innovators devising new ways to pay for and sustain necessary investments? • Who decides? Two-phase, exploratory project • Refine framing and narrative • Characterize conditions, opportunities, and obstacles in different contexts • Develop tools and guides for groups at different stages of readiness, with insights from other countries and sectors • Craft hypotheses for directed tests • Expand a learning network 55
- 56. More Money forShorter Lives Four Promising Shifts… Nation to Nested Sectors to System Goals to Pathways Scarcity to Abundance 56
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