The Practical Playbook National Meeting 2016 www.practicalplaybook.org Bringing Public Health and Primary Care Together: The Practical Playbook National Meeting was at the Hyatt Regency in Bethesda, MD, May 22 - 24, 2016. The meeting was a milestone event towards advancing robust collaborations that improve population health. Key stakeholders from across sectors – representing professional associations, community organizations, government agencies and academic institutions – and across the country came together at the National Meeting to help catalyze a national movement, accelerate collaborations by fostering skill development, and connect with like-minded individuals and organizations to facilitate the exchange of ideas to drive population health improvement. The National Meeting was also a significant source of tools and resources to advance collaboration. These tools and resources are available below and include: Session presentations and materials Poster session content Photos from the National Meeting The conversation started at the National Meeting is continuing in a LinkedIn Group "Working Together for Population Health" and Twitter. Use #PPBMeeting to provide feedback on the National Meeting. The Practical Playbook was developed by the de Beaumont Foundation, the Duke University School of Medicine Department of Community and Family Medicine, the Centers for Disease Control and Prevention (CDC), and the Health Resources & Services Administration (HRSA).

1. Sustaining Population Health Outcomes
William J. Kassler, MD, MPH
Practical Playbook Meeting
May 2016

2. U.S Health in International Perspective
• US spends far more per person on health care
• Shorter life span, Poorer health
• Consistent and pervasive over entire life:
Infant mortality & low birth weight
Injuries & homicides
HIV/AIDS
Drug-related deaths
Obesity & diabetes
Heart disease
Chronic lung disease
Disability

3. Factors that Determine Health
Adapted from Kindig JAMA 2008; 299(17): 2081-2083.

4. Number of Deaths from Behavioral Causes
Source: Mokdad et al JAMA 2004

5. Impact Of Obesity On Medical Spending:
1987 – 2001
• Obesity increased by 10% in population
• Spending for obese was 37% higher
than for non-obese
• Rate of growth in spending higher for
obese:
63% ↑ obese vs. 37% ↑ non-obese
• Obesity accounted for 27% of growth in
spending
Thorpe et al Health Affairs, no. (2004):10.1377

6. Socio-economics factors linked to poor
health outcomes
• Area Deprivation Index (ADI)
– Neighborhood-based composite measure
consisting of 17 markers of socioeconomic status
• ADI correlated with:
– Mortality rates (age and race adjusted) for men
and women
– 30 day readmission rates
• increase with worsening ADI
• Magnitude equal to COPD and > diabetes
Sources:
Singh, GK Area deprivation and widening inequalities in US mortality, 1969-1998. Am J Public Health July 2003
Kind, AJ et al Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study Ann Intern Med Dec 2014

7. Health vs Social Services Expenditures

8. Determinants
SOCIAL,
ENVIRONMENTAL,
and BEHAVIORAL
FACTORS
(60%)
GENETICS
(20%)
HEALTH CARE
(20%)
8
HEALTH CARE
SPENDING
(65%)
SOCIAL SERVICE
SPENDING
(35%)
Investment
Mismatch
Courtesy of Elizabeth Bradley

9. Investing in Social Services

10. How?
Population Management
vs
Total Population Health

11. Reconciling the clinical perspective with a
broader community perspective
Community:
Public Health,
Social Services
sectors
Health Systems:
Hospitals, ACOs,
Health Plans
Clinical Practices:
Primary Care
Medical Homes,
Specialty Care
Subgroups of
Patients:
Panels,
Racial/Ethnic
groups, patients
with specific
chronic diseases
Based on Kassler et al. N Engl J Med 372; 2015

12. Clinical Practices
• Population-based approaches:
– considering what happens between visits
– using registries and tools to improve preventive care
– addressing health disparities by including social, economic,
and cultural factors
– referring patients to a wider range of community services
• Supportive strategies:
– Medical homes and care management payments
– Linking practices and patients to community supports
– Practice support (Transforming Clinical Practice Initiative)
– Community Health Workers - translation, appointment
scheduling, referrals, and transportation

13. Delivery Systems
• Population-based approaches:
– Assessing community health needs
– Investing community benefit dollars
– Collaborating with other organizations to support
nonmedical services delivered in community
settings
• Supportive Strategies:
– Performance based alternative payment models
(e.g. ACOs) incentivize investments

14. Health Plans
• Medicaid and Medicare contracts afford
greater flexibility than FFS to pay for
population services
• Some MCOs cover bicycle helmets, car seats,
participation in the YMCA’s Diabetes
Prevention Program or March of Dimes Baby
and Me Tobacco Free program

15. Medicaid Managed Care
Positively Impacting Social Determinants of
Health: How Safety Net Health Plans Lead
the Way June 2014
Leveraging Medicaid contracts through sponsorships,
grants, and partnerships to invest in:
• Housing support,
• Employment initiatives,
• Literacy programs,
• Services for overcoming food insecurity.

16. Communities / States
• Medicaid
– Historically covers many non-medical support services
– Waivers & Demos provide additional opportunities to invest in
upstream strategies (Vermont waiver)
• State Innovation Models
– Use multiple levers for health systems transformation
– Population health plans
• Accountable Health Communities

17. Accountable Health Communities Model
Intervention Approaches
• Track 1: Awareness – Increase beneficiary awareness of available community
services through information dissemination and referral
• Track 2: Assistance – Provide community service navigation services to assist high-
risk beneficiaries with accessing services
• Track 3: Alignment – Encourage partner alignment to ensure
that community services are available and responsive to the needs
of beneficiaries

18. Looking ahead: MACRA
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
is a bipartisan legislation signed into law on April 16, 2015.
• Repeals the Sustainable Growth Rate (SGR) Formula
• Changes the way that Medicare rewards clinicians for value
over volume
• Streamlines multiple quality programs under the new Merit-
Based Incentive Payments System (MIPS)
• Provides bonus payments for participation in eligible
alternative payment models (APMs)

19. CMS has adopted a framework that
categorizes payments to providers
Payments are
based on
volume of
services and
not linked to
quality or
efficiency
Category 1:
Fee for Service
– No Link to
Value
Category 2:
Fee for Service
– Link to
Quality
Category 3:
Alternative Payment Models -
- Built on Fee-for-Service
Architecture
Category 4:
Population-Based
Payment
At least a
portion of
payments vary
based on the
quality or
efficiency of
health care
delivery
Some payment is linked to
the effective management
of a population or an
episode of care
Payments still triggered by
delivery of services, but
opportunities for shared
savings or 2-sided risk
Payment is not directly
triggered by service
delivery so volume is
not linked to payment
Clinicians and
organizations are paid
and responsible for the
care of a beneficiary for
a long period (e.g., ≥1
year)
Source: Rajkumar R, Conway PH, Tavenner M. CMS ─ engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.

20. Lessons Learned: ACOs
• Demographics vary …
– Urban/rural, large/small, HIT, populations served
• ... But culture similar
– Focus on value & population perspective before
started ACO
– Emphasis on strengthening primary care
(e.g. built on integrated medical home)
– History of coordination across sites of care
(e.g. leveraged pre-existing relationships/focus on transitions)
– Strong clinician leadership / engagement
– Familiarity with data

21. Strategies for Sustainability
• Embed population health
– Value-based payments (MIPS metrics and
incentives)
– Advanced APMs
• Support infrastructure development
• Partnership, collaboration and alignment
across sectors
• Lessons learned from model testing

22. Hospitals’ Role in Population Health:
• To retain tax exempt status, non-profit hospitals must:
– Conduct “community health needs assessment” every 3 yrs
– Adopt implementation strategy to meet the community health needs
identified through the assessment
• Community Building. IRS-approved activities:
– Leadership development / training for community
– Community health improvement advocacy
– Physical improvements and housing
– Coalition building
– Economic development
– Community support
– Environmental improvement
– Workforce development

23. Next generation models?
• Incentives for cross-sector collaboration
– CHNA, Community Building
• Risk adjusted payments for poverty
• Community incentive payments (e.g. tobacco)
• Social Impact Bonds

24. Challenges
• Fiduciary constraints on payers
– Funding non-medical services & upstream approaches
– Funding services for non-beneficiaries
• Scale-up from testing to implementation
– Time horizon and actuarial standards
• Provider scope of practice and accountability
• Measurement and data infrastrucure

25. Policy – Related Research Priorities
• Paucity of effectiveness data on psychosocial
interventions
– associated culture of resistance to evaluation
• Behavioral economics
• Emerging role for local public health agencies
• Practice infrastructure to manage populations
• Measurement
• Health disparities
• Collaboration and consolidation

26. Thank you