Bridging Hospitals and Community Health: Community Benefit and Health Reform

1. Bridging Hospitals and Community Health:Community Benefit and Health Reform • 2010 NNPHI Conference • Navigating Emerging Opportunities • June 8, 2010 • Kevin Barnett, Dr.P.H., M.C.P. • Senior Investigator • Public Health Institute

2. Outline • Evolution of CB practices and policies • Health reform – Emerging opportunities • The case for hospital – public health collaboration • A sampling of exemplary practices

3. 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

4. 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

5. 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

6. Community Benefit and Health Reform Primary Prevention Community Problem Solving Community-Based Preventive Services Clinical Service Delivery PAYMENT MODELS Fee for Service Episode-Based Partial---Full Risk Global Budgeting Reimbursement Capitation INCENTIVES Conduct Evidence-Based Expanded Care Reduce Obstacles to Procedures Medicine Management Behavior Change Fill Beds Clinical PFP Risk-adjusted PFP Address Root Causes METRICS Net Revenue Improved Reduced Preventable Aggregate Improvement Clinical Outcomes Hospitalizations/ED in HS and QOL Reduced Readmits Reduced Disparities Reduced HC Costs

7. Opportunities for Hospital – PH Collaboration PH 10 Essential Functions Hospital Community Benefit 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.

8. Opportunities for Hospital – PH Collaboration PH 10 Essential Functions Hospital Community Benefit 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. Evaluateeffectiveness, 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

9. 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

10. A Sampling of Exemplary Practices

11. 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

12. 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

13. 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.

14. 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

15. 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

16. 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

17. 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

18. 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, carecoordination

19. Contact Information • Kevin Barnett, Dr.P.H., M.C.P. Public Health Institute 555 12th Street, 10th Floor Oakland, CA 94607 Tel: 925-939-3417 Mobile: 510-917-0820 Email: kevinpb@pacbell.net • ASACB standards, tools, and model programs available on website @ www.asacb.org

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

21. What: Kaiser Permanente’s Community Benefit Strategy Health Access Make a Measurable Impacton Health • Medicaid and CHIP • Charitable Care and Coverage • Safety Net Partnerships Fulfill Our Charitable Mission Healthy Environments Be the Model for Community Benefit in the Field Eliminate Health Disparities • Community Health Initiatives • Environmental Stewardship • Educational Theater Program Build a Performance Culture to Ensure Operational Excellence Health Knowledge • Research • Workforce Development • Public Education • U.S. and International Policy Embed Community Benefit as a Core Principle of Kaiser Permanente

22. Why: Behavior and Environment Drive Health

23. Obesity and Park Access Why: Place and Race Shape Health Source: KP Utility for Care Data Analysis, 2009

24. County Health Rankings Model Why: Environment and Behavior Shape Health

25. Safety net partners PHIs Community Coalitions State and local health departments How: Working in Partnership Our Community Work Our National Work

26. 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

27. The Opportunity: Going Upstream • Community-based prevention • Environmental Stewardship • Policy change as a tool • Becoming Accountable Organizations