Population Health

1. Population Health Structural “Accountable” Care Approaches for Target Population Lecture c This material (Comp 21 Unit 3) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0005. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Structural “Accountable” Care Approaches for Target PopulationLearning Objectives — Lecture c • Summarize the current state of the business of population health, including the value statement, the sustainability of the population health management business, and the identity of key stakeholders.

3. The Competitive Challenge • “Today, we are spending over $2 trillion a year on health care — almost 50 percent more per person than the next most costly nation. And yet, as I think many of you are aware, for all of this spending, more of our citizens are uninsured, the quality of our care is often lower, and we aren’t any healthier. In fact, citizens in some countries that spend substantially less than we do are actually living longer than we do.” • President Barack Obama, Speech to the American Medical Association, June 15, 2009.

4. U.S. Spending More on Health Care • The U.S. spends more on health care as a percentage of GDP than any other developed country in the world. • In spite of these investments, Americans are obese, and millions suffer from preventable chronic diseases. • According to the Institute of Medicine, despite spending far more per person on health care than any other nation, the U.S. ranks 17th (for men) and 16th (for women) in terms of life expectancy among 17 high-income countries. 3.22 Figure. OECD. (2013). Institute of Medicine, 2013

5. Population Health from the Perspective of Employers — 1 • Many of the determinants of health are affected both positively and negatively by employers who contribute substantially to population health by creating jobs and family income, by setting employment polices, and by influencing health behaviors through worksite cultures, safety practices, and health care purchases. • Business leaders have incentives and compelling reasons to build cultures of health in the worksite and community. Business for Social Responsibility. (2013).

6. Population Health from the Perspective of Employers — 2 • Employers must develop strategies for workforce and community health if they wish to maximize employees as a competitive asset. • To date, most companies have focused on investments that seek to meet health care and safety expectations, from providing basic health care services to employees to reducing or mitigating the negative health impacts from company operations or product use. Business for Social Responsibility. (2013).

7. Business and Population Health • The nation’s largest companies face increasing pressure to improve health outcomes by promoting wellness and prevention — not only for their employees, but also for the broader population that is impacted by their corporate actions. • Stakeholders reflect a sphere of influence that extends well beyond a company’s care employee base: • Employees. • Government. • Community organizations. • Consumers. • Investors. Business for Social Responsibility. (2013).

8. Prevention and Population Health • Companies: asserting strong roles in improving population health through prevention and wellness. • Efforts address employees, customers, suppliers, local communities, and the general public. • Examples: • Walmart committed to providing greater access to affordable and nutritious food in areas composed of lower-income neighborhoods and communities. • Kaiser Permanente is partnering with Home Box Office to raise awareness about the obesity epidemic in the U.S. Business for Social Responsibility. (2013).

9. Incentives for Employers to Improve Population Health • Improve the health status, therefore productivity, of the employer’s workforce. • Control direct and indirect (absenteeism, disability, presenteeism) costs to employer. • Create both the image and the reality of a healthy community that may help recruitment and retention of workforce talent. • Increase buying power and consumption level for business products by improving the health of the community. • Strengthen employer’s brand recognition in the community. • Generate positive feelings of civic pride and responsibility and of being a constructive member of the community. • Create public and private partnerships and a multistakeholder community leadership team that can become the foundation for community-based collaboration and problem solving. Webber, A., & Mercure, S. (2010).

10. Employer-based Health Coalitions • Community-based health improvement strategies: • Emerging from employer-based coalitions during past three decades. • Purpose: to address rising health care costs through value-based purchasing (Partnership for Prevention). • Coalitions collectively represent employers and can provide more leverage on local health care delivery system than any single company. • Coalitions now applying that same philosophy to influence strategies for broader community health improvement.

11. Examples of Employer-based Health Coalitions • National Business Coalition of Health (NBCH): partnerships focus on cardiovascular health, diabetes, asthma, and depression as well as prevention and wellness. • Florida Health Care Coalition (FHCC): partnered with American Lung Association to bring asthma program, Open Airways, a school-based asthma risk assessment and health education program for children, to local schools.

12. The Business of Wellness and Population Health • 92 percent of employers with 200+ employees offered wellness programs. • Most frequently targeted behaviors: • Exercise (63 percent of employers offered). • Smoking (60 percent of employers offered). • Weight loss (53 percent of employers offered). • Participation rates low: <20 percent of eligible employees participate. • Program impact: • Summative review in the scientific literature provides evidence of positive impact on diet, exercise, smoking and alcohol use, physiologic markers, and health care costs. • Limited evidence for effects on absenteeism and mental health. Mattke, S. et al. (2012).

13. Uptake of Population Health Programs • Wellness programs have achieved a high penetration in the U.S. • ACA increases employer-based coverage and promotes wellness programs through numerous provisions: • $200 million dedicated to wellness program start-up grants for businesses with fewer than 100 employees. • Centers for Disease Control and Prevention (CDC) provides resources for evaluating employer wellness programs. • Department of Health and Human Services will award $10 million from ACA funds to develop and expand wellness activities, such as tobacco-free policies, flextime for physical activity, and health food choices in the workplace. • Raises the limit on rewards employers are allowed to offer for those participating in a wellness program. Mattke, S. et al. (2012).

14. Impact on Business — 1 • These challenges have a profound impact on business: • U.S. business community competes in a dynamic global economy. • U.S. has historically achieved success in global marketplace by excelling at traditional measures of business performance: innovation, technology application, production engineering, capital deployment, marketing, sales, distribution, and customer service. Webber, A., & Mercure, S. (2010).

15. Impact on Business — 2 • Increasingly, two factors put the U.S. business community at a competitive disadvantage: • Disease burden, such as obesity. • Increases in costs, such as health insurance for employers. • How well the U.S. business community responds to the related challenges of improving health and transforming health care becomes a key driver of market success and of America’s future competitiveness and economic security. Webber, A., & Mercure, S. (2010).

16. Population Health Programs: Evidence for Impact • Do the benefits of wellness programs justify the investment? • Promoting health and preventing disease unites the goals of improving population health and decreasing health care costs. • Whether wellness and prevention programs are cost-effective or not depends on such factors as the cost of the intervention, probability of disease onset in a population, the effectiveness of the intervention, and the cost of the manifest disease. • Some preventive measures may be cost saving, while others may be more expensive than high-tech medical care for the disease. • Employers satisfied with results of programs, though 50 percent do not know their programs’ return on investment (ROI). • Peer-reviewed literature for ROI is sparse, compared to the widespread uptake of wellness programs. Buck Consultants.(2010).

17. Who Delivers Population Health Programs? • Health insurers/carriers: • United HealthCare: Optum Health. • Health care delivery systems (hospitals, clinics). • Wellness companies: • Healthways, Corporate Wellness Solutions, WellAdvantage, hundreds of other for-profit companies. • Medical organizations (American Lung Association offers programs for asthma). • Public health agencies (Departments of Health, Aging, Disability, etc.).

18. State of the Wellness Market • Workplace wellness programs have achieved a high penetration. • 75% of employers with more than 50 employees now offer a program, which equals 100,000 organizations. • Uptake in smaller employers is reportedly much lower. • Uptake is expected to continue to increase as programs become more comprehensive and more accessible for smaller workplaces. • Employers are taking a long-term view on investments and returns. • The Affordable Care Act will help sustain the trend of increase in programs, as it is likely to increase employer-based coverage and employers’ interest in cost-saving measures. • Dynamic and innovative industry has outpaced its proof of concept. Mattke, S. et al. (2012).

19. Structural “Accountable” Care Approaches for Target PopulationSummary — Lecture c • Perspective of population health from the employers’ perspective. • Incentives for employers to improve population health. • Business of wellness and population health. • Impact on business.

20. Structural “Accountable” Care Approaches for Target PopulationUnit Summary — 1 • Accountable care movement,clinically integrated networks, models of care, and payment reform. • Population-based care management and the challenges of chronic care management, the role of social and community factors, and how health IT can be effective for improving population-based care management.

21. Structural “Accountable” Care Approaches for Target PopulationUnit Summary — 2 • The business of population health: the value proposition, sustainability, and key stakeholders of the business of population health.

22. Structural “Accountable” Care Approaches for Target PopulationReferences — Lecture c — 1 References Buck Consultants. (2010). Working well: A global survey of health promotion and workplace wellness strategies. San Francisco, CA: Buck Consultants. Business for Social Responsibility. (2013). A new CSR frontier: Business and population health: Mobilizing CSR to strengthen corporate engagement on health and wellness across the value chain. Retrieved April 16, 2016, from http://www.bsr.org/reports/BSR_A_New_CSR_Frontier_Business_and_Population_Health.pdf Institute of Medicine (2013). US Health in International Perspective: Shorter Lives, Poorer Health: Report Brief. National Academy of Sciences. Retrieved April 29, 2016 from http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2013/US-Health-International-Perspective/USHealth_Intl_PerspectiveRB.pdf Mattke, S., Schnyer, C., & Van Busum, K. R. (2012). A review of the U.S. workplace wellness market. Santa Monica, CA: RAND Corporation. Retrieved April 16, 2016, from U.S. Department of Labor Web page: http://www.dol.gov/ebsa/pdf/workplacewellnessmarketreview2012.pdf

23. Structural “Accountable” Care Approaches for Target PopulationReferences — Lecture c — 2 References Obama, B. (2009, June 15). Remarks by the President to the annual conference of the American Medical Association. Retrieved April 16, 2016, from the White House Office of the Press Secretary Web page: https://www.whitehouse.gov/the-press-office/remarks-president-annual-conference-american-medical-association OECD. (2013). Health at a glance 2013: OECD indicators. Paris, France: OECD Publishing. doi: 10.1787/health_glance-2013-en Webber, A., & Mercure, S. (2010). Improving population health: The business community imperative. Preventing Chronic Disease, 7(6), A121. Retrieved April 16, 2016, from Centers for Disease Control and Prevention Web page: http://www.cdc.gov/pcd/issues/2010/nov/10_0086.htm Woolf, S. H., & Aron, L. (Eds.). (2013). U.S. health in international perspective: Shorter lives, poorer health. Washington, DC: National Academies Press. Retrieved April 16, 2016, from http://www.nap.edu/catalog/13497/us-health-in-international-perspective-shorter-lives-poorer-health

24. Structural “Accountable” Care Approaches for Target PopulationReferences — Lecture c — 3 Charts, Tables, Figures 3.22 Figure: Health as percentage of GDP. Adapted from OECD. (2013). Health at a glance 2013: OECD indicators. Paris, France: OECD Publishing. doi: 10.1787/health_glance-2013-en

25. Population HealthStructural “Accountable” Care Approaches for Target PopulationLecture c This material (Comp 21 Unit 3) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0005.