POPULATION HEALTH
IMPLICATIONS of the
AFFORDABLE CARE ACT

WORKSHOP SUMMARY

Joe Alper, Rapporteur

Roundtable on Population Health Improvement

Board on Population Health and Public Health Practice

INSTITUTE OF MEDICINE
              OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

www.nap.edu



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Joe Alper, Rapporteur Roundtable on Population Health Improvement Board on Population Health and Public Health Practice

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THE NATIONAL ACADEMIES PRESS   500 Fifth Street, NW   Washington, DC 20001 NOTICE: The workshop that is the subject of this workshop summary was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This activity was supported by contracts between the National Academy of Sci- ences and The California Endowment (20112338), the California HealthCare Foun- dation (17102), HealthPartners, Health Resources and Services Administration (HHSH25034015T), Kaiser East Bay Community Foundation (20131471), Kresge Foundation (101288), the Mayo Clinic, Missouri Foundation for Health (12-0879- SOF-12), the National Association of County and City Health Officials (2013- 010204), Nemours, New York State Health Foundation (12-01708), Novo Nordisk, and the Robert Wood Johnson Foundation (70555). The views presented in this publication do not necessarily reflect the views of the organizations or agencies that provided support for the activity. International Standard Book Number-13:  978-0-309-29434-8 International Standard Book Number-10:  0-309-29434-7 Additional copies of this workshop summary are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2014 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2014. Population health implica- tions of the Affordable Care Act: Workshop summary. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the ­ cademy has a mandate that requires it to advise the federal govern- A ment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the char- ter of the National Academy of Sciences, as a parallel organization of outstand- ing engineers. It is autonomous in its administration and in the selection of its m ­ embers, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in pro- viding services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PLANNING COMMITTEE ON POPULATION HEALTH IMPLICATIONS OF THE AFFORDABLE CARE ACT1 GEORGE R. FLORES (Co-Chair), Program Manager, The California Endowment DAVID KINDIG (Co-Chair), Professor Emeritus, University of Wisconsin School of Medicine and Public Health DEBBIE I. CHANG, Vice President, Policy and Prevention, Nemours DAVE CHOKSHI, White House Fellow, Department of Veterans Affairs JEFFREY LEVI, Executive Director, Trust for America’s Health, and Assistant Professor, Department of Health Policy, George Washington University JUDITH A. MONROE, Director, Office for State, Tribal, Local and Territorial Support, Centers for Disease Control and Prevention KAVITA PATEL, Fellow and Managing Director, Engelberg Center for Health Care Reform, The Brookings Institute ANDREW S. REIN, Associate Director for Policy, Centers for Disease Control and Prevention Consultant JOE ALPER, Consulting Writer IOM Staff ALINA B. BACIU, Study Director COLIN F. FINK, Senior Program Assistant LYLA HERNANDEZ, Senior Program Officer ANDREW LEMERISE, Research Associate CAROL MASON SPICER, Associate Program Officer ROSE MARIE MARTINEZ, Director, Board on Population Health and Public Health Practice 1 Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteur and the institution. v

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ROUNDTABLE ON POPULATION HEALTH IMPROVEMENT1 GEORGE ISHAM (Co-Chair), Senior Advisor, HealthPartners, and Senior Fellow, HealthPartners Institute for Education and Research DAVID KINDIG (Co-Chair), Professor Emeritus, University of Wisconsin School of Medicine and Public Health TERRY ALLAN, President, National Association of County and City Health Officials, and Health Commissioner, Cuyahoga County (Ohio) Board of Health CATHERINE BAASE, Chief Health Officer, The Dow Chemical Company RAYMOND J. BAXTER, Senior Vice President, Community Benefit, Research and Health Policy, Kaiser Permanente, and President, Kaiser Foundation International DEBBIE I. CHANG, Vice President, Policy and Prevention, Nemours GEORGE R. FLORES, Program Manager, The California Endowment MARY LOU GOEKE, Executive Director, United Way of Santa Cruz County, California MARTHE R. GOLD, Visiting Scholar, New York Academy of Medicine, and Professor, Sophie Davis School of Biomedical Education, City College of New York PEGGY A. HONORÉ, Director, Public Health System, Finance and Quality Program, Office of the Assistant Secretary for Health, Department of Health and Human Services ROBERT HUGHES, President and Chief Executive Officer, Missouri Foundation for Health ROBERT M. KAPLAN, Director, Office of Behavioral and Social Sciences Research, National Institutes of Health JAMES KNICKMAN, President and Chief Executive Officer, New York State Health Foundation PAULA LANTZ, Professor and Chair, Department of Health Policy, The George Washington University School of Public Health and Health Services MICHELLE LARKIN, Assistant Vice President, Health Group, Robert Wood Johnson Foundation THOMAS A. LaVEIST, Professor and Director, Hopkins for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health JEFFREY LEVI, Executive Director, Trust for America’s Health 1Institute of Medicine forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the work- shop rapporteur and the institution. vii

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SARAH R. LINDE, Rear Admiral, U.S. Public Health Service, Chief Public Health Officer, Health Resources and Services Administration SANNE MAGNAN, President and CEO, Institute for Clinical Systems Improvement PHYLLIS D. MEADOWS, Senior Fellow, Health Program, Kresge Foundation, and Associate Dean for Practice, Office of Public Health Practice, School of Public Health, University of Michigan JUDITH A. MONROE, Director, Office for State, Tribal, Local and Territorial Support, Centers for Disease Control and Prevention JOSÉ MONTERO, President, Association of State and Territorial Health Officials, and Director, New Hampshire Division of Public Health Services MARY PITTMAN, President and Chief Executive Officer, Public Health Institute PAMELA RUSSO, Senior Program Officer, Robert Wood Johnson Foundation LILA J. FINNEY RUTTEN, Associate Scientific Director, Population Health Science Program, Department of Health Sciences Research, Mayo Clinic BRIAN SAKURADA, Senior Director, Managed Markets and Integrated Health Systems, Novo Nordisk MARTIN JOSÉ SEPÚLVEDA, IBM Fellow and Vice President, Health Systems Policy Research, IBM Corporation ANDREW WEBBER, Chief Executive Officer, Maine Health Management Coalition IOM Staff ALINA B. BACIU, Study Director COLIN F. FINK, Senior Program Assistant LYLA HERNANDEZ, Senior Program Officer ANDREW LEMERISE, Research Associate CAROL MASON SPICER, Associate Program Officer ROSE MARIE MARTINEZ, Director, Board on Population Health and Public Health Practice viii

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Reviewers T his workshop summary has been reviewed in draft form by individ- uals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the insti- tution in making its published workshop summary as sound as possible and to ensure that the workshop summary meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this workshop summary: Georges Benjamin, American Public Health Association Lawrence Deyton, George Washington University David Kindig, University of Wisconsin–Madison Kate Papa, AcademyHealth Although the reviewers listed above have provided many construc- tive comments and suggestions, they did not see the final draft of the workshop summary before its release. The review of this workshop sum- mary was overseen by Susan J. Curry, University of Iowa. Appointed by the Institute of Medicine, she was responsible for making certain that an independent examination of this workshop summary was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this workshop summary rests entirely with the rapporteur and the institution. ix

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Contents ACRONYMS xiii 1 INTRODUCTION 1 2 OVERVIEW 5 3 CURRENT MODELS FOR INTEGRATING A POPULATION HEALTH APPROACH INTO IMPLEMENTATION OF THE AFFORDABLE CARE ACT 9 A Nonprofit Model of Integration, 10 All-Payer Hospital Payment Reform, 12 State-Wide Health System Transformation, 14 The Community Health Center Perspective, 16 Discussion, 18 4  PROPOSAL TO BRIDGE THE DIVIDE BETWEEN A HEALTH AND HEALTH CARE 21 Discussion, 23 5 CATALYZING AND SUSTAINING THE ADOPTION AND INTEGRATION OF A POPULATION HEALTH CONCEPT 25 Perspectives from an Integrated Child Health System, 26 The Role of Grassroots Leaders in Improving Community Health, 28 xi

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xii CONTENTS Creating a Funding Stream to Reward Improvements in Population Health, 29 Building Better Health at the County Level, 31 The Massachusetts Experience with Innovations in Integrating Population Health, 34 Moving Hospitals Toward Population Health, 36 Discussion, 37 6 FINAL THOUGHTS 41 APPENDIXES A References 45 B Biographies of Speakers 47 C Workshop Agenda 55

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Acronyms ABIA Austen BioInnovation Institute in Akron ACA Affordable Care Act ACC accountable care community ACO accountable care organization CCO coordinated care organization CCROPP Central California Regional Obesity Program CDC Centers for Disease Control and Prevention CHA Catholic Health Association CHNA community health needs assessment CHW community health worker CMS Centers for Medicare & Medicaid Services CPPW Communities Putting Prevention to Work EHR electronic health record HHSA Health and Human Services Agency IOM Institute of Medicine IRS Internal Revenue Service NACCHO National Association of County and City Health Officials xiii

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xiv ACRONYMS ONC Office of the National Coordinator for Health Information Technology SCHIP State Children’s Health Insurance Program TCE The California Endowment