FINANCING
POPULATION HEALTH
IMPROVEMENT

WORKSHOP SUMMARY

Joe Alper and Alina Baciu, Rapporteurs

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.

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FINANCING POPULATION HEALTH IMPROVEMENT WORKSHOP SUMMARY Joe Alper and Alina Baciu, Rapporteurs 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 Contract/Grant No. 245367 between the National Academy of Sciences and The Kresge Foundation. 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:  978-0-309-30746-8 International Standard Book Number-10:  0-309-30746-5 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 2015 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. Cover credit: “Invest in Me” image used with permission of Joeff Davis, photographer. Suggested citation: IOM (Institute of Medicine). 2015. Financing population health improvement: 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 Academy has a mandate that requires it to advise the federal govern- 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 charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its mem- bers, sharing with the National Academy of Sciences the responsibility for advis- ing 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. Victor J. Dzau 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 RESOURCES FOR POPULATION HEALTH IMPROVEMENT1 TERRY ALLAN (Co-Chair), President, National Association of County and City Health Officials; Health Commissioner, Cuyahoga County Public Health GEORGE ISHAM (Co-Chair), Senior Advisor, HealthPartners; Senior Fellow, HealthPartners Institute for Education and Research DEBBIE I. CHANG, Vice President, Policy and Prevention, Nemours MARY LOU GOEKE, Executive Director, United Way of Santa Cruz County JIM HESTER, Consultant, Former Director, Health Care Reform Commissioner for the Vermont State Legislature PEGGY HONORÉ, Director, Public Health System, Finance and Quality Programs, Department of Health and Human Services JEFFREY LEVI, Executive Director, Trust for America’s Health GLEN P. MAYS, F. Douglas Scutchfield Endowed Professor of Health Services and Systems, University of Kentucky JOSÉ MONTERO, Director, New Hampshire Division of Public Health Services ANDREW WEBBER, Chief Executive Officer, Maine Health Management Coalition IOM Staff ALINA BACIU, Senior Program Officer COLIN FINK, Senior Program Assistant AMY GELLER, Senior Program Officer LYLA HERNANDEZ, Senior Program Officer ANDREW LEMERISE, Research Associate CAROL MASON SPICER, Associate Program Officer (until March 2014) DARLA THOMPSON, Associate Program Officer (from May 2014) ROSE MARIE MARTINEZ, Director, Board on Population Health and Public Health Practice Consultant JOE ALPER, Consulting Writer 1Instituteof 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 rapporteurs and the institution. v

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ROUNDTABLE ON POPULATION HEALTH IMPROVEMENT1 GEORGE ISHAM (Co-Chair), Senior Advisor, HealthPartners, Inc.; 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; Health Commissioner, Cuyahoga County Board of Health CATHERINE BAASE, Chief Health Officer, Dow Chemical Company GILLIAN BARCLAY, Vice President, Aetna Foundation RAYMOND J. BAXTER, Senior Vice President, Community Benefit, Research and Health Policy; President, Kaiser Foundation International, Kaiser Foundation Health Plan, Inc. DEBBIE I. CHANG, Vice President, Office of Policy and Prevention, Nemours GEORGE R. FLORES, Program Manager, The California Endowment MARY LOU GOEKE, Executive Director, United Way of Santa Cruz County MARTHE R. GOLD, Professor, Sophie Davis School of Biomedical Education, City College of New York GARTH GRAHAM, President, Aetna Foundation PEGGY A. HONORÉ, Director, Public Health System, Finance and Quality Program, Office of the Assistant Secretary for Health, U.S. 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, George Washington 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 Center for Health Disparities Solutions, Johns Hopkins University 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 rapporteurs 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 Chief Executive Officer, Institute for Clinical Systems Improvement PHYLLIS W. MEADOWS, Associate Dean for Practice, Office of Public Health Practice, School of Public Health, University of Michigan; Senior Fellow, Health Program, The Kresge Foundation 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; 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 MARTIN JOSÉ SEPÚLVEDA, Fellow and Vice President, Health Research, IBM Corporation ANDREW WEBBER, Chief Executive Officer, Maine Health Management Coalition IOM Staff ALINA BACIU, Senior Program Officer COLIN FINK, Senior Program Assistant AMY GELLER, Senior Program Officer LYLA HERNANDEZ, Senior Program Officer ANDREW LEMERISE, Research Associate CAROL MASON SPICER, Associate Program Officer (until March 2014) DARLA THOMPSON, Associate Program Officer (from May 2014) 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: Janet Corrigan, The Dartmouth Institute for Health Policy and Clinical Practice Robert Hughes, Missouri Foundation for Health Glen Mays, University of Kentucky Paul Stange, Independent Consultant 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 George C. Benjamin, American Public Health ix

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x REVIEWERS Association. Appointed by the Institute of Medicine, he 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 rapporteurs and the institution.

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Contents ACRONYMS xiii 1 INTRODUCTION AND OVERVIEW 1 The Roundtable on Population Health Improvement, 2 Workshop Scope and Objectives, 3 Organization of the Summary, 4 2 PAYING FOR POPULATION HEALTH IMPROVEMENT: AN OVERVIEW 5 Discussion, 9 3  HEALTH CARE SYSTEM INVESTMENTS IN POPULATION HEALTH IMPROVEMENT 13 Opportunities, Challenges, and Priorities, 14 Health Care Systems as Partners in the Transformation of Community Health, 18 The Role of Affordable Housing in Population Health, 22 Discussion, 23 4 COMMUNITY DEVELOPMENT AND POPULATION HEALTH 25 History, Dimensions, and Opportunities, 26 Lesson from the Reinvestment Fund, 28 Community Development Strategies for Improving Population Health, 30 Discussion, 33 xi

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xii CONTENTS 5 PAY-FOR-SUCCESS FINANCING AND POPULATION HEALTH 35 Overview, 35 Social Impact Investment and Population Health, 38 Impact Investing for Better Health and Financial Outcomes, 39 Discussion, 41 6 IMPLICATIONS OF NEW AND EMERGING SOURCES OF POPULATION HEALTH FUNDING 45 Final Reflections and Comments, 48 APPENDIXES A REFERENCES 51 B WORKSHOP AGENDA 53 C BIOGRAPHICAL SKETCHES OF WORKSHOP SPEAKERS AND MODERATORS 57

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Acronyms ACA Affordable Care Act CDFI community development financial institution CMS Centers for Medicare & Medicaid Services EHR electronic health record HEPA high-efficiency particulate air HICCup Health Initiative Coordinating Council HUD U.S. Department of Housing and Urban Development IOM Institute of Medicine IRS Internal Revenue Service OECD Organisation of Economic Co-operation and Development TOD transit-oriented development TRF The Reinvestment Fund xiii

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