The challenge facing the nation, and the opportunity afforded by the Affordable Care Act (ACA), is to move from a culture of sickness to a culture of care and then to a culture of health, said Stephen Shortell, the Blue Cross of California Professor of Health Policy and Management and Dean Emeritus of the School of Public Health at the University of California, Berkeley, in a keynote presentation to the workshop audience. In the United States, he said, that means creating a market for health. “We have a market for disease and a market for care, but I would argue that we do not yet have a market for health,” he said. Creating such a market “involves changing fundamentally what we pay and how we pay for it. If we start paying for health and wellness, then we will create markets for health and wellness, and providers and others in the community will develop capabilities to respond to those new incentives. I think that is at the heart of our challenge.”
A key to making that change, said Shortell, is to pay for technology-enabled, team-based systems of care to keep people well. Making this change calls on the health care enterprise to engage people, not just patients, and it also calls for a community-wide population focus that extends beyond individual accountable care organizations (ACOs) or integrated delivery systems. He added that changing the payment system to one based on risk-based global budgets will unleash great opportunities for innovation that will be aimed at keeping people from becoming patients in the first place, and if they do become patients, helping them recover their health as quickly as possible.
Shortell briefly reviewed some of the provisions of the ACA concerning workforce issues and prevention and public health efforts, and suggested that the roundtable might undertake an effort to track how the nation is progressing on enacting those provisions. He then discussed the concept of communities and how that concept can be incorporated into a population-based health continuum that has the goal of creating what he called a chronically well population while reducing the number of chronically ill individuals, who currently account for 75 percent of U.S. health care expenditures. A community, he said, is a group of individuals with a sense of shared space, shared responsibilities, and perceived interdependence. Creating a community health care management system, he explained, requires assessing the health needs of that community; identifying the community assets, capabilities, and resources that may be necessary to meet the needs identified; and then aligning service providers, managers, and governance within and across medical, health, and community sectors. Information systems, he added, provide the data and feedback to measure progress and refine the system. A lasting system will only result when the necessary strategic, structural, cultural, and technical components are all in place (Shortell et al., 2000).
Changing the health care delivery system will be critical for creating a health care system that produces a chronically well population, stated Shortell. The process of achieving change must start with redefining “the product” from illness to wellness, from patients to healthy people. The business model needs to change from filling hospital beds to keeping them empty. The delivery system also needs to move from the hospital, clinic, and doctor’s office to the home, workplace, and school, and the definition of providers needs to be extended beyond health care professions to include teachers, social workers, architects, urban planners, and community development specialists.
Medical homes implementing primary care interventions represent one development providing early evidence that changes in the delivery system can have a significant impact on creating a healthy population rather than treating a sick one. To make that point, Shortell provided a few examples. Group Health Cooperative of Puget Sound, for instance, has reduced emergency department visits by 29 percent and ambulatory sensitive admissions by 11 percent, while the Geisinger Health Systems in Pennsylvania has achieved a 7 percent reduction in medical costs. The chronic care demonstration project at the Massachusetts General Hospital reduced hospital and emergency department visits by 20 percent, produced a decline in mortality, and netted a 4.7 percent annual savings.
Shortell also outlined changes that must occur in the public health sector. Greater flexibility is needed in the use of funds, he said, and public health must create new partnerships with delivery systems that better
target those most in need of preventive services. Public health and health care providers must also develop joint goals with metrics to measure progress and share infrastructure that can help sustain the workforce. In addition, the community development and social service sectors need to include health in all of its policies, including those pertaining to zoning, housing, transportation, labor, and education. When population health becomes something that everyone thinks about, it can help other sectors of the community become more effective at achieving their strategic goals. Shortell acknowledged that making these types of systemic changes is difficult, but there are many examples, including those being discussed at this workshop, demonstrating that hard work does produce results.
He then made what he called a bold proposal—that the Centers for Medicare & Medicaid Services and other payers create a risk-adjusted, population-wide health budget to be overseen by a community-wide entity tied to multiyear performance targets. Examples of performance targets might include
• reduction in newly diagnosed diabetics,
• reduced infant mortality,
• reduced preterm births,
• reduced obesity rates in children and adults,
• lower blood pressure for patients with congestive heart failure,
• reduced disability and work days lost due to illness, and
• greater functional health status scores among samples of the population.
This is not a “pie-in-the-sky” proposal, he said, noting that California is working toward this end. Shortell described some survey data showing that several payment reform ideas have significant support among various organizations in the state. For example, two-thirds of the organizations reported they are attempting to link patient care with private or public community efforts to improve population health. The key challenge, he said in closing, will be in building the needed partnerships based on shared goals, shared information, innovations in the use of human resources, and cross-sector, cross-boundary leadership.
During the brief discussion period that followed Shortell’s presentation, Mary Pittman, President and Chief Executive Officer of the Public Health Institute and a member of the roundtable, noted that the Centers for Disease Control and Prevention has established the National Leadership Academy for the Public’s Health to enable multisector jurisdic-
tional teams to address public health problems within their communities through team-identified community health improvement projects. She then asked Shortell why he believes that leadership across sectors is so important. He replied that inertia is a major obstacle to progress. “Individuals have to pay attention to the needs of their own organizations before they spend additional time working on these community-wide efforts,” he said, “so executives need incentives to include engagement in community-wide efforts as part of their job.” He added that the depth of leadership needs to be increased so that community leaders can come from the ranks of an organization, not just its executive suite.
David Stevens of the National Association of Community Health Centers asked where the political will would come from to turn the bold proposal into reality. Shortell said it will need to come from the state and local levels. In California, the Secretary of Health and Human Services has taken the lead. Leaders in the private sector, including the chief executives of the state’s large insurance companies and integrated health care organizations, have joined in the effort. Called the Berkeley Forum, this collaborative effort generated a report that calls for a transition to global budgets as quickly as possible (Berkeley Forum, 2013). He added that it is important to tell politicians and interest groups that money going into the health sector is not available to spend on other priorities.