Health Care Under Trump

Health Care Leaders: Bill or No Bill, We Still Have Work to Do

Article · October 18, 2017

Like many of you, we closely follow everything in the media about health care — especially over the past few months. Frankly, health care news has been hard to avoid. Headlines about the Affordable Care Act (ACA), insurance coverage, Medicaid, and contentious town meetings jump out from every corner of the Internet into our complex worlds as health care leaders around the country. We scoured the recent NEJM Catalyst Insights Report, Anticipating the Trump Administration’s Impact on Health Care, and found ourselves nodding in agreement at many of the charts and graphics. Analyses, opinions, commentaries — you name it, we read it. And as leaders, we’ve experienced it.

Like many of you, we are concerned about changes to the ACA. We’ve already made contingency plans for our organizations, met with employees, and created lots of what-if scenarios. We’ll be waiting anxiously to see which scenarios we’ll have to make realities. The American Health Care Act (AHCA) is more than a piece of legislation to us; its implications will have a significant impact on the health of our patients, our communities, and our organizations’ missions.

Like many of you, especially after the U.S. House of Representatives voted to approve the AHCA bill on May 4, we’ve turned our attention to one important question: Now what?

Bill or no bill, we still need to move forward and continue our focus on improving health and health care for our patients and our communities while reducing costs. Now is the time to double down on our work.

Far from the noise and bluster of Washington, D.C., we’re focusing our attention on serving real communities whose voices don’t easily break through in these contentious times. If we could get the microphone more often, we’d talk about a fundamental pact many health care leaders like us have made to achieve the Triple Aim.

The Triple Aim can be succinctly summarized as better health for populations, better care for patients, and lower costs of health care. It’s a simple yet powerful concept, and we use it as the measuring stick for our work in improving the quality and affordability of health and health care.

To create better health for populations, we invite you to consider three overriding goals:

  • Help preserve access to preventive care to enable healthy lives.
  • Work with health care exchanges and other private and public payers to deliver more affordable options to patients.
  • Partner with communities (at all levels) to find collective solutions that have the greatest impact on health and access to health care for all.

For example, a partnership between the Legal Aid Society of Greater Cincinnati and Cincinnati Children’s Hospital helped uncover housing violations in a certain neighborhood that were contributing to an increase in asthma among many young patients. The physicians and attorneys worked with families, the tenants’ association, the city’s health department, and the Cincinnati Child Health-Law Partnership (Child HeLP) to force an absentee developer to make major repairs in 19 apartment buildings, improving living conditions for the patients. The improvements included removing pests, fixing water damage, and providing adequate ventilation. One year later, cases of ED admission for asthma from that neighborhood had decreased.

Another example is the Roanoke Chowan Community Health Center (RCCHC), a Federally Qualified Health Center (FQHC) in rural North Carolina that serves a population where the average education level is high school/GED or lower. Leaders at the organization found educational level to be an important factor in medical spending for most of RCCHC’s patients, and aimed to help them by integrating behavioral health into its Accountable Care Organization (ACO) patient care meetings. By partnering more intentionally with their community, creating a behavioral health access point, and holistically focusing on these high-cost patients, RCCHC has seen early success with a test group of 25 patients in reducing ED utilization — in fact, some patients have stopped relying on the ED altogether. Leaders plan to roll out the new care management approach to more patients as part of the organization’s ACO operations.

To ensure better care for patients, take three critical steps:

  • Work with patients to ensure health care best meets and respects their needs and aligns with their values. In other words, deliver the right care, in the right place, at the right time.
  • Focus on (and share) the best ways to improve the quality and safety of health care.
  • Improve coordination and communication when a patient moves from one health care setting to another. Simply put, the onus to ensure that care is coordinated should not be on patients and families but on the systems that provide their care.

For example, at Providence St. Joseph Health, improvement teams focused on sepsis. It was the leading cause of mortality in the organization, registering about 10,000 cases per year at a cost of about $150 million in care delivery. Organization leaders pulled together frontline physicians and nurses, pharmacists, and quality leaders to redesign the process for early identification and treatment of sepsis, using the latest evidence and guidelines. They then spread the new processes and learning throughout the organization, which includes dozens of hospitals in the western United States. In the first phase of this ongoing work, the organization has already saved more than 300 lives and $8.4 million.

Another example: The South Carolina Birth Outcomes Initiative is a multi-stakeholder collaborative comprising more than 125 participants from across the state, which focuses on improving maternal child health outcomes, including reducing non–medically necessary early elective deliveries. All birthing hospitals and obstetricians throughout the state agreed to receive no payment for such deliveries from Medicaid or Blue Cross and Blue Shield. Over the last 5 years, the initiative has led to a 70% improvement in early-elective delivery rates overall and has resulted in more than $11 million in savings. That savings has since been invested in other initiatives, including coverage of long-acting reversible contraceptives.

And to lower the costs of health care, commit to the following:

  • Focus on high-value care — in other words, the best quality care at the lowest cost.
  • Work with employers and other payers to keep premium increases under control.
  • Take waste out of the system and reinvest that savings within communities.

What do we mean by cost? Cost for whom?

Affordability of health care is critical — and it’s not just about the premiums people pay each month. It also includes deductibles and the co-payments patients make when they access care. When we view it all together, the best ways to improve affordability while ensuring everyone has access to care are to reduce inefficiency and low-value services, and to improve preventive health.

For example, 14 years ago, Bellin Health Systems in Green Bay, Wisconsin, began to focus on improving the health and wellness of its own employees. Buoyed by the success of these efforts — e.g., 72% of employees have no discernible gaps in care, leading to $25 million in savings — Bellin went on to establish 20 risk-based relationships with local employers. One large local employer has decreased its average health care spend by 3% over the last 4 years and performs 5.5 points above the national average on Health Risk Appraisal scores.

We see significant overlap among the three components of the Triple Aim. Prevention, for example, is critical to the health of populations and controlling costs. Improving coordination, likewise, results in better care for individual patients and helps reduce waste and unnecessary resources within a health system.

Of course, there are more actions within each category — but these are a good place to start.

We invite all of you reading this to join us in pursuing the Triple Aim, and work with your clinicians, your systems, and your communities to achieve it. Now more than ever, the message of health care providers must be about hope and action. Now more than ever, we need to do this work together.


This article originally appeared in NEJM Catalyst on June 8, 2017.

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