A discussion from the Institute for Healthcare Improvement National Forum. Part 2 of a two-part series.
- Donald M. Berwick, MD, MPP, President Emeritus and Senior Fellow, Institute for Healthcare Improvement
- Melinda B. Buntin, PhD, Professor and Chair, Department of Health Policy, Vanderbilt University School of Medicine
- Patrick Conway, MD, President and CEO, Blue Cross and Blue Shield of North Carolina
- Raymond P. Vara, Jr., MBA, ACHE, President and CEO, Hawaii Pacific Health
- Edward Prewitt, MPP, Editorial Director, NEJM Catalyst
Edward Prewitt: A number of you have touched on social determinants of health, and that’s very interesting. It’s not necessarily the result of health care policy changes. Again, it’s something that makes sense, something that costs more up front, perhaps, but saves money on the back end. Patrick, you said that Blue Cross of North Carolina is working on this. Tell us more about that.
Social Determinants of Health
Patrick Conway: Yeah, we are investing in a number of ways. We have some communities where we’re investing to address issues like birth outcomes in high-risk women, food insecurity, transportation, homelessness, racial and ethnic disparity, so really investing at a community level. We also, as we go into Medicaid, are thinking deeply about addressing these issues in the Medicaid population. I was just talking to Rebecca Onie and Rocco Perla about how could we screen for social determinants of health broadly across our entire population and then address those social determinants at a population level.
I’m not aware of a commercial payer that’s ever done that at scale, and so we’re trying to think through those issues. I will do a challenge to the audience. When I was at Cincinnati Children’s, we were getting pretty darn good at quality of care and starting to address costs and starting to work some on population health and social determinants. Turn the QI “industrial complex” to the social determinants of health and population health issues. In addition to safety and harm and others, address suffering, vulnerability — these issues that have such a large impact on health and cost.
Prewitt: Okay, that’s another big idea for the audience. The previous one was “thriving-based care,” creation of a new acronym. Patrick, does any of that investment that you’ve been doing rely on health care policy, and are there changes — a corollary question — in 2018 that might undermine that investment?
Conway: I’ll start, but others can add on. I have to admit, when I left D.C., I stopped reading Politico, and I’m happier now that I don’t know, if I’m honest. So I don’t even barely know what’s going on anymore. Most of it does not depend on federal policy. I think the one issue is access to care, whether that’s through Medicaid or marketplace or other things.
To address a lot of these issues, you typically do need access to care, and a frame for Blue Cross or whoever your health insurance company or whoever your provider is, to care for you. When you don’t have access to care [for] these vulnerable populations, you’re going to see worse health outcomes. I take care of mainly a pediatric population on Medicaid with multiple chronic conditions, on weekends, as a volunteer. They need help. The reality is you have families that aren’t getting the support they need, and that’s disappointing.
Melinda B. Buntin: I [will] just add the small footnote that I had the privilege of serving on a National Academy panel on ways to incorporate what we called social risk factors into value-based payment. I do think that’s important because we don’t want, in a push toward value-based payment, to give incentives to serve only the easiest-to-serve patients. We need to make sure that we level the payment playing field and we give resources that will help institutions to address those social risk factors and achieve equal outcomes to other facilities that may have a more advantaged population. That is an important part of what we’re doing.
Prewitt: Ray, when we were speaking earlier, you talked about how your policy concerns extend well beyond health care, to education and housing.
Raymond P. Vara, Jr.: Right.
Prewitt: Which is these kinds of [social risk] issues. How much of that is a decision that your organization has made and how much of it is driven by policy?
Vara: It’s mostly one our organization has made. When we look at our population in Hawaii, what things are driving the kind of outcomes that we see? We know that we have populations that are underserved, and the question is how do we create access for those populations? But the other piece is we’ve been investing in education and supporting programs that get adult-aged people of Hawaii some form of post–high school education, because when we statistically look at the health statistics for those populations who have some form of post–high school education versus those who don’t, there’s a clear disparity, and so we invest in those kinds of programs.
We look at our homeless population, which has made national news in Hawaii, although truly it represents 6,000 or 7,000 people across the state. But our adult tertiary care facility, they represent 30% of our most complex patients. Their average length of stay is almost 40% longer. Their mortality is almost 30 years less. They survive 30 years less than the rest of our patient population, and so this is a population in need. This is a population that, again, I think we have a burden of responsibility to figure out solutions, to get to them with community-based care out where they live.
Donald M. Berwick: You know, there’s good news here. I’m feeling it this year, even at this meeting, examples of places, like Ray was just talking, about stepping up. I don’t know how they’re doing it. Kaiser Permanente’s thrilling to watch. This sounds authentic there. Lisa Schilling has been talking about, at this meeting, some of the moves they’re making, and Bernard Tyson has been very clear that payment or no payment, this is a job of trying to cause health. Anna Roth is doing it in the Contra Costa area in her presentation just this morning about really beginning to tackle social determinants as real. Uma Kotagal, brilliant leadership at Cincinnati Children’s Hospital Medical Center, is taking on not [only] leadership but convening for the well-being of 60,000 kids in Cincinnati, and that’s in a fee-for-service environment. I don’t think they have much risk.
So the models are surfacing. I had the pleasure of spending part of a couple days with Rushika Fernandopulle in Iora Health. This is a private-sector venture, but they’ll only accept global risk. There’s no other payment they’ll accept, and then he describes how recognizing that an elderly woman was becoming isolated in her home, didn’t know how to use a bus system, and sending a social worker out to her home to ride the bus with her, to teach her how to use a bus system, reducing her utilization. So I’m optimistic the models are emerging, if we have the will and can begin to pay sensibly. I think we know a lot.
Prewitt: We’ve heard an interesting dichotomy here. There’s innovation, experimentation in the market at different levels, and yet there’s a lot of uncertainty about health care policy. One response to uncertainty can be to wait, to not try new things. What’s your sense, Melinda, when you look at things from your perspective: Do you feel that people are waiting to find out what’s going to happen, or are they going ahead?
Innovation and Experimentation vs. Uncertainty
Buntin: I really have the increasing sense that people are waiting or they’re so uncertain, they’re just not sure which way to go while they’re waiting. While state officials are waiting to determine what direction federal policy’s going to send them and what the boundaries are going to be, or while we’re waiting to understand how broad the reach of value-based payment might be, there’s so much else going on.
There’s all these new drugs and technologies, there’s consolidation in industry like we have not seen before, and all of that means that even though Ray [Vara] was calling these things training wheels, many of the providers I talk to in my region, they’re not even ready for training wheels because their environment is so tough to operate in without even . . . getting on the bike path. So I think the environment is changing around people, and the policy environment is just one element of the intense uncertainty that people are facing.
Conway: I think there’s a lot of innovation and change that can happen at the local level. The uncertainty, it certainly creates challenges because you are managing . . . the premiums and other things. It creates things that are suboptimal, but I still would challenge folks in the audience on the array of issues we talked about today. I don’t think waiting is a good option. I think we’ve got a huge improvement opportunity, and I think, if anything, we need to test and learn and scale in a much more rapid fashion.
Vara: I would agree with Patrick. I would urge the audience . . . we’re here as health care leaders, and now we need to lead as leaders. We know what needs to happen. We need to drive this change, and frankly I would like to believe as we deliver results and we move the needle and we begin to bend the cost curve on our own, we’ll be able to use that to impact policy. I don’t think anybody knows the dynamics of this industry like we do, and I think, frankly, if we’re sitting back, waiting, we’re waiting for someone else to take us in a direction that is likely less informed.
Prewitt: I want to throw out one health care policy change that’s been much discussed. I think it’s fair to say it’s not on the horizon in 2018, but single-payer health care, it’s gained a lot of support in just the last year. Don, it’s something you’ve been talking about for a while. What’s your prognosis for single-payer or some form of universal health care?
Berwick: My prognosis? I wish we could go there. I think it would make more sense for the public. We could better defend the interest of patients, make wiser choices about where resources go, take a stronger stance against some abuses that exist in the delivery system. I loved being the Administrator of Medicare and Medicaid. It was the best job I could ever have (except, of course, running IHI) because I could stand up for 100 million people and figure out how to help them, and I had the responsibility and the opportunity to work on their behalf, in a better-than-fragmented way. And the administrative burdens at our end were much, much, much lower. I don’t think it’s likely right now.
The pushback from the current status quo players would be big. With Patrick [Conway] now at an insurance company, I’m going to change my bet a little bit about how far that sector can go, but I don’t think it’s likely. I think maybe some state experiments emerge. If we could figure out how to do those mechanics, that would be very interesting, and but I still think we’re built a viciously complicated system, hard to use, moving a lot of paper, not able to take strong, declarative positions around defending the public, the public interest, and I wish that would be different. I’d love to get Patrick a job back in the public sector now, but that may be a ways away.
Prewitt: Melinda, your thoughts?
Buntin: I think that many people, most people, feel like they don’t like major aspects of our current health care system, and some people would be willing to throw it out and start afresh. But the polling around single-payer, I think, is misleading. I don’t think that there is a thing called single-payer that a majority of people or even a growing minority of people could all agree on. If you talk to physicians, maybe they like the sound of single-payer because they think it means less paperwork, or if you talk to Don, he’d like to really run something on behalf of all of us, but it means so many things to different people. There are different single-payer models around the world, and until we have a lot richer and more protracted discussion of what we mean when we say single-payer, I don’t know whether people would actually like what it would entail.
Read/watch part 1 of this discussion.