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“social determinants of health”

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3 healthcare changes that can outlast the ACA

Whatever the Republican efforts to kill the Affordable Care Act, some healthcare changes encouraged by the ACA that have particularly developed over the past few years will almost certainly continue, predicts The New York Times.

Three of them are:

  • Early intervention through much expanded community-health efforts that address the social determinants of health.
  • Alternative payment models, such as bundled payments, in a continued move away from fee for service and to fee for value and outcomes.
  • More emphasis on care coordination and team-based care, including better coordination between clinicians and outside social services.

To read The New York Times piece, please hit this link.


How to get primary care and behavioral health to march together

 march

This article  by Benjamin Miller looks at creating a “culture of whole health” in which primary care and behavioral heath advance together.

A report looks at:

  • Organizing integration efforts.
  • Workforce training and other education.
  • Financing, with  the current fee-for-service payment system presenting huge barriers to team-based integrated care.
  • Technology.
  • Care delivery, with integrated-care delivery requiring curating and sharing evidence on integrating mental health and primary care and including prevention and health promotion. 
  • Population and Community Health: The effort must consider such social determinants of health as housing, education, employment and environmental conditions. 

Showing system ‘how to deal with new payer world’

 

applegate

Vineyards in Jackson County, Ore.  Jackson Care Connect serves many low-income agricultural workers.

It took considerable courage and enthusiasm three years ago to launch Jackson Care Connect (JCC), a Coordinated Care Organization in Oregon created to serve mostly low-income people on Medicaid.

In the past year, Cambridge Management Group (CMG) has participated in a nationally watched project to help JCC accelerate its mission to improve care and medical outcomes for its population while saving money as the U.S. healthcare system moves toward payment for value from fee for service.

Jackson Care Connect has brought together many organizations and other constituencies – some of them economic rivals of each other — to improve how it uses its limited resources.

A key part of Cambridge Management’s JCC engagement,  which included Bob Harrington, Marc Pierson, M.D.,  and Annie Merkle, was to study the individual parts of the healthcare-related environment in which Jackson Care Connect operates and then to explain, in part through mapping, the linkages among providers and a wide range of other community players — many not healthcare institutions per se — and the social determinants of health. CMG’s research is richly presented in graphics and a report.

(Biographical sketches of the CMG team may be found at this link to the “Professional Staff” page of CMG’s Web site.)

CMG had to understand the function of each part of the JCC universe before it could propose ways to make all players mesh their operations for the benefit of the entire population being served.

Cambridge Management suggested how JCC could best coordinate all these moving parts to meet the Triple Aim of improving the individual patient experience (including quality and satisfaction); improving the health of populations — of particular importance to an organization like Jackson Care Connect — and cutting the per-capita cost of healthcare.

Informing all this work has been the need to address the social determinants of health (which experts consider account for up to 90 percent of health, with direct contact with the healthcare system accounting for the rest). These determinants include, among many other factors, family income, family stability or lack thereof, environment, transportation and education.

Dr. Pierson, we should note, is a former emergency physician and hospital executive who is longtime expert on the social determinants of health and how to reform the healthcare system to address them. His work on addressing these determinants of health in Washington State has drawn national attention.

Jackson Care Connect’s chief executive, Jennifer Lind, said that the CMG team found “areas where things didn’t work,’’ helped determine where operations and attitudes could be most quickly improved, and then facilitated more efficient “interactions between the moving parts.’’

“Cambridge Management broke down what everyone was doing and then convened different constituencies together to try to fulfill larger vision. They worked with us to align the different groups to create a community vision of improving outcomes and capturing savings – not just adding more services upstream.’’

“Bob and Marc as conveners got excitement for change going in the various groups by helping them see what they could do better individually and, especially, together.’’

Cambridge Management’s engagement with JCC — informed by CMG’s decades of working with physicians to align their interests and work with their institutions — sparked new thinking about how clinicians and others could make the new value-based payment systems work better. Ms. Lind said that “clinicians, especially, were inspired by Bob {Harrington} and Marc {Pierson} to help develop new initiatives.’’ These included, Ms. Lind said, “improving care transitions between hospitals and nursing homes and between primary-care physicians and specialists.’’

She noted the complexity of the move to fee for value. “We asked people to do really complex stuff. Some people just don’t like being thrown into complex projects.’

But of course transforming American healthcare is complex stuff: The U.S. system is by far the world’s most complicated and among the most inefficient.

Further, she said, improving Medicaid at the provider and user end is particularly difficult because it doesn’t have the much more powerful economic and political constituencies of Medicare and private insurers. Further, there’s no central authority with statutory power to impose the sort of coordination that Jackson Care Connect and similar regional groups seek to help their populations.

Still, that JCC’s initiatives so far have shown all its constituencies the value of care coordination, and that a wide range of important constituencies are represented on its board, should over time increase its ability to implement new clinical and payment models.

Ms. Lind said: “With Cambridge Management’s help, we’ve been showing the system how to deal with the new payer world.’’

By explaining the linkages through a “system and process lens,’’ CMG helped them make order out of the seeming “chaos’’ of the community health environment.

Here’s a poster describing the linkages of Jackson County’s healthcare entities and related information: OHA Summit 2015 Jackson Poster am.ppt (PowerPoint file will download).

A report, with graphics, on the findings and recommendations of the CMG engagement is linked here (PDF) and appendix here. (PDF)

Read the description by Marc Pierson, M.D., of Cambridge Management Group’s convening and mapping process.


More health systems move into social initiatives

 

Herewith a  national look at how some hospitals systems  are working to promote social initiatives to improve population health and cut the astronomical cost of healthcare.Cambridge Management Group has long been working in the field of social determinants of health, most  recently in its recent engagement with Jackson Care Connect, in Oregon.

As Modern Healthcare notes: “A small but growing group of not-for-profit hospitals and health systems is spending more money on nontraditional community benefit programs designed to address social determinants that affect health, including crime, education, housing, hunger, jobs, poverty and violence.

“Many of these projects fall outside the conventional range of community benefit activities, such as free clinics and health screening events. Instead, their focus is on building healthier communities by bettering people’s lives. ”

There are some high hopes, but some public-health experts say that community health improvement initiatives might take as long as a generation to make a significant impact, and get a good return on investment for health systems.

As Modern Healthcare noted: “{S}ome researchers question whether these efforts by health systems will be big enough to dent broad societal problems such as poverty and income inequality, and whether the systems are willing to step into controversial political fights that could involve government spending and regulation. Health systems are still trying to gather the evidence that their programs are having the intended impact.”

“Increasing access to medical care is less important to health outcomes than addressing social factors such as income inequality and support for parents during the first year of a child’s life, Stephen Bezruchka, M.D., a senior lecturer in the health-services department at the University of Washington, told Modern Healthcare. “You have to recognize that nonmedical factors are what produce health. {But} I don’t see any hospitals trying to advocate for social change.”

 


Conn. hospitals denounce Medicaid cuts

 

malloy

Governor Malloy.

Connecticut Gov. Dannel Malloy will make more than $63 million in new cuts to hospital Medicaid payments, says  a WSHU report.

His budget office said the cuts are necessary for the state to maintain a balanced budget.

Not surprisingly, Connecticut Hospital Association CEO Jennifer Jackson said reducing hospitals’ Medicaid payments will hurt patients and providers.

“With nearly one in five Connecticut residents on Medicaid, withdrawing even more funding from the state’s obligation is outrageous. It puts a tremendous additional strain on healthcare providers who already provide services with reimbursement that is nowhere near the actual cost of delivering that care.”

The cuts will certainly hurt, but we at Cambridge Management Group note that there’s vast opportunity to save money in Medicaid by reducing the number of avoidable hospital re-admissions and far better integrating behavioral healthcare and other healthcare.

This is particularly important in Connecticut’s struggling cities, with their large low-income populations.

The long failure to adequately address the impact of behavioral, emotional and mental illness on the cost of treating “physical illness” accounts for much of Medicaid’s spiraling expenses. And connected with this is American healthcare long giving short shrift to the social determinants of health.


Personalized-medicine focus seen threatening public-health efforts

vaccine

1802 caricature of Edward Jenner vaccinating patients who feared it would make them sprout cowlike appendages.

Ronald Bayer, Ph.D., and Sandro Galea, M.D., both of the Columbia University Mailman School of Public Health, argue in The New England Journal of Medicine that the federal government and the healthcare industry’s focus on personalized medicine could hurt efforts to improve population health.

They argue that  precision medicine advocates’ focus on treatment  at the individual level means that they tend to ignore such  pressing concerns as  the United States’ low ranking among developed nations in care quality or socio-economic factors’ (aka the “social determinants of health”) big effect on mortality.

The authors say that  the Feds have invested about five times more in  National Institutes of Health research, increasingly focused  on individualized-care models, than in the Centers for Disease Control and Prevention.  And, they write, the proportion of NIH-funded initiatives with “population” or “public” in their names fell 90 percent in the last decade.

“Without minimizing the possible gains to clinical care from greater realization of precision medicine’s promise, we worry that an unstinting focus on precision medicine by trusted spokespeople for health is a mistake — and a distraction from the goal of producing a healthier population.”


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