Re­form cat­a­lysts

Health foun­da­tions can of­fer money, ex­per­tise to­ward im­ple­ment­ing re­form law

Modern Healthcare - - Opinions Commentary - Karen Fe­in­stein

The Pa­tient Pro­tec­tion and Af­ford­able Care Act is the most sig­nif­i­cant do­mes­tic pol­icy leg­is­la­tion of the past 40 years. The new law ex­tends far be­yond cov­er­age and ac­cess pro­vi­sions; it will cat­alyze in­no­va­tions in how health­care ser­vices are de­liv­ered and paid for, con­sumer in­for­ma­tion about qual­ity and safety, health­care work­force devel­op­ment and much more. In do­ing so, it also cre­ates new op­por­tu­ni­ties for the phil­an­thropic world, which spawned many of the in­no­va­tions the new law now seeks to re­fine and take to scale.

The Af­ford­able Care Act touches ev­ery health fun­der’s agenda. More­over, suc­cess­ful im­ple­men­ta­tion of key pro­vi­sions of the new health re­form law may de­pend on health fun­ders un­der­tak­ing new roles and com­mit­ments.

Driv­ing the need for foun­da­tions’ in­volve­ment is the rapid de­vo­lu­tion of re­spon­si­bil­ity for re­form from Washington to the states and lo­cal com­mu­ni­ties. The scope of the new pro­grams and re­spon­si­bil­i­ties be­ing passed on to the states is un­prece­dented, and these new re­spon­si­bil­i­ties are com­ing at a par­tic­u­larly chal­leng­ing time. Not only are state and lo­cal gov­ern­ments cop­ing with sig­nif­i­cant fi­nan­cial stresses, im­pend­ing elec­tions will usher in changes in many states’ po­lit­i­cal lead­er­ship.

In­for­mal talks among health foun­da­tion lead­ers about im­ple­ment­ing re­form mor­phed into a for­mal gath­er­ing this Au­gust at the Heller School for So­cial Pol­icy and Man­age­ment at Bran­deis Uni­ver­sity that brought to­gether 70 foun­da­tion lead­ers.

These lead­ers took their cue from Atul Gawande’s ad­dress to the con­fer­ence. The well-known physi­cian ar­gued that in­stead of a one-size-fits-all so­lu­tion dic­tated from Washington, in­di­vid­ual com­mu­ni­ties should be­come lab­o­ra­to­ries for devel­op­ment of value-driven mod­els, based on lo­cal needs and mar­ket cir­cum­stances. Need­less to say, this view found a re­cep­tive au­di­ence.

There was sur­pris­ing con­ver­gence of is­sues and con­cerns among the par­tic­i­pants. All rec­og­nized that their in­di­vid­ual states need help with grant-writ­ing, tech­ni­cal as­sis­tance, strate­gic plan­ning and stake­holder con­ven­ing, and coali­tion-build­ing. Jim Knick­man, pres­i­dent and CEO of the New York State Health Foun­da­tion, summed up the op­por­tu­nity—and the im­per­a­tive—for health foun­da­tions to act: “Phi­lan­thropy can be more nim­ble than state govern­ment—foun­da­tions can fund key play­ers with-

Foun­da­tions must help state and lo­cal gov­ern­ments with un­prece­dented re­spon­si­bil­i­ties

de­volved from Washington.

out the long lead times in­volved with state pro­cure­ment. Be­cause we don’t have a ‘dog in the fight,’ we can cred­i­bly bring to­gether the var­i­ous ac­tors that need to be in­volved: con­sumers, em­ploy­ers, health plans and govern­ment.”

Not­with­stand­ing dif­fer­ences about other as­pects of the health re­form law, those present agreed that sup­port­ers and op­po­nents should work to im­ple­ment ini­tia­tives that have the po­ten­tial to bend two crit­i­cal curves: flat­ten­ing the sky­rock­et­ing tra­jec­tory of health­care costs and turn­ing the arc of qual­ity im­prove­ment steeply up­ward.

Here are the most promis­ing is­sues and op­por­tu­ni­ties that emerged.

De­liv­ery and pay­ment sys­tem re­form. Hos­pi­tal care is the biggest com­po­nent of health­care spend­ing. Elim­i­na­tion of pre­ventable hos­pi­tal­iza­tions, es­pe­cially read­mis­sions within 30 days, is, there­fore, a ma­jor fo­cus of de­liv­ery and pay­ment re­form. Ef­fec­tively co­or­di­nated care can sig­nif­i­cantly re­duce hos­pi­tal read­mis­sions: timely com­mu­ni­ca­tion among providers, stan­dard­ized med­i­ca­tion re­view, pa­tient self-man­age­ment and ed­u­ca­tion while hos­pi­tal­ized, well-planned tran­si­tions of care and post-dis­charge fol­low-up.

Congress has ap­pro­pri­ated bil­lions of dol­lars to un­der­write devel­op­ment of com­ple­men­tary new pay­ment ap­proaches that will elim­i­nate re­wards for in­con­sis­tent care and of­fer in­cen­tives for care co­or­di­na­tion across set­tings (e.g., ac­count­able care or­ga­ni­za­tions, med­i­cal homes). New mod­els of de­liv­ery and pay­ment will be tested in lo­cal mar­kets, where foun­da­tions can play im­por­tant roles as con­ven­ers, grantwrit­ers, tech­ni­cal re­sources and seed fun­ders.

Med­i­caid, CHIP and the Safety Net. As­sur­ing health­care cov­er­age for tens of mil­lions of un­der­in­sured and med­i­cally un­der­served Amer­i­cans will put un­prece­dented de­mands on safety net providers—in par­tic­u­lar on fed­er­ally qual­i­fied health cen­ters (FQHC) and other sim­i­lar or­ga­ni­za­tions. Foun­da­tions can sup­port FQHCs to be­come pa­tient-cen­tered med­i­cal homes and en­cour­age them to act as com­pre­hen­sive pri­mary-care ser­vice cen­ters for small pri­mary-care prac­tices.

Work­force. Short­ages in high-de­mand and newly emerg­ing oc­cu­pa­tions are wide­spread: physi­cian as­sis­tants and nurse prac­ti­tion­ers, care man­agers, den­tal hy­gien­ists, med­i­cal tech­nol­o­gists and as­sis­tants, be­hav­ioral health spe­cial­ists, health in­for­ma­tion technology pro­fes­sion­als and health­care ed­u­ca­tors. Foun­da­tions can help with ob­tain­ing fed­eral grants to ex­tend re­cruit­ment, train­ing and ed­u­ca­tion; stim­u­late con­tin­u­ing ed­u­ca­tion in qual­ity im­prove­ment; and ad­vo­cate for ex­panded li­cens­ing for para-pro­fes­sion­als.

Con­sumer ed­u­ca­tion. Bend­ing the curve on cost be­gins with the pa­tient. Health fun­ders can as­sist em­ploy­ers and lo­cal and state govern­ment agen­cies to en­gage pa­tients in healthy be­hav­iors, en­cour­age them to com­ply with treat­ment plans, and re­spond to ex­ac­er­ba­tions of chronic con­di­tions and ill­nesses in ways that avert ER vis­its.

The dis­cus­sions at Bran­deis were a call to ac­tion, driv­ing home the im­por­tance of foun­da­tion sup­port for car­ry­ing out health re­form in com­mu­ni­ties and states.

Karen Fe­in­stein is pres­i­dent and CEO of the Pitts­burgh Re­gional

Health Ini­tia­tive, an in­de­pen­dent cat­a­lyst for im­prov­ing health­care safety and qual­ity in south­west­ern

Penn­syl­va­nia.

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