Spe­cial re­port: Providers not wait­ing on feds to push preven­tion

Along with more fed­eral fund­ing for public health avail­able through the ACA, providers and other pri­vate or­ga­ni­za­tions are step­ping up in­vest­ment in com­mu­nity health ini­tia­tives

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Ear­lier this year, Part­ners Health­Care awarded nearly $1 mil­lion to sup­port health preven­tion pro­grams in four east­ern Mas­sachusetts cities served by the sys­tem’s hos­pi­tals. While Bos­ton-based Part­ners has funded some lo­cal preven­tion pro­grams for years, the fi­nan­cial com­mit­ment re­flects a greater fo­cus by the health sys­tem to look at the role preven­tion can play in low­er­ing costs, notably as Part­ners moves for­ward as one of the par­tic­i­pants in the CMS’ Pioneer model for ac­count­able care or­ga­ni­za­tions.

“Now we rec­og­nize that we’re ac­count­able in a more di­rect way for the well-be­ing of pop­u­la­tions,” says Matt Fish­man, Part­ners’ vice pres­i­dent of com­mu­nity health.

As part of the com­mit­ment, the health sys- tem promised the Bos­ton-area cities of Chelsea, Lynn, Re­vere and Salem a $60,000 gift each ev­ery year for four years. The fund­ing will en­able Salem and Lynn to join Mass in Mo­tion, a state-led obe­sity preven­tion ef­fort, while Chelsea’s fund­ing will sup­port a com­mu­nity-based coali­tion, and Re­vere will use the sup­port to help fund a public-pri­vate part­ner­ship be­tween the city and an or­ga­ni­za­tion called Re­vere Cares.

It’s the first time that Part­ners, which has said the goal of the $960,000 in fund­ing is to im­prove ac­cess to healthy and af­ford­able foods and phys­i­cal ac­tiv­i­ties, has sup­ported neigh­bor­hood-level or city-level preven­tion pro­grams in Lynn and Salem, Fish­man said.

The 12-hospi­tal sys­tem owns mul­ti­ple hos­pi­tals in and around the four cities.

“The im­por­tant thing is that it’s much, much bet­ter for the pa­tient, but it’s also go­ing to be bet­ter for the health­care sys­tem that we’re op­er­at­ing as part of,” Fish­man says. “There is a greater fo­cus on this kind of ac­tiv­ity here than there was five years ago, or even than there was one or two years ago.”

Even with the al­lo­ca­tion of bil­lions of dol­lars for preven­tion and public health as part of the Pa­tient Pro­tec­tion and Af­ford­able Care Act, preven­tion has clearly be­come a key area of in­vest­ment for health­care providers. Hos­pi­tals have tra­di­tion­ally been slow to fully take on preven­tion re­spon­si­bil­i­ties in the com­mu­ni­ties they serve. How­ever, the shift away from a fee-for-ser­vice pay­ment model has led to a change in the way some providers, such as Part­ners, think about preven­tion.

This move for­ward by providers, as well as by pri­vate in­sur­ers and foun­da­tions, to look more crit­i­cally at the role of preven­tion comes at a time when state and lo­cal gov­ern­ments are deal­ing with on­go­ing cuts to preven­tion and public health fund­ing.

The Na­tional As­so­ci­a­tion of County & City Health Of­fi­cials re­leased a study in Oc­to­ber that found 55% of all lo­cal health de­part­ments had to re­duce or elim­i­nate at least one pro­gram and 43% lost at least one em­ployee from July 2010 to June 2011.

“Public health faces a num­ber of chal­lenges, in­clud­ing in­suf­fi­cient fund­ing to ful­fill its mis­sion, a shrink­ing work­force, and in­ad­e­quate in­vest­ments in health in­for­ma­tion tech­nol­ogy,” the In­sti­tute of Medicine said in a re­cent re­port.

How­ever, one bright spot for preven­tion sup­port­ers has been the for­ma­tion of the Preven­tion and Public Health Fund, the multi­bil­lion-dol­lar fund that was in­cluded in the Af­ford­able Care Act.

So far, the fund has dis­trib­uted $2.25 bil­lion to com­mu­nity preven­tion, clin­i­cal preven­tion, in­fra­struc­ture and train­ing, and re­search and track­ing pro­grams. An­other $1 bil­lion will be awarded dur­ing fed­eral fis­cal 2013.

How­ever, the fund has also served as a con­tin­ual pos­si­ble source of fund­ing to off­set bud­get deficits in Washington. The fund­ing lev­els re­mained in­tact un­til Fe­bru­ary’s pas­sage of the Mid­dle Class Tax Re­lief and Job Cre­ation Act, which cut the fund by $6.25 bil­lion

though fis­cal 2021 in part to avert the 27.4% cut in Medi­care pay­ments to physi­cians for the rest of this year (See chart).

“It’s un­for­tu­nate be­cause in the early part of the dis­cus­sions of the Af­ford­able Care Act, it was the first time preven­tion had been el­e­vated to promi­nence in the dis­cus­sions about health­care re­form,” says Dr. James Marks, se­nior vice pres­i­dent and di­rec­tor of the health group at the Robert Wood John­son Foun­da­tion.

Two months later, law­mak­ers pro­posed to repeal the Preven­tion and Public Health Fund as part of leg­is­la­tion that would pre­vent stu­dent loan in­ter­est rates from dou­bling. In an April 27 state­ment, the White House Of­fice of Man­age­ment and Bud­get said the pro­posal was “po­lit­i­cally mo­ti­vated” and Pres­i­dent Obama’s ad­vis­ers would rec­om­mend that that he veto the bill.

Preven­tion pro­po­nents say that be­cause less than 5% of na­tional health spend­ing goes to public health, the fund is needed to en­hance public health and preven­tion fund­ing. Op­po­nents call it a “slush fund.”

Richard Ham­burg, deputy di­rec­tor of the Trust for Amer­ica’s Health, says the ad­min­is­tra­tion’s state­ment will make it nearly im­pos­si­ble for the fund to be re­pealed or de­funded in the fu­ture.

“The ad­min­is­tra­tion has been very sup­port­ive of the fund de­spite the fact that there was a ne­go­ti­ated cut in the fund a cou­ple months ago,” Ham­burg says. “They’ve been very sup­port­ive and have de­fended ef­forts to com­pletely evis­cer­ate the fund and this would be the most public state­ment in sup­port of the fund.”

Not-for-profit or­ga­ni­za­tions such as the TFAH say that they and large em­ploy­ers rec­og­nized the need for com­mu­nity-based preven­tion decades ago. Marks, of the RWJF, notes that large com­pa­nies can of­ten see an im­prove­ment in their bot­tom line within three to five years when they ad­dress work­site health pro­mo­tion.

“Even the most in­no­va­tive ones are start­ing to say, ‘It’s im­por­tant for us to help our com­mu­ni­ties be healthy, too. That’s where the fam­ily mem­bers live. That’s where we’re go­ing to hire new em­ploy­ees from. It’s bet­ter for us when they are health­ier,’ ” Marks says.

There has also been as shift in how the foun­da­tion, which awarded about $300 mil­lion in public health grants in 2010, as­sesses pro­grams to fund. Marks says the RWJF has started to look at the out­comes of a body of work rather than what a sin­gle grant can pro­duce.

“We’re think­ing of this in a big­ger picture way and I think other foun­da­tions are start­ing to do that, too,” Marks says. “We’re reach­ing out to a much broader ar­ray of part­ners than we ever had be­fore. We see it as cru­cial for our coun­try that our pri­vate sec­tor is strong and that they rec­og­nize how im­por­tant it is for them that our na­tion’s health­care costs growth are slow­ing.”

In ad­di­tion, some hos­pi­tals and health sys­tems are start­ing to “step up,” by help­ing ad­dress public health is­sues through med­i­cal care or com­mu­nity sup­port, Marks says.

“We think that’s an im­por­tant bridge to build be­tween clin­i­cal care and public health,” Marks says. “They’ve been sep­a­rate in their ac­tions for too long and help­ing build bridges and con­nec­tions and see­ing how they can be sup­port­ive of each other is some­thing we think is im­por­tant for the long run.”

Part­ners’ Fish­man says that the health sys­tem ex­pects its fi­nan­cial in­vest­ment in preven­tion to serve as a sup­port to fed­eral and state preven­tion pro­grams, such as the Cen­ters for Dis­ease Con­trol and Preven­tion’s Com­mu­nity Trans­for­ma­tion Grants, which aim to re­duce chronic dis­eases, and Mas­sachusetts’ Mass in Mo­tion ini­tia­tive.

It also sup­ports Part­ners’ par­tic­i­pa­tion in the Pioneer ACO pro­gram.

The Chelsea, Mass., com­mu­nity will ben­e­fit from added in­vest­ment in the “Healthy Chelsea” ini­tia­tive, which pro­motes ex­er­cise and bet­ter food choices.

In­creas­ing en­gage­ment in pri­mary care, re­duc­ing emer­gency depart­ment uti­liza­tion and avoid­ing hos­pi­tal­iza­tions and read­mis­sions are im­por­tant. So is en­sur­ing that el­derly pa­tients re­ceive im­mu­niza­tions for pneu­mo­nia and the flu, Fish­man says.

“It’s the right thing to be do­ing in these com­mu­ni­ties, but it’s also the right thing to be do­ing be­cause the eco­nom­ics of health­care are now mov­ing in a di­rec­tion where the ex­pec­ta­tion is that we’re go­ing to do our best to keep peo­ple as healthy as pos­si­ble,” Fish­man says. Al­lina Health Sys­tem, a 10-hospi­tal sys­tem based in Min­neapo­lis, is also par­tic­i­pat­ing in the Pioneer ACO model. In April, it launched a neigh­bor­hood health pro­gram for com­mu­ni­ties in Min­nesota and western Wis­con­sin that pro­vides free health screen­ings, grants up to $250 to sup­port “healthy neigh­bor­hood ac­tiv­i­ties” and so­cial net­work­ing tools to sup­port healthy life­styles. The to­tal in­vest­ment for the Neigh­bor­hood Health Con­nec­tion pro­gram is about $100,000 in com­mu­nity grants, said Dr. Courtney Jor­dan Baech­ler, med­i­cal di­rec­tor of Al­lina Health’s Penny Ge­orge In­sti­tute for Health and Heal­ing, a health clinic that also does ed­u­ca­tional work and re­search.

It’s the first of sev­eral health pro­mo­tion and preven­tion pro­grams that Al­lina plans to launch.

“Over­all, there has been a philo­soph­i­cal

change and, specif­i­cally, an in­ter­est (in preven­tion) be­cause I think we’ve done a great job within the hospi­tal set­ting of tak­ing care of real sick pa­tients,” Baech­ler says. “But our in­ter­est is re­ally to keep peo­ple health­ier longer and be able to have sig­nif­i­cant ex­per­tise in com­mu­nity health and pop­u­la­tion health go­ing for­ward.”

In March, the health sys­tem re­ported that it has ex­panded the scope of the Penny Ge­orge In­sti­tute to in­clude preven­tion and health pro­mo­tion and that the fa­cil­ity had been re­or­ga­nized as a sup­port­ing clin­i­cal ser­vice line for Al­lina.

Provider in­vest­ment in preven­tion is also a trend no­ticed by Dr. Gor­don Nor­man, chief in­no­va­tion of­fi­cer at Alere, a di­ag­nos­tics and health man­age­ment ser­vices firm.

“In the post-re­form en­vi­ron­ment that we’re in right now, the in­ter­est­ing thing that we’re see­ing is the ad­vent of greater re­spon­si­bil­ity by hos­pi­tals and providers in try­ing to achieve pop­u­la­tion health im­prove­ments in the pop­u­la­tions they serve,” Nor­man says.

“Many peo­ple will go to the same doc­tor or same hospi­tal or health sys­tem for their care over a much longer pe­riod of time than they might work for a sin­gle em­ployer or carry a sin­gle in­sur­ance,” he says. “If that is the case, and ACOS are in­creas­ingly ex­pected to take risk and re­spon­si­bil­ity for mea­sured out­comes of the folks they take care of, they may also take a longer-term per­spec­tive on do­ing things like preven­tion.”

What will be likely is that pri­mary-care physi­cians, who may have less train­ing when deal­ing with is­sues such as obe­sity and diet, will work along­side care man­agers and ex­er­cise phys­i­ol­o­gists in an ACO set­ting, Nor­man says.

For the in­sur­ers and health man­age­ment com­pa­nies that have sup­ported em­ployer­based preven­tion pro­grams, the ad­di­tion of hos­pi­tals as a provider of preven­tion and well­ness pro­grams may pro­vide its own mar­ket op­por­tu­ni­ties.

“Hos­pi­tals are now re­spon­si­ble for the to­tal­ity of is­sues that im­pact a pa­tient,” says Dr. Lonny Reis­man, Aetna’s chief med­i­cal of­fi­cer. “This shift in ac­count­abil­ity and re­spon­si­bil­ity is tec­tonic in terms of the im­pli­ca­tions for how hos­pi­tals have to look at the world.”

Reis­man noted Aetna’s own trans­for­ma­tion and tri­als in its ap­proach to preven­tion, in­clud­ing con­duct­ing stud­ies that have found some fi­nan­cial in­cen­tive pro­grams such as pro­vid­ing at risk-pa­tients with free med­i­ca­tions don’t al­ways work. “It’s a pro­found chal­lenge,” he says.

The Hart­ford, Conn.-based in­surer, which Chair­man, Pres­i­dent and CEO Mark Ber­tolini of­ten refers to as a health IT com­pany, has in­vested bil­lions of dol­lars in health tech­nol­ogy dur­ing the past decade and is in­creas­ingly sharp­en­ing its abil­ity to tai­lor mes­sages to cul­tural dif­fer­ences among pa­tients.

“Preven­tion in iso­la­tion isn’t prob­a­bly as in­ter­est­ing a con­ver­sa­tion as preven­tion in the con­text of pa­tient en­gage­ment, in­cen­tives, ac­count­abil­ity by providers and a de­sir­abil­ity from a so­ci­etal per­spec­tive in terms of ul­ti­mate med­i­cal costs and the pro­duc­tiv­ity and health of our pop­u­la­tion,” Reis­man says.

TAKE­AWAY: Preven­tion has be­come a pri­or­ity for the fed­eral gov­ern­ment and providers, with hos­pi­tals, health sys­tems and oth­ers in­creas­ingly in­vest­ing in preven­tion in an ef­fort to bet­ter con­trol costs.

Al­lina Health pro­motes par­tic­i­pa­tion in its Neigh­bor­hood Health Con­nec­tion pro­gram at public events such as farmer’s mar­kets.

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