Pioneering approaches to population health
Many healthcare organizations have improved health outcomes while forging community partnerships that focus on prevention and accountability. But how will these endeavors shape up Niyum in the future? For this discussion, moderator Gandhi, executive vice president and chief population officer at Mount Sinai Health System in New York City Dr. Marc Harrison, talked with CEO of Intermountain Dr. Bechara Choucair, Healthcare; Kaiser Permanente’s Michael Ugwueke, chief community health officer; and CEO of Methodist Le Bonheur Healthcare. Gandhi started by asking the panelists what was most important in their ability to serve their communities.
Harrison: We based a lot of our activity around our Community Health Needs Assessment, which I think can be just an exercise for many organizations, but we’ve actually gone deep. We’re interested in hypertension and preventing diabetes, but we also have identified opioid misuse as something of extraordinary importance to our community. Utah ranks in the top seven states nationally in terms of deaths from opioid misuse. And we see about half the people in our state and in southern Utah in a year—but we aren’t big enough to do everything by ourselves, and nor should we, and so we work with the community. But, in fact, we are probably the biggest problem in the community. Intermountain writes about 400,000 opioid prescriptions per year and puts about 19 million pills into our community, so it’s about 10 for every Utahan on an annual basis. So we’ve pledged to take 5 million pills off the street per year. And through data, we found that in many cases, there’s a 10-times difference between two clinicians for the same procedure. And these aren’t bad doctors. They’ve just been trained differently. And we think we can drop the average number of pills per prescription by 40% without any impact on health except for a good impact.
Choucair: Kaiser Permanente has around 12 million members and we are in communities where 65 million people live. Since the day we were founded 70-plus years ago, we were about improving the health and well-being of our members. But we know very well that there’s no way we can optimize the health and well-being of our members if we don’t do the same in the communities where they live. And yes, it is the right thing to do, the nice thing to do, it’s all these things we do to maintain our tax-exempt status—but it’s really core to our strategy. So we realized through our Community Health Needs Assessment that childhood obesity is an issue, healthy eating/active living is an issue, and one of the efforts that we’ve engaged in is called HEAL Cities, or the Healthy Eating and Active Living Cities initiative, where over the past eight years and in about five states, we’ve worked with 2,400 elected officials to change policy in those cities. And as someone who has run a health department in one of the largest cities in the country, to say that we’ve changed about 1,000 policies in 330 cities where 20 million people live-that allow healthier food in schools, more bike lanes, things we know make a difference in childhood obesity-that’s an example of how we approach one specific issue.
Ugwueke: Our six-hospital system is based in Memphis, Tenn. Five of those hospitals are in Memphis, one in Mississippi. Unfortunately we have very high poverty in
the community. And you can go down the list of every health ranking—we tend to rank toward the bottom, so that presents its own challenges. And our market also is still very much fee-for-service. There is really no alignment or incentive to drive traditional population health initiatives. In spite of that, we—a faith-based, not-for-profit healthcare system—realize that our job is not just limited to taking care of people in the hospital. So one issue is asthma in children. About 3,500 kids come to our emergency department every year because of asthma-related issues, so we embarked upon a
$2.9 million innovation project through the CMS. It’s called CHAMP, or Changing High-risk Asthma in Memphis through Partnerships. And through care coordination, we have navigators who work with families and patients or kids with asthma. We were able to significantly reduce the incidence as well as ED visits. And now kids are able to stay in school.
Harrison: We can’t really help people through community health if they’re not economically in decent shape, right? And when healthcare is too expensive and we’re having people pay for things that don’t really need to be done, we’re hurting them. And my provocative statement to all of you who run systems is you’ve got to wean yourself off the volume. You have to go to your boards and tell them that you’re going to have less revenue next year because you’re going to stop doing things that people don’t really need. And particularly, in an era of high-deductible plans, these are real people who are paying out of their pocket. It’s not some nameless, faceless payer. And we’re hurting them, and we’re hurting community health because we’re making them pay for stuff they don’t really need.
How do you make sure you’re screening for social determinants?
Choucair: The first thing is to get into the discipline of screening and asking for those questions. The second piece is empowering doctors and nurses and social workers and medical assistants with solutions. The third piece is particularly important for us; we need to get to a point where we can predict which members are at risk of homelessness, food insecurity, lack of transportation, etc. And that’s, I think, the space that’s really promising now with a lot of the predictive modeling, not only looking at your own clinical and demographic data but adding data from public health departments. That would allow us to get really good at predicting who would need a service so you can target it pre-emptively to that person.
Harrison: It’s never going to happen unless leadership actually wants it to happen. So it’s really a question of how serious are people about actually doing this for other folks? Does the leadership of the system or the hospital actually care about population health, and how do they manifest that by how they set up their organization? How do they do their contracting? And it’s easy to figure it out. You just say, “How much of your revenue is at risk?” And what you’ll get is people will say 1%, 2 %, 5%, and so they aren’t going to really truly drive that home unless they have some skin in the game.
My provocative statement to all of you who run systems is you’ve got to wean yourself off the volume.
Dr. Marc Harrison
What will your future initiatives look like?
Ugwueke: We have a number of activities that are forcing us to use data and evidence. So this will really force us as a system to not only reduce the noise but focus more of our energy on those things that truly make a difference in the lives of people in our community.
Choucair: We’ve learned that in Colorado, 6% of our seniors—those are Kaiser Permanente members—have food insecurity issues. We surveyed two of our pediatrics clinics and they had 12% and 16% of kids who are dealing with food insecurity. So we’ve done all this amazing work supporting food banks and making sure that we have a good, solid referral mechanism. We have around a million Medicaid members, and about 200,000 of them qualify for food stamps and don’t get them. Think about that for a moment. At $147 per month, that’s more than $350 million every year. So that opportunity to make sure those members can do better from a community perspective—and we know the relationship between food insecurity and health and healthcare costs—is something I’m extremely excited about for 2018.
Harrison: I’m excited that we’re going to be the first digitally enabled, consumer-centric, integrated system in the U.S. I just named the former head of global consumer insights for Disney to be our first chief consumer officer, and we’re about to make really intentional investments in a digital transformation. We will follow people when they’re well, when they’re managing their chronic illness, when they’re acutely ill—we’re going to give them power. And I think this very paternalistic, provider-centric system that most of us run is just terrible, right? It is disrespectful. It doesn’t bring out the best in people. It doesn’t engage them, whether they’re rich or poor. I think there’s never been a better time in healthcare. This is really hard, but you’re going to see enormous innovation, and I’m excited that we’re going to try and give the power to the people.
Dr. Marc Harrison
Dr. Bechara Choucair