Pi­o­neer­ing ap­proaches to pop­u­la­tion health

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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

Michael Ug­wueke

Dr. Bechara Chou­cair

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