Access to Health 2008 Texas Indigent Health Care Association Conference

1. Access to Health2008 Texas Indigent Health Care Association Conference Eduardo Sanchez, M.D., MPH VP and Chief Medical Office, Blue Cross and Blue Shield of Texas Former, Texas Commissioner of Health

2. A “Transformed” Health System • The objective is optimal population-health • Redesigned to prevent and manage chronic diseases • Better integration of public health and medical care • Evidence-based intervention and practice • Prioritization and adequate funding/reimbursement of interventions that optimize health • Best use of health information and health information technology

3. Our health care system “an expensive plethora of uncoordinated, unlinked, economically segregated, operationally limited microsystems each performing in ways that too often lead to suboptimal performance” (Halvorson, 2007)

4. Our health care system • 54% of Americans with chronic disease skip pills and appointments because of cost • Diabetes • Heart disease • Cancer • depression • 42% spent > $1000 on out of pocket medical costs • 4% in the U.K. • 8% in the Netherlands • More likely to have suffered from a lack of coordination of care Commonwealth Fund, Health Affairs on line

5. Blue Cross Blue Shield AssociationThinking About Health Care Reform • Employer-based Health Insurance System • 59% US • 50% Texas • Variations in Cost and Quality • 30 percent of care rendered today, according to some studies, is unnecessary, redundant and, in some cases, even harmful. • Cost Impact of Chronic Disease • Cut the prevalence of diabetes in half • obesity, weight management, nutrition, fitness and health risk assessment • Overview of the Uninsured • Higher mortality rate for the uninsured

6. Indigent Health Care Needs • Screening and early detection services • Health education • Immunizations, management of other communicable diseases • Reproductive care, including prenatal and family planning services • Diagnosis and management of chronic health conditions (diabetes, hypertension, etc.) • Primary care • Additional medical care

7. Who are the Uninsured in Texas? • They are of all ages • They are from all income groups • They live all over Texas • Most of them work • Most of them are legal, US citizens • Their population is growing

8. The Uninsured • United States = 15.0% • Texas (6,000,000) = 25.0% • 70% of whom are at <200% FPL • Texas children (1,500,000) = 22.0% • 1/3 < FPL • 1/3 100-200% FPL • 1/3 >200% FPL CPPP, 2008

9. Determinant of Diabetes? Persons living in low income communitiesare 80% more likely to be hospitalizedfor diabetes or related complications compared with those living in affluent areas (AHRQ)

10. Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured

11. Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured Many uninsured

12. Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured Uninsured utilize higher than necessary levels of care Many uninsured

13. Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured Uninsured utilize higher than necessary levels of care Many uninsured Higher uncompensated costs

14. Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured Uninsured utilize higher than necessary levels of care Many uninsured Higher uncompensated costs Increased charges to paying customers

15. Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured Uninsured utilize higher than necessary levels of care Many uninsured Higher uncompensated costs Increased charges to paying customers Insurance companies raise premiums for insured

16. Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured Uninsured utilize higher than necessary levels of care Many uninsured Higher uncompensated costs More employers drop coverage because of high premiums Increased charges to paying customers Insurance companies Raise premiums for insured

17. Vicious Circle of Health Cost Increaseswith High Numbers of Uninsured Even more uninsured

18. Health Care Spending in the United States $2.1 trillion per year $7,000 per person per year

19. * %GDP spent on health care

20. Estimated Health Care Spendingin Texas $100 billion is spent on health care annually (conservative estimate) $70 billion, physician and hospital care $15 billion, drugs and other professional health services $85 billion, direct client care $13 billion (15%) spent on indigent care

23. The Real Problem: The Full Cost of Poor Employee Health Personal Health Costs Medical Care Pharmacy Medical & Pharmacy Costs $3,376 PEPY 25% Productivity Costs Absenteeism Short-term Disability Long-term Disability Health-RelatedProductivity Costs $10,128 PEPY 75% Presenteeism Overtime Turnover Temporary Staffing Administrative Costs Replacement Training Off-Site Travel for Care Customer Dissatisfaction Variable Product Quality Total Costs = $13,504 PEPY Sources: Edington DW, Burton WN. Health and Productivity. In McCunney RJ, Editor. A Practical Approach to Occupational and Environmental Medicine. 3rd edition. Philadelphia, PA. Lippincott, Williams and Wilkens; 2003: 40-152 and Loeppke, R., et al. Health and Productivity as a Business Strategy. Journal of Occupational and Environmental Medicine. Vol 49, No. 7, July, 2007. Pages 712-721 and the 2006 Mercer Employer Annual Survey; 23

26. F as in Fat 2008; Trust forAmerica’s Health Texas • Obesity #15 • Diabetes #11 • Physical inactivity #8

27. Aiming Higher: Results from a State Scorecard on Health System Performance Texas #49 • Access #51 • Quality #46 • Avoidable hospital use & costs #48 • Healthy lives #24 Commonwealth Fund

28. Determinants of Health Biological Socioeconomic Behavioral Environmental

29. What Drives Health Status and Health Care Costs? How Can We Encourage and Support Behavior Change? Source: IFTF and Center for Disease Control and Prevention, Health and Healthcare 2010, January 2000 29

30. Scrimping on Medical Care • “The economic crisis is exposing further weaknesses in this country’s healthcare system. …many Americans are skimping on medications, physician visits and preventive screening in order to pay other household bills… • Some evidence suggests that many people are cutting back on drugs that fight chronic conditions like high cholesterol, high blood pressure, osteoporosis, and diabetes” (New York Times, 10/26/08)

31. Health Care: Are We Getting Our Money’s Worth? People of the U.S. Medical Care Public Health Dollars Expended

32. Changing Health Systems to Improve Health Status • The health and disease paradigm has been shifting in the United States from an acute, infectious disease model of morbidity and mortality to a chronic, non-infectious model.  • The systems and interventions that helped prevent and treat infectious diseases at the individual and population level must be transformed to prevent and treat chronic diseases. • The United States needs a population-based, prevention-centered health system that interrelates public health and medical care.

33. Demand Older Heavier More Sedentary Un & Underinsured Health Illiterate Supply Increasing Access Increasing Workforce System Redesign Improving Quality of Care Improving Technology Improving Meds The Health Care Equation is Out of Balance Demand Reduction Is Imperative

34. Health promotion and Disease prevention How to achieve balance Supply • Increasing Access • Increasing Workforce • System Redesign • Improving Quality of Care • Improving Technology • Improving Meds Demand Reduction Is Imperative

35. "Healthy choices need to bethe easy choices” – World Health Organization's Ottawa charter

36. Framework on Population Health . . .(adapted from CDC, Public Health Action Plan to Prevent Heart Disease and Stroke) A Vision of the Future Social and Environmental Conditions Favorable to Health Health Promoting Behavioral Patterns Low Population Risk Low Disease Occurrence Good Quality Of Life Until Death Full Functional Capacity Policy and Environmental Change Behavior Change Risk Factor Detection And Control Acute Case Management/ Treatment Chronic disease Management/ Rehabilitation End-of-Life Care Approaches to Intervention The Present Reality Unfavorable Social and Environmental Conditions Adverse Behavioral Patterns Disease Occurrence 1st Event Fatal Complications/ Decompensation Major Risk Factors Poor Health Status/Disability Target Population Large and general Small and specific

37. The Consequences of Misplaced Priorities To maximize health, we should pursue interventions in proportion to their ability to improve outcomes Woolf, JAMA, V.297,#5

38. The Consequences of Misplaced Priorities • Choosing effective services (appropriate use of things that work vs. overuse of things that don’t ) To maximize health, we should pursue interventions in proportion to their ability to improve outcomes Woolf, JAMA, V.297,#5

39. The Consequences of Misplaced Priorities • Choosing effective services (appropriate use of things that work vs. overuse of things that don’t ) • Delivering care (services delivery system improvements vs. biomedical advances) To maximize health, we should pursue interventions in proportion to their ability to improve outcomes Woolf, JAMA, V.297,#5

40. The Consequences of Misplaced Priorities • Choosing effective services (appropriate use of things that work vs. overuse of things that don’t ) • Delivering care (services delivery system improvements vs. biomedical advances) • Preventing disease (tobacco cessation versus b-blockers) To maximize health, we should pursue interventions in proportion to their ability to improve outcomes Woolf, JAMA, V.297,#5

41. The Consequences of Misplaced Priorities • Choosing effective services (appropriate use of things that work vs. overuse of things that don’t ) • Delivering care (services delivery system improvements vs. biomedical advances) • Preventing disease (tobacco cessation versus b-blockers) • Fostering social change (educational attainment versus medical advances) To maximize health, we should pursue interventions in proportion to their ability to improve outcomes Woolf, JAMA, V.297,#5

42. Education: The Greatest Predictorof Longevity • Lower education = unhealthy behaviors • Lower education = higher death rate • < 12 years of education: 615.6 deaths per 100,000 foradults 18-65 • >13 years of education: 207.9 deaths per 100,000 foradults 18-65 CDC National Center for Health Statistics, Vital Statistics Vol. 53, #5, Deaths, 2002

43. The Primary Solution Mending Texas’ Fractured Health Care System • Grow Texas’ primary care physician base • Create a consolidated loan repayment program for Texas’ primary care physicians and other qualified health care professionals who agree to serve in medically underserved areas • Increase funding for family medicine residency programs and primary care residency programs • Fully fund primary care pre-ceptorship programs • Invest in health information technology • Create a matching investment fund to provide HIT infrastructure for residency programs and primary care physician practices ©2008, Primary Care Coalition

44. The Primary Solution Mending Texas’ Fractured Health Care System • Ensure Texans have access to affordable healthinsurance options • Pursue innovative, market-based approaches to reduce the ranks of the uninsured • Build upon the reforms initiated by Senate Bill 10 to use Medicaid dollars to extend private coverage for low-income parents and adults • Support funding for local public-private collaborations such as the three-share model designed to extend affordable health care and coverage for the uninsured ©2008, Primary Care Coalition

45. The Primary Solution Mending Texas’Fractured Health Care System • Reinvest in Medicaid and CHIP • Support competitive physician reimbursement rates that keep pace with the amount it costs to provide the services, and include rewards for physicians who implement after-hours care, open-access scheduling and other features of the patient-centered medical home • Enact 12 months continuous coverage for children enrolled in Medicaid and CHIP; strengthen outreach initiatives to enroll children who are eligible but not enrolled in CHIP or Medicaid • Reduce the Medicaid “hassle factor” to entice more physiciansto participate, modernize outdated information technology, andsupport extended use of HIT such as electronic medical recordsand e-prescribing ©2008, Primary Care Coalition

46. The Primary Solution Mending Texas’Fractured Health Care System • Support a patient-centered primary care medical home forall Texans • Assure that patients receive the right care at the right time, every time by supporting and nurturing the establishment of a medical home for every Texan • Provide incentives to physicians who adopt components of the medical home model into their practices such as after-hours care, open-access scheduling and health information technology • To provide the best care at the lowest price for their patients ©2008, Primary Care Coalition

47. Another consideration toImprove the Health of Texans An investment of $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking and other tobaccouse could save the country more than $16 billion annually(and Texas more than $1.3 billion annually) within five years.This is a return of $5.60 for every $1 • Invest $240 million on population health measures Blueprint for a Healthier America: MODERNIZING THE FEDERAL PUBLIC HEALTH SYSTEM TO FOCUS ON PREVENTION AND PREPAREDNESS

48. America’s Health Insurance Plans (AHIP) A Vision for Reform A Vision to Assure Health Coverage for All Americans • SCHIP reauthorization • Medicaid eligibility for adults < 100% FPL

49. Community-oriented Primary-care Health System Medical Care Public Health Specialty/Tertiary Care Access to Healthy Foods & Activities Specialty Care Diagnostic Testing Primary Care • Patient Centered • Medical Home • (mental/dental/medical) • Easy access • Continuity of care • Comprehensive care • Coordination of all care • (Clinical preventive services • and disease management) Coordinated School Heath & Worker wellness Hospital Based Care Inpatient Care Emergency and trauma care Comprehensive Tobacco Control = Optimal Communication (Integrated Virtual System) Including best use of health informational technology Concept

50. “One of the first duties of thephysician is to educate the masses not to take medicine” Sir William Osler (1849-1919)