Are we really ready for health care reform?

1. Are we really ready for health care reform? Joanne Disch, PhD, RN, FAAN Clinical Professor, University of Minnesota School of Nursing

2. Just ask a kid Wireless everywhere Harry Potter iPods & Palm Pilots Purple M&Ms Spinning No air travel w/o removing shoes Facebook, MySpace & iTunes FOFL Or look at health care HPV vaccine P4P HIE, NHIN, RHIO, EHR Vioxx Diabesity Medical tourism A dinner plate that knows what’s on it Just how much can happen in 10 years?(modified from P Brennan, 9/21/2007) UM School of Nursing

3. Did you know? • In 2011, 1/3 of the workforce > 50 • Watches are becoming obsolete • Consumers are suing to avoid having to see a physician • 50% of boomers are using the web for games, networking, matchmaking • An 85 y.o. man was noted to have ‘died unexpectedly’ UM School of Nursing

4. Our world is becoming - V-U-C-A (BoardSource, 12/06) UM School of Nursing

5. Objectives • Review trends in society and the health care environment • Explore indicators of the public’s appetite for change • Examine options being recommended for health care reform • Reflect on what we ourselves will need to do if health care reform is to occur UM School of Nursing

6. The problem • $2.2 trillion (2007 = slowest growth rate in 10 years) • % of GNP = 16.2% • $7,421/person UM School of Nursing

7. The problem Health Status Measure U.S. Ranking Infant mortality 25 Maternal mortality 22 Life expectancy from birth/women 23 men 22 Adults receiving recommended care 40 Hosp adults receiving rec care 84 Hosp-standardized mortality rates 101 UM School of Nursing

8. Another way to think about it • Access • Affordability • Quality • Consistency and predictability UM School of Nursing

9. How did this happen? • Certain costs are growing exponentially and hard to rein in, e.g., pharmaceuticals • Expanded use – overuse? – of expensive therapies, e.g., MRIs • Our financing mechanisms reward expensive hospital-based, physician-dependent, acute care • Chronic disease is on the rise • We are America ! UM School of Nursing

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14. Toto, we’re definitely not in Kansas anymore… • Age • In 1950, 16 million people >65 (8%) • Today, 36 million (13%) • By 2050, 20% will be >65 • Those >85 are the fastest growing; by 2050, they will comprise 5% • Diversity • In 2025, 37% of US population = minority • Today, 1 in 5 people speak a foreign language at home (many are ‘linguistically isolated’) • St. Paul School system – 50+ languages spoken UM School of Nursing

15. Chronic illness • Almost half of Americans have one or more chronic disease or condition • Whites and women reported having more chronic diseases • Average person with 1 condition sees 4 physicians a year • Those with 5 or more conditions see 14 physicians a year UM School of Nursing

16. Chronic disease UM School of Nursing

17. Caring for an Aging America(The Commonwealth Fund, 2007) • At 65, Americans can expect to live to 87 • 80% of boomers report they’ll be working at least part time, and this group wants to be engaged in health care decisions • WSJ: 44.4 million adult caregivers (21% of the adult population) – average = 21 hrs/wk • Women face particular challenges as they age UM School of Nursing

18. The Boomers • Factors in deciding to work (2006) • 87% - stay mentally active • 85% - stay physically active • 77% - be productive or useful • 71% - do something fun • 68% - need health benefits UM School of Nursing

19. Changing assumptions about aging • People will expect to live to a very old age • Breakthroughs in science will change thoughts about old and very old • Illness is sometimes a surprise • Consumers will have knowledge but less wisdom • Caregiving will not be place or time bound • Diversity of cultures and experiences will force change and create new opportunities • Aging happens to all of us, and can be good UM School of Nursing

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23. Rethinking our words • Retirement • Work • Seniors • Volunteers • The second 50 • The third act • Younger-old; older-old UM School of Nursing

25. “Old age is 15 years older than I am” (Oliver Wendell Holmes) UM School of Nursing

26. What do these have in common? • The Mall of America • Cub Foods • Minneapolis/St. Paul airport • A gas station UM School of Nursing

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29. e-communication UM School of Nursing

30. Growth in adult day centers • In 1974 ~ 18 centers • Today ~ 3500 centers, serving more than 150,000 daily • Reasonable cost • National daily average = $61 • Range $21 (Alabama) to $130 (Vermont) UM School of Nursing

31. Key factors • Human connection • Choice • 89% of people >50 want to stay in their own homes or communities as they age • Respite for ‘informal’ caregivers • Family, friends, others Enables people to age with dignity and purpose UM School of Nursing

32. The changing face of the American public: - more diverse - living longer - electronically dependent - ‘families’ are more dispersed - expect to be more engaged in choices about their care and care providers UM School of Nursing

33. Consumers are speaking up - • I want convenience – • I want choice • I want a relationship with my caregiver • I want reasonable costs UM School of Nursing

34. The current health care system • Costly • Inconsistent • Uncoordinated • Impersonal • Payment systems skewed toward treatment of disease rather than health promotion and disease prevention • System still based on physician as hub of wheel • Specialists earn much more than primary care providers • 80% of expenses to treat 20% • Disproportionately large costs at end of life (futility) UM School of Nursing

35. What’s being done? • Increasing cost sharing w/ consumers • Multitier pharmacy plans • A shift from copayments to coinsurance • Increased deductibles • Combining deductibles with copayments • Smaller provider networks forcing consumers to seek out-of-network care • Spending with age; higher for women, whites and non-Hispanics • Drugs the costliest type of exp for all groups UM School of Nursing

36. Important questions • What would be the cost to insure • Some Americans? All Americans? Declared aliens? Undeclared aliens? • What services should be covered? • Who should pay? • Where does the money come from? UM School of Nursing

37. Policy considerations - • Revised insurance approaches • Nationalized health care system • Universal coverage • Single-payer health care system UM School of Nursing

38. BUT . . . We’re fixing the wrong problem . . . We need to change the focus of our health care investment toward health promotion, chronic disease prevention – and a care delivery system that acts like a system UM School of Nursing

39. What could it look like? • Lifespan planning with emphasis on financial and health optimization • Managing chronic illness in the home • Bringing health education into the home or community • Establishing caregiver networks • Using technology to stay connected and stay healthy UM School of Nursing

40. Examples of programs • Evercare • Minute-clinic • Block Nurse Program • Nurse-Family Partnership Program • Enhancing Care Coordination Project • Minnesota Visiting Nurses Association UM School of Nursing

41. Evercare- • NP or care manager (CM) at the center of an integrated care team - coordinate services; facilitate communication among physicians, institutions, patients and their families; • Reduced hospitalizations for nursing home residents by 45%, and ER trips by 50%. • High satisfaction: 91% of enrollees • Saved Texas ~ $123 million in Harris County alone in 2 yrs UM School of Nursing

42. The Harambee Nursing Center • "Harambee" is an African tribal term: "a community coming together to better society.“ • A community-based, nurse-led center offering health care - accessible, acceptable and affordable. • Reduced hospitalizations 25% • Reduced cost of primary care 50% UM School of Nursing

43. Hospital at Home • Geriatric Evaluation and Management • Nurses Improving Care for Healthsystem Elders • Acute Care for Elders • Transitional Care Program UM School of Nursing

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45. Other ideas - • Increased use of ambulatory services, hospice (22% up vs. 9% down) • The Boston Community Co-op • Sally’s idea • Workplace changes UM School of Nursing

46. Workplace • Healthy snacks in machines (40%/50%) • Discount/waived fee for gym • Nutritional info in the cafeteria • Health risk assessment • Smoking cessation program (21%/70%) • Health coaching • On-site exercise facilities • Weight loss programs (19%/54%) • Bicycle-to-work programs • Classes in nutrition (14%/44%) UM School of Nursing

47. Are you ready? • Participate in exercise (programs) • Eat a healthy diet • Stop smoking • Drink moderate amounts of alcohol • Get enough rest • Establish relationships and networks • Manage stress • Engage in religious/spiritual activities • Wear seat belts – drive safely • Take drugs as prescribed • Give back to your community UM School of Nursing

48. From communities • Revise community planning approaches – encourage more sidewalks, playing options • Change school programs to include healthy foods, exercise • Change zoning laws to allow for mixed communities EX: The Netherlands UM School of Nursing

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50. The Divided We Fail Platform • We believe that the opportunity to have access to health care and long-term financial security is a basic need that all Americans share. We believe it is the foundation for future generations. • We believe all Americans should have access to affordable, quality health care • We believe all Americans should have peace of mind about their future long-term financial security UM School of Nursing