center for healthier children, families & communities blue sky rethinking health system reform...

Center for Healthier Children,Center for Healthier Children,Families & CommunitiesFamilies & Communities

Blue Sky

Rethinking Health System ReformAcademyHealth Research Meeting

June 26, 2006


What We Hope To Accomplish• Importance of a Transformative Approach

Shifting & broadening the discourse on health

reform• Incremental

• Comprehensive

• Transformative

Responsive & Strategic Value

• New Framework to Guide Health System Transformation

• Engage Health Services and Policy Communities in supporting this approach


Overview

• Blue Sky: Expanding the focus of current reform strategies

• The Blue Sky Framework

• The Politics of Transformative Policy Making

• Summary & Next Steps


The Current Health System Debate

• The Prevailing Analysis is inadequate Cost, Access, Quality and Disparities are usually

considered as significant and independent problems rather than as symptoms of more fundamental systems dysfunction

Comprehensive reform must extend beyond the Medical Care Sector

• Incremental & piecemeal approaches are inadequate and tend to maintain the status quo


What’s Different about Blue Sky?

• Goal Should be Optimal Health Status

• Health Status is a Function of Multiple Determinants

• Early Exposures Affect Health Status Later in Life


Inputs into Health & Well-Being

Medical Care Sector

Civic Sector

Public Health Sector

Population Health Sector


The Evolving Health System

• The First Era Focus on acute and infectious disease Vertically integrated operating system Insurance-based financing

• The Second (current) Era Focus on chronic disease Sub specialization, increased technology →increased costs Prepaid benefits

• The Third (emerging) Era Focus on optimal health status Need for new operating system


• Medical Applications

• Public Health Applications

• Population Health Applications

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Memory Memory

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Memory Memory

386 CPU

386 CPU

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Common Operating System: Windows




internet

Pentium 2.6 GHz Pentium 2.6 GHz Pentium 2.6 GHz



Medical Care Sector

Civic Sector

Public Health Sector

Population Health Sector


Blue Sky FrameworkComponents Current System

Transformed System

Change Strategies

Logic

Organization of Health Producing Sectors

Organization & Delivery of Individual Care

Medical Education & Workforce

Market

Funding

Planning

Regulation & Governance

Performance Monitoring


Logic

• The Current System Infectious disease control Chronic disease management and prevention Medical Care predominates

• The Future System Optimizing population health across the life span Disease prevention and health promotion focused on reducing

risks, enhancing protective factors, and enabling health promoting pathways for individuals and populations

Delaying and compressing morbidity (optimizing health across the life span)


How Risk Reduction and Health Promotion Strategies How Risk Reduction and Health Promotion Strategies influence Health Developmentinfluence Health Development

Trajectory Without RR and HP Strategies

0 20

Hea

lth

Dev

elo

pm

ent

40 60 80Age (Years)

HP

RR Risk Reduction Strategies

Health Promotion Strategies

Optimal Trajectory

Protective Factors

HP HPHP

RR

RR

RR

Risk Factors

From: Halfon, N., M. Inkelas, and M. Hochstein. 2000. The Milbank Quarterly 78(3):447-497.


Logic – Change Strategies

• Communication about needed changes: Consumers Business Policy makers

• Leadership

• Research


Blue Sky Framework

Components Current System Transformed

SystemChange Strategies

Logic




Market

Funding

Planning




Organization of Health-Producing Sectors

• Sectors in the Current System Medical (dominant) Public Health (under funded) Population Health (limited) Civic (ignored)

• The Future System Strategic linkages across sectors to facilitate integration along

service delivery pathways Workforce growth in public health, population and civic sectors Medical education incorporating concepts of and opportunities to

experience integrated, placed-based care


System Organization – Change Strategies

• Coordinate and integrate across sectors Form community pathways Support with IT

• Integrate over the life cycle Support with IT

• Align financing mechanisms with new goals


Blue Sky Framework



Logic




Market

Funding

Planning




Organization and Deliveryof Individual Care

• The Current System Subspecialty care is medically focused and institutionally centered Increasing technological sophistication (and cost) of Dx and Rx

• The Future System Patient centered, community based, primary care model (increased

use of place-based and non-traditional service locations) Core benefits should include individual and population-focused

health promotion, and disease prevention services as well as appropriate physical, specialty and mental health care services



CivicSector

PublicHealthSector

PopulationHealth

“Sector”

Primary Care

Medical Care Sector

SpecialtyCare



CivicCivicSectorSector

PublicHealthSector

PopulationHealth

“Sector”

Medical Care Sector

Primary Care

SpecialtyCare

SpecialtyCare Specialty

Care


Individual Care – Change Strategies

• Shift emphasis from specialty medical care to preventive care In communities In primary care

• Develop a work force to meet the needs of a more decentralized, more prevention-oriented system

• Coordinate care across sectors (clinics, schools, etc.) by relying more on IT


Blue Sky Framework



Logic




Market

Funding

Planning




Market

• The Current System Mixed private and public market with no coordinating mechanism Mismatch of private incentives and public interest Consumers lack information needed to make informed choice of

providers

• The Future System Embedded, mixed market focused on maximizing the common

good, and organized to support the public interest Consumer choice of providers (i.e., health care providers as well

as facilities) informed by more complete knowledge


Government – (Medicare, Medicaid)

Health Plan

Health Plan

Health Plan

Business

Private Sources


Health Trust

Government – (Medicare, Medicaid)

Health Plan

Health Plan

Health Plan

Business

Private Sources

PUBLIC HEALTH Population Health Services

LINKAGE


Market – Change Strategies

• Embed private/public delivery system within a community trust

• Use double bottom line strategies for funding decisions (i.e., benefit accrues to both the business sector and communities)

• Provide consumers and purchasers better information on service access, quality and availability


Blue Sky FrameworkComponents Current System

Transformed System

Change Strategies

Logic




Market

Funding

Planning




Funding

• The Current System Mixed but uncoordinated public and private sources of funding

Limited public health funding (apart from recent influx of bioterrorism funds)

Differential access to population health services

• The Future System Universal coverage Funding as a long term investment in optimizing health Pathway, Public Health and infrastructure funding Reallocation of resources to include funding for Population Health

Services


Funding-Change Strategies

• Upfront investment in realigning the system

• Independent entity to oversee health financing mechanisms Ensure evidence-based funding decisions at the

community levelAdvocate for population health investments


The Politics of Transformative Policy Making


“Thinking Big, Thinking Small, and Not Thinking at All”

(Robert Goodin and Ilmar Waldner. Public Policy, Winter 1979) “Punctuated equilibria”

(Frank Baumgartner and Bryan Jones, Agendas and Instability in American Politics)

Manhattan project National Defense Highway System Apollo Moon Landing Mission Reversal on Nuclear Power Even Social Security


John Kingdon—Three Streams(Agendas, Alternatives, and Public Policies)

Po

liciesP

olicies

Window of Window of OpportunityOpportunity

Politics

Politics Problems

Problems


Domestic Policy Mood of the NationSource: James A. Stimson, Tides of Consent, Figure 3.6, p. 81

45

50

55

60

65

70

75

Lib

era

lism

(P

erc

en

t)


Kingdon—The Policy Window and Possible Triggers

Po

licyP

olicy

Politics

Politics Problems

Problems

Window of Window of OpportunityOpportunity

Major Crises(health care system

tipping point?)

Change in Administration

(2008?)

Change in Congress (2006?)

Viable Policy Option

(Blue Sky)

Systematic Signs of Decline or

Missed Opportunities?

Disruption of Interest Group

Alliances?

Swing in the National Mood


Lesson Drawing in American Policy Making

Experts

Organized Interests

Politicians MajorChange

RoutinePolicy

PastPastPolicyPolicyAction/Action/InactionInaction

PolicyLessons(What Works)

PoliticalLessons(What’s Doable)

SocialLearningEffects

Analysis

Stakeholder Interests

Com

mon S

ense

© Mark Peterson. Simplified version of schematic in Mark A. Peterson, “The Limits of Social Learning: Translating Analysis into Action,” Journal of Health Politics, Policy and Law 22 (August 1997).


Framing and Reframing Without effective communication, people

default to the dominant “pictures in their heads”

With a viable plan and effective communication, people can see an issue from a different perspective, tapping into their existing but different values and underlying models of how the world works

© 2006 Frameworks Institute—Susan Bales and Frank Gilliam


IssueVisible “Polled” Attitude

Model CModel C

Implication 9Implication 9



Model BModel B




Model AModel A(current dominant)(current dominant)






People Need Values Cues(Based on George Lakoff)

Level One: Big ideas, like freedom, individual rights/responsibilities, justice, prevention, family, equality, security, and opportunity

Level Two: Issue-types, like women’s rights, the environment, children’s issues, work

Level Three: Specific proposals, like the earned income tax credit, day care, affordable housing, minimum wage


Th

is D

irec

tio

n N

ot

Wo

rk


Frameworks Institute: Most Convincing Values-based Messages

InterdependenceFor healthcare to run smoothly we should find ways for everyone to participate, because a person

without insurance ends up costing more in emergency visits, and in the costs of delaying care. Healthcare reform needs to find a way for everyone to participate in the health insurance system, which will make healthcare more efficient for us all.

7.9

Practical Manager – Step-by-StepThere is no one fix that will address all the problems in the health insurance system. What is

important is that we put a long-term plan in place and begin to take the necessary steps toward improving healthcare.

7.9

PreventionQuality health insurance that includes check-ups, immunizations, well baby care, pre-natal care

and other preventive care, pays for itself in the long run by preventing problems before they happen or become serious. By expanding health insurance coverage, healthcare reform will pay for itself and result in healthier communities.

7.8

Since the numbers of uninsured people are growing, communities are seeing increases in preventable diseases. When people are without healthcare, they delay going to the doctor and do not get the preventive care they should. Healthcare reform should expand healthcare coverage and fully fund community clinics to help our communities be healthier.

7.7

RightsEvery person should have a basic human right to health care. It is just not fair that in our society

some people have no access to a regular source of health care.

7.5



From Interdependence to Health Coverage Infrastructure

“In the last 50 years the United States has built a series of modern networks that are essential to our economy and our quality of life – our power grid, phone systems, water systems, interstate highways, and the Internet. But with health coverage we’re stuck in the 1940s, because we never built a modern Health Coverage Infrastructure. Instead, we still have job-based insurance, which has become an increasingly hit-or-miss, inefficient, and unreliable approach. What we have is the equivalent of scattered wells, individual generators, and county roads but no Health Coverage Infrastructure we can rely on, no system for making sure that people have health coverage.”



The Values Cues

Level One: Interdependence, prevention, security, equality, and opportunity

Level Two: Health system infrastructure

Level Three: Blue Sky Health and Health Care System Framework and Architecture

© 2006 Frameworks Institute—Susan Bales and Frank Gilliam (amended)


IssueVisible “Polled” Attitude

PreventionPrevention

Healthy others Healthy others mean healthier memean healthier me

Stay healthyStay healthy

Self financingSelf financing

Inter-Inter-dependentdependent

Current system inefficient and unreliableCurrent system inefficient and unreliable

Every one is in this togetherEvery one is in this together

Need an infrastructureNeed an infrastructure

ConsumerConsumer

Reform: “Do me no harm”Reform: “Do me no harm”

Private goodPrivate good

Personal cost issuePersonal cost issue

© 2006 Frameworks Institute—Susan Bales and Frank Gilliam (amended)


The Biggest Political Challenge


The Public’s Political Ideology(Source: 1972 National Election Study)

0

5

10

15

20

25

30

35

40

Ext Lib Liberal Slight Lib Moderate Slight Cons Conserv Ext Conserv

Variable 720652, responses only (N=1,157); excluded “Haven’t thought much about it” (N=467) and “don’t know (N=140)


Ideological Positions on House Roll Call Votes, 93rd Congress (1973-74) (Source: Poole and Rosenthal, http://voteview.uh.edu/dwnomin.htm)

0

10

20

30

40

50

60

70

80

-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1

Dw-Nominate Scores (1st Dimension)

Nu

mb

er

of

Re

pre

se

nta

tive

s

AllRepublicansDemocrats

38%


The Public’s Political Ideology(Source: 2000 National Election Study)

0

5

10

15

20

25

30

35

Ext Lib Liberal Slight Lib Moderate Slight Cons Conserv Ext Conserv

Variable 000440, summary of combined ftf and ph, unforced; responses only (N=673); excluded “Haven’t thought much about it” (N=184) and “don’t know (N=9)


Ideological Positions on House Roll Call Votes, 107th Congress (2001-02) (Source: Poole and Rosenthal, http://voteview.uh.edu/dwnomin.htm)

0

10

20

30

40

50

60

70

-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1

DW-Nominate Scores (1st Dimension)

Nu

mb

er

of

Re

pre

se

nta

tive

s

AllRepublicansDemocrats

3%


0

10

20

30

40

50

60

70

80

-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1

Dw-Nominate Scores (1st Dimension)

Nu

mb

er

of

Re

pre

sen

tativ

es

0

10

20

30

40

50

60

70

-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1

DW-Nominate Scores (1st Dimension)

Nu

mb

er

of

Re

pre

se

nta

tive

s


Understanding Differences Among Public’s Perception of Needs, the Experts Assessments, and the Political Assessments

“Actualneeds”

Public’sperceived needs,

priorities

Resources,feasibilities,

policy

B

C

DAAA

E

LW Green, Inst of Health Promotion Research, Univ. British Columbia, Vancouver, BC V6T 1Z3


Strategies to Reconcile Perceived & Actual Needs, & Resources

Strategic ResearchStrategic Research

AAA

Strategic mobilizationStrategic mobilization& organizational& organizationalDevelopment Development (state & (state & local)local)

Strategic Strategic CommunicationsCommunications

(Framing & advocacy)(Framing & advocacy)

Adapted from LW Green & MW Kreuter,1999.


Summary• Importance of a Transformative Approach

Shifting & broadening the discourse on health reform• Incremental

• Comprehensive

• Transformative

Responsive & Strategic Value

• New Framework to Guide Health System Transformation

• Engage you in supporting this transformative approach & moving this forward

[email protected]


CBO Projection of Social Security, Medicare, and Medicaid

Social Security

Medicare

Medicaid

0.0

5.0

10.0

15.0

20.0

25.0

30.0

2003

2005

2007

2009

2011

2013

2015

2017

2019

2021

2023

2025

2027

2029

2031

2033

2035

2037

2039

2041

2043

2045

2047

2049

Fiscal Year

Pe

rce

nt

of

GD

P

2.5 Percent Excess Cost Growth

18 percent

Source: See figure 1, page 2 of Restoring Fiscal Sanity 2005


Historical and Projected Components of Federal Spending, 1962 – 2050

Defense

Other Federal Spending

Interest

Social Security, Medicare, Medicaid

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

Year

Pe

rce

nt

of

GD

P

Actual Predicted 2.5 Percent Excess Cost Growth (Simulation 1)

Long-term Revenue 18.4%

Source: Congressional Budget Office

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