State Health Policy Leaders Examine Reform Landscape

ATLANTA — Starting with an assessment of how far the U.S. health system still has to go and ending with a look back at how far it’s already come, state policy leaders got a wide range of perspectives last week at the 27th Annual State Health Policy Conference.

Elizabeth Bradley, professor at Yale’s School of Public Health and director of the Yale Global Health Initiative, opened the three-day conference with sobering conclusions about why the expensive U.S. health system doesn’t  yield better results, particularly compared with other relatively wealthy nations.

“We don’t invest as much as other countries in social service goodies that make their countries healthy,” Bradley said. “What is different in the U.S. is that we believe that health and health care are the same thing … if we invest in health care, we’ll have better health. We have to move away from that kind of thinking,” Bradley said.

Co-author of a new book, “The American Healthcare Paradox: Why Spending More is Getting Us Less,” Bradley said her research shows that if the U.S. spent more on housing, education and income support, the country’s overall health would improve.

Bradley and other speakers said the Affordable Care Act is a good beginning, but the country still has a long way to go to fix a dysfunctional health care system.

Among the 34 relatively wealthy European, Scandinavian and Asian countries in the Organization for Economic Co-operation and Development, the U.S. spending on health care is far higher than any other country.

“And in some ways we have tremendous benefits from high spending,” Bradley said. “We have more kidney transplants, more knee replacements and more MRIs than anywhere else in the world.

“But out of the 34 OECD countries we are 25th in maternal mortality, 26th in life expectancy and 28th in low birth weight. This issue is not only about the poor,” Bradley added. “If you look at studies that compare people in the U.S. with higher income and more education, they fare worse than their counterparts in Western Europe.”

Bradley said the factors that determine good health can generally be divided into three categories. “It’s about 20% genetics, 20% health care and about 60% social determinants — things like income, housing, education. The U.S. does a great job on the health care part of the equation, but we don’t do so well in the larger, more important area of social determinants.”

Satcher Notes How Far System Has Come

In the other bookend address closing the National Academy for State Health Policy conference, David Satcher, surgeon general under President Clinton and now director of the Satcher Health Leadership Institute in Atlanta, noted that this year marks the 50th anniversary of the first Surgeon General’s report on tobacco.

Satcher said that while the milestone indicates how far the country has come over the past half century in efforts to promote public health, there is still much work to be done. He urged state policy leaders to work with federal and private sector officials to push the vision of a reformed health system forward.

From DSRIP to Pregnant Medicaid Beneficiaries

Between opening and closing remarks from Bradley and Satcher, some 630 policy leaders from all 50 states and the District of Columbia explored new wrinkles in health policy during three days of workshops and presentations.

California, as is often the case in national health issues, was looked on as leader in several arenas, ranging from dealing with new complexities faced by pregnant Medicaid beneficiaries under the ACA to the arcane use of DSRIP — Delivery System Reform Incentive Payment programs.

In a workshop — “Creatively Addressing Complexities in Coverage for Pregnant Women under the ACA” — René Mollow, deputy director of the California Department of Health Care Services, gave an overview of how state officials are trying to make coverage more accessible for pregnant women.

Low- and moderate-income pregnant women in all states now have multiple options for health insurance, including Medicaid, subsidized coverage in the commercial marketplace, and, in some states, Children’s Health Insurance Programs, which cover pregnancy-related services. The array of options, along with new federal eligibility guidelines, has created a complex coverage landscape that can be difficult for women to navigate and for states to administer.

“We hoped that the ACA would make things easier, but that’s not really the case in some circumstances,” Mollow said. “In California, one of our principle goals is to have one umbrella of public programs that will cover pregnant women, no matter what their circumstances are.”

Mollow, one of three featured speakers in the workshop, said she and other California officials work closely with stakeholders. “We have a very robust advocacy group in California, particularly where it applies to motherhood and early childhood,” Mollow said.

There are “lots and lots of discussions going on” about how to smooth the way for pregnant women, Mollow said.

Gretel Felton, Medicaid deputy commissioner for beneficiary services for Alabama, stepped to the microphone during the question session after the presentations and said, “Thank you, René, for figuring it all out for us. We really appreciate it.”

Mollow also led a workshop aimed at increasing state officials’ ability to maintain continuity of care for youths in the juvenile justice and foster care systems.

California DSRIP Leading the Way

Linette Scott, chief medical information officer for DHCS, also played a focal role in two workshops. She was moderator of a panel discussion examining ways for states to creatively use new ACA standards for not-for-profit hospitals to support community health. She also filled in for California colleague DHCS Medical Director Neal Kohatsu as a speaker in a workshop on DSRIPs.

California, in 2010, was the first state to launch a formal DSRIP program — one of a new generation of ACA-era acronyms pronounced “disrip.” It is one of the tools officials hope can shift the payment system away from fee-for-service.

Part of the state’s “Bridge to Reform” Medicaid waiver, California’s DSRIP is a pay-for-performance quality improvement initiative for the state’s 21 public hospitals in 17 health care systems. The goal is to strengthen care delivery, improve efficiency and ultimately save money. California’s DSRIP includes up to $3.3 billion in federal incentive payments.

“We started this before the ACA kicked in and after the high-tech act had been passed but hadn’t kicked in yet,” Scott said. “This DSRIP was at the leading edge of that tech movement.

“Data collection — in and of itself — was a major challenge when it started,” Scott said. “The adoption of [electronic health records] has been a help but it’s still early. This is still very much a train being built in motion.”

California, one of three states featured in the DSRIP workshop, was considered the “veteran” state and asked to share results and best practices. New Jersey was the “intermediate” state, and New York was the “newcomer.”

Social Impact Bonds for Private Investors

In the true spirit of free enterprise, a new health care funding mechanism taking shape in the U.S. got some time in the spotlight during the Atlanta conference. Social impact bonds are being touted as a way for private investors to put up money for government health programs with the hope of getting paid back when the programs bear fruit by reducing costs and improving public health.

South Carolina is exploring the possibilities.

“Who thinks farther out beyond the silos we’re always talking about?” asked Tony Keck, director of the South Carolina Department of Health and Human Services.

“It’s the corporations. A social impact bond takes some of risk away from legislatures and states and puts it onto private investors who say, ‘We’re willing to take that risk but we want a payout that’s commensurate with that risk.'”

The idea is to get expensive health programs started with private investments that will be repaid once the programs are paying dividends with a less-expensive health care system and a healthier population.

How to measure all that is yet to be determined.

“You take these programs that need a lot of money up front but promise a long return and you have private investors put the money up,” Keck said.

“You can see when a bridge is built or a new road opens, but seeing progress or a completed process in health care is different. The key in social impact bonds is you need results and you need to be able to measure them,” Keck said.

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