Guest Commentary: Spending More Resources on Preventive Services is our Common Strategy

Akira Babazono, MS, MD, PhD**
Chair and Professor
Department of Health Care Administration and Management
Graduate School of Medical Sciences, Kyushu University, Japan


Dr. Saito and I visited JSPH to meet most faculty members, with the help of. Dr. Nash, this past August. We thanked them to have given precious information concerning healthcare problems. We are very happy to agree that we need more resources on primary care, including prevention, rather than for specialized care in developed countries where chronic diseases are prevalent.

Lifestyle-related diseases account for about 60% of deaths and we spend majority of health care expenditure on treatment for those diseases in Japan. The Japanese government has mandated insurers to provide health examinations and guidance related to metabolic syndrome since 2010. Insurers have to determine the risk for metabolic syndrome, including level of obesity (abdominal circumference and BMI), blood glucose and lipid levels, blood pressure, and the presence or absence of a smoking habit for every insured person aged 40 and over. Then, insurers are obliged to offer health guidance interventions according to the degree of risk of each insured person.

There are several studies that have reported favorable outcomes. The health examinations and guidance program would be productive because it is the efficient way to motivate patients to continue to maintain a healthy lifestyle in order to prevent chronic diseases.

I hear that the Patient Protection and Affordable Care Act mandates insurers to make co-payments on cancer screening free and to give subsidies to the insured to participate in fitness programs. I believe that we are on the right track because chronic diseases, which cannot always be cured by procedures, are preventable.


** Dr. Babazono and his colleague, Dr. Takao Saito, MD, PhD, attended the Tenth Quality Colloquium at Harvard in August, 2011 and spent the following week at JSPH. This is Dr. Babazono’s 3rd visit with JSPH.

Guest Commentary: Population Health on the World Stage: The UN High Level Conference on Non-Communicable Diseases (NCDs)

Rob Simmons, DrPH, MPH, MCHES, CPH

Director, MPH Program

Jefferson School of Population Health

For only the second time in its 66-year history, the first being in 2001 on HIV/AIDS, the United Nations held a high level (Heads of State and Ministries of Health) meeting of the General Assembly on a population health topic.

Jefferson School of Population Health (JSPH) was one of only eight US university schools to be invited to participate in this historic meeting representing the Civil Society and the NCD Alliance on the health and economic impact of non-communicable diseases (chronic diseases). Along with our colleague, Global Health Specialist Dr. Lucille Pilling, , I was honored to represent JSPH at this event in New York earlier this week.

The five major NCDs are those we are all familiar with in the U.S.: cardiovascular diseases (CVDs), cancers, chronic respiratory diseases (CRDs), diabetes, and mental illness. The major NCD risk factors include poor diet and physical inactivity, tobacco use, and excessive alcohol use.

Currently, more than 60% of all deaths worldwide stem from NCDs. It is estimated that 80% of all NCD deaths occur in low and middle-income nations, up sharply from just under, 40% just twenty years ago.

NCDs have been established as a clear threat not only to human health, but also to development and economic growth. Once considered “diseases of affluence”, NCD’s have now encroached on developing countries, most of whom have limited health, education, and economic infrastructure to address the changing demographics in their countries.

A global analysis of the economic impact of NCDs recently released by the World Economic Forum and the Harvard School of Public Health reported that cumulative economic losses to low and middle-income countries are estimated to surpass US $7 trillion over the fifteen year period of 2011-2025 (an average of $500 billion per year). This yearly loss is equivalent to approximately 4% of these countries’ current annual output. The negative health and economic impact will put a major strain on the budgets of every country around the globe, especially low and middle-income nations.

For these reasons, world leaders came together for this two-day meeting to ratify a series of policies and action steps to address the burden of NCDs. Highlights included presentations from UN Secretary General Ban Ki-moon, Dr. Margaret Chan, Director General of the World Health Organization, 19 “Heads of State,” and leaders from a range of public and private foundations. Throughout the conference, collaboration between the public and private sectors of society was emphasized as the only viable, sustainable platform to reduce the growing and potentially devastating burden of NCDs around the world.

The UN High Level Conference on NCDs was only the first step in a multiple decades-long endeavor to avert a global health and economic crisis. Each nation, multi-national and national public and private organizations, and global business leaders were asked to pledge their political and economic support (to the best of their ability) to this global health initiative. Hopefully, over the next decade and beyond, we will be able to look back at this seminal event and recognize the importance of population health being on the world stage at this place in time.

To learn more about the UN High Level Meeting on NCDs and the global health NCD initiatives, here are some websites regarding the event and actions taken:

http://www.un.org/en/ga/ncdmeeting2011/

http://www.un.org/en/ga/president/65/issues/ncdiseases.shtml

http://www.who.int/nmh/events/un_ncd_summit2011/qa_hlm.pdf

http://www.un.org/apps/news/story.asp?NewsID=39642&Cr=non-communicable+diseases&Cr1=

Some just released resources on NCDs include:

“The Global Economic Burden of Non-communicable Diseases”, Harvard School of Public Health, World Economic Council, September, 2011

“Scaling Up Action Against Non-communicable Diseases: How Much Will It Cost”, World Health Organization, 2011

“From Burden to “Best Buys”: Reducing the Economic Impact of Non-communicable Disease in Low- and Middle-Income Countries”, World Health Organization, World Economic Forum, 2011

“NCDs: Time for Change”, Global Health, Issue 12, Fall, 2011, Global Health Council

“A Call to Action on Health Promotion Approaches to Non-Communicable Disease Prevention”, International Union for Health Promotion and Education”, September, 2011

BACK on the ROAD AGAIN

As the School of Population Health officially starts its second full academic year I want to take a moment to thank our entire team---the faculty and staff who make it possible for us to bring first-rate "in person and online content" to so many students around the nation. Right now we have more than 310 students taking at least one 3-credit course with us, either in person or online, across our 5 degree programs. It is thrilling for me to report these numbers to you!

On another note, I have been "back on the road again" preaching the gospel, if you would, of health reform through improvement, leadership, waste reduction, and care coordination. Everything that our school stands for and teaches. My message has been very well received...

This past week I was in Colorado Springs for the Fall meeting of the Governance Institute--I have served on their faculty for nearly 20 years and now I generally headline the opening day event. I spoke to almost 300 leaders from hospitals across the nation about the role of good governance in promoting quality and safety. The next day, I led the AHA Center for Governance Meeting in Boston, MA. I reiterated my message to this group and then led 2 workshops where we dug into the details about the structure and function of a good Board Committee on Quality.

Later in the week I attended the National Quality Forum Annual Awards Dinner and meeting in Washington, DC, and was in attendance when Norton Healthcare won the 2011 Annual Award. I am especially proud of Norton as they are partners with Humana in a successful Accountable Care Organization model in Louisville, KY. More on that another time.

I capped off the week with the closing plenary for the South Carolina Hospital Association at their meeting in Hilton Head Island. Here, I emphasized the need for care coordination and the creation of a physician leadership class. I also had the wonderful experience of signing scores of copies of my latest book, Demand Better.

Finally, I am especially proud of my ongoing affiliation with the Main Line Health System in suburban Philadelphia where I chair the Board Committee on Quality. In case you missed it, MLH was named by the Joint Commission as one of the very top systems in the entire country. Kudos should go to the leaders of MLH including Jack Lynch, Don Arthur, and Denise Murphy.

What are you doing to be a part of the solution for health care? DAVID NASH

Guest Commentary: RECs – Help for Ambulatory Care Physicians in Implementing EHRs

Richard Jacoby, MD
Clinical Associate Professor
Jefferson School of Population Health

Over the past year, states across the country have developed Regional Extension Centers (RECs) to support the electronic health record (EHR) initiative passed as part of the American Recovery and Reinvestment Act (ARRA) of 2009. Why is this important? With benefit of a little background information, the answer is pretty clear.

The evidence suggests -- and it is generally believed -- that adoption of EHRs by physicians and other health care providers is a critical first step in enhancing the quality and value of health care delivered in the U. S. However, adoption of electronic health records by physicians has been painfully slow in this country. How many of you still have to fill out a paper form when you visit your doctor?

The Health Information Technology for Economic and Clinical Health (HITECH) Act was included as part of ARRA to provide incentives for physicians and other health care providers to adopt and use EHRs in a meaningful way. By meeting HITECH criteria for “meaningful use”, physicians and other providers can qualify for up to $44,000 from Medicare and/or $63,750 from Medicaid to offset their EHR purchase costs. However, there is a stick to go along with the carrot. Beginning in 2015, CMS will impose financial penalties on providers who do not engage in meaningful use of health information technology.

But adopting and utilizing a new technology can be a daunting task – especially when the technology is implemented in the context of health care provider practices. Recognizing this, the HITECH act established and partially funded RECs to act as consultants – i.e. to support priority primary care providers and certain critical access hospitals in making choices, adopting, and “meaningfully using” EHRs.

RECs assist providers in evaluating the available EHR systems offered by different vendors and selecting one that meets the needs and budget of the practice. Next comes the really hard part – providers must re-engineer the way care is delivered in the practice to coincide with the new technology! It requires a detailed analysis of the practice workflow pre-and post-EHR implementation -- i.e., understanding what each employee currently does, and what that employee will do post-implementation, from the moment a patient enters the office until the time he/she leaves.

Once the practice is up and running with the new technology in place, challenges remain. Providers must understand and comply with specific rules in order for the practice to qualify for incentive payments. If all goes as planned, RECs may play an important role in helping with the transition from paper-based to electronic systems.

The Jefferson School of Population Health is providing services to physicians as part of the REC effort in Pennsylvania. For more information, contact Richard Jacoby, M.D. at richard.jacoby@jefferson.edu.

Guest Commentary: Revisiting Managed Care – 10 Years On

David Woods, PhD, FCPP
CEO, Health Care Media International
Adjunct Faculty, Jefferson College of Graduate Studies

More than decade ago I wrote a book for the Economist Intelligence Unit, The Future of the Managed Care Industry and its International Implications.

What's changed about managed care in 10 years? Well, certainly not public perception. In fact, in a poll at that time a solid majority of respondents believed that the quality of medical care would be harmed rather than improved by the trend toward more managed care.

Yet, despite subsequent studies showing that quality of care has not been demonstrably compromised under managed care, it is hard to find many friends of the system. The media cite horror stories about denial of care; and TV series featured doctors trying to do good despite managed care’s strictures.

Today, more than 80% of Americans insured by their employers are in some sort of managed care plan -- as are the overwhelming majority of doctors.

Alain Enthoven, PhD, a professor at Stanford University and a leading authority on healthcare systems and policy, defines managed care as a strategy used by purchasers of healthcare. Four essential principles of managed care are: selective provider contracting; utilization management; negotiated payment; and quality management.

The principal objection of patients to managed care was the prospect of being thrown out of the hospital within hours of major surgery. They also disliked the necessity of having to go through gatekeepers, typically primary care doctors, before being allowed to see a specialist.

One thing I certainly got wrong in the book was my contention that if managed care has achieved anything, it has slowed the breakneck speed at which US healthcare costs were growing. In fact, those costs have now reached a stratospheric $2.3 trillion a year.

So, according to the premise of my book’s title, I asked the question: What is the future for managed care? I answered it by saying that managed care will not only survive but thrive in the US. I also suggested that managed care would need to get away from the perception that its main function is to restrict care, but rather to supply a service to members that should include such care as is needed.

Managed care plans are seeking to rebuild damaged relationships with providers... and they're looking to shift more responsibility for payment on to users. As they move into less restrictive products they lose their ability to control costs, a fact that is likely to contribute to further premium increases, which in turn could put additional pressure on public programs.

In a recent interview, Dr Alain Enthoven told me that despite deficiencies in managed care that tend to favor fee-for-service delivery, Kaiser Permanente has prospered, he says, mainly because it has rolled out an electronic health record that has led to a cultural change both for patients and for physicians. What has impeded managed care’s progress, he says, is that employers continue to offer fee-for-service care and many have still not even tried managed care. And while managed care companies have made steady progress, employers still don't provide employees with incentives to choose economical healthcare.

Despite changes in managed care over the years, some of the original ambitious goals have not been achieved, including cost containment and universality. Some of the challenges of managed care might be obviated by passage of the Affordable Care Act. Unless the Act is significantly diluted it is perhaps the most significant change in healthcare delivery over the past decade. Gone will be denial of care for pre-existing conditions; and, for any type of insurance to work, the requirement that there be 100% enrollment is central.