Community health groups, with focus on prevention, fight to be part of new setup for lowering health costs, improving outcomes

The Patient Protection and Affordable Care Act is forcing doctors and hospitals to collaborate on lowering health-care costs while improving health outcomes. Community health groups that focus on preventive care are battling to be included as part of the solution, Laura Ungar reports for The Courier-Journal and USA Today.

One way physicians and hospitals are coming together to "reduce the duplication of services and keep large groups of patients well" is by forming accountable care organizations. Community health groups are having to fight for a "seat at the table" in these "doctor-dominated boards of ACOs," Ungar writes.

Such groups often offer less expensive, non-medical solutions for preventive health, according to a 2014 report by a North Carolina physicians' coalition. Some ACOs are beginning to include them as partners, but Bo Bobbitt, a Raleigh health-care lawyer who was lead author of the report, told Ungar, "The bad news is that the gap between the medical system treating illness and disease and the community health system was larger than we had feared."

Jose Pagan, a health economist who directs the New York Academy of Medicine's Center for Health Innovation, told Ungar that another key challenge is that doctors and hospitals are going to keep working to keep the money flowing their way. "If you go to a surgeon for a solution, they're not going to give you massage therapy," he says. "There's going to be progress, but it's going to be very slow."

Traditionally U.S. health care has focused its attention on "costly medical intervention," Ungar reports, instead of lifestyle changes, with only 3 percent of the $2.6 trillion health-care budget being spent public health and prevention, despite preventable chronic conditions accounting for 75 percent of medical care, according to a 2012 Institute of Medicine report.

"Compared to even the best medical therapy, we can decrease heart attacks, strokes and deaths by between 35 percent and 45 percent by changing lifestyle," Paul Rogers, a Louisville cardiologist at one of KentuckyOne Health System's healthy lifestyle centers, told Ungar.

For example, losing about 10 percent of weight reduces cardiac risks significantly, and losing 15 to 20 percent begins to reverse diabetes, lowers blood pressure, improves sleep and improves cholesterol level, Rogers said.

Another challenge for community-based programs is that little money goes into research on wellness programs, "and without studies, few will invest in their programs," Ungar notes.

Some members of Congress don't see nutrition, physical fitness or stop-smoking campaigns as health funding and gripe about the "nanny factor," Georges Benjamin, a physician who is executive director of the American Public Health Association, told Ungar.

As a result, "annual funding authorized by the ACA for the Prevention and Public Health Fund was supposed to hit $2 billion starting in 2015 but won't reach that level until at least 2022," Ungar reports.

Lifestyle changes are known to help chronic conditions, and Ungar gives many examples in the article. Here is one: Kevin French, 57, a construction contractor in Louisville, told Ungar that he began having chest pain and had to have two stents implanted in his heart in 1993.  And through cardiac rehab, he learned that his previous eating habits, which included lots of fast food, lack of exercise and smoking, played a big part in his heart problems. But with the help of the healthy lifestyle center, he said he  has "basically changed everything" about  his lifestyle and that's "improved not only his health but his family's as well."

Clinton, Beshear, Humana chief and others discuss Medicaid expansion, other changes in health systems, and chronic illness

By Melissa Patrick and Al Cross
Kentucky Health News

The economic advantages from expanding Medicaid under federal health reform should outweigh any ideology that is holding states back from participating in it.

At least that was the consensus of a panel discussion about economics and health care led by former President Bill Clinton on Jan. 27, the last day of the Clinton Foundation's fourth annual Health Matters Activation Summit in Coachella Valley, Calif.

Gov. Steve Beshear, the leadoff panelist, said the Patient Protection and Affordable Care Act is a "transformative tool" to help change the dire health statistics in Kentucky, and while the decision to expand the Medicaid program to people with incomes up to 138 percent of the federal poverty level was "morally the right thing to do," it was economically the right thing to do, too.

Citing figures from a PriceWaterhouse Coopers study that predicted Medicaid expansion would bring money and jobs to Kentucky by expanding health care, he also said it would help create a healthier workforce to compete for jobs and this would give Kentucky an economic advantage over the surrounding states that didn't expand Medicaid.

"We are going to go past them pretty fast, from an economic standpoint," the governor said.

The study Beshear cited is being replicated to give a fresh forecast of the expansion's economic impact now that the state has a year's experience -- a year in which Medicaid enrolled more people than the first study said would enroll by 2020, and two-thirds as many health jobs were created as the predicted number for 2020. Republicans have voiced doubt that the expansion will pay for itself once the state has to pay for part of it: 5 percent in 2017, rising to the law's cap of 10 percent in 2020.

Clinton, a Democrat, said Republican-run states that had used Republican consultants for their Medicaid studies had found that expansion would pay for itself. Laughing, Clinton said the reports weren't well read because they didn't say what the Republicans had wanted them to say, and the consultants replied that "Yes, they were Republicans, but they also believed in arithmetic."

Trevor Fetter, president and CEO of Texas-based Tenet Healthcare, said that as a provider and member of the Texas business community, "It is a big mistake not to expand Medicaid, not to offer this access." He said many in Texas are "trapped" because the state hasn't expanded Medicaid and they make too much to qualify for it and too little to qualify for the federal subsidies for private insurance.

Meredith Rosenthal, professor of health economics and policy at the Harvard School of Public Health, said, "The most compelling argument for those who resist coverage expansion is an economic one," especially because health care is the largest employer in most communities.

The most talkative panelist was Bruce Broussard, president and CEO of Louisville-based insurer Humana Inc. He said expansion "is a good thing" because it allows access to insurance for people as they move or change jobs, decreases the burden of stress on the under-served and will save businesses money because it costs less to take care of healthy people than sick ones.

In discussing the health-care industry's new focus on patient outcomes, Broussard said outcomes will improve as the U.S. shifts from model built around treating episodic conditions to one that treats chronic conditions.

"It's not about the insurance, it's not about the treatment. It's how do we help people stay healthy no matter where they are in their journey," he said to a round of applause.

Experts say rising levels of chronic disease among baby boomers are a major concern. Clinton asked the panel to name the one thing we need to do that isn't being done now to deal with chronic conditions like diabetes.

Broussard said yearly health assessments "would help people make better health decisions." It is important to tell them what their current health is, relative to where it should be. "When people know their numbers, they make more effective decisions," he said.

Rosenthal said, to a room full of applause, "The biggest thing you could do to prevent diabetes in this country is to look at the agriculture policy." Clinton suggested working directly with all of the stakeholders involved in food production and distribution to create change.

The discussion shifted to the role of transparency and interoperability (different systems working together) in health-care finance as a way to improve health outcomes and decrease costs. Michael Peterson, president of the Peter G. Peterson Foundation, said "We are spending 3 trillion dollars a year without any regard to cost or quality."

Broussard said, "I think interoperability will bring transparency, better data analytics and will empower the consumer."

Beshear said Kentucky has already shifted to a pay-for-performance model by switching Medicaid to managed care, in which insurance companies are paid a flat fee per person as an incentive to limit costs.

"We want people to learn how to take care of themselves and to take responsibility for themselves and stay well," he said. "And if we are successful in doing that, we will bend this cost curve."

As for the reform law, Beshear said that while there is still work to do, "We've got to get past this talk of we're going to throw the whole baby out with the bath water" and make it work.

"The ACA is not going anywhere as far as I'm concerned," he said. "It is going to stay and we are going to implement it and we are going to better the lives of our people."