03 New Slides
7/7/2006
What We Hope To Accomplish
• Importance of a Transformative Approach
9 Shifting & broadening the discourse on health
reform
Blue Sky
• Incremental
• Comprehensive
• Transformative
Rethinking Health System Reform
AcademyHealth Research Meeting
June 26, 2006
Center for Healthier Children,
Families & Communities
9 Responsive & Strategic Value
• New Framework to Guide Health System
Transformation
• Engage Health Services and Policy Communities in
supporting this approach
Center for Healthier Children,
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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
9 Cost, Access, Quality and Disparities are usually
considered as significant and independent problems
rather than as symptoms of more fundamental
systems dysfunction
9 Comprehensive reform must extend beyond the
Medical Care Sector
•
Incremental & piecemeal approaches are
inadequate and tend to maintain the status quo
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03 New Slides
7/7/2006
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
Population
Health
Sector
Public
Health
Sector
Medical Care Sector
Civic Sector
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Center for Healthier Children,
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The Evolving Health System
•
The First Era
Word
Word
Perfect
Word
Plus
286
CPU
286
CPU
286
CPU
9 Focus on acute and infectious disease
9 Vertically integrated operating system
9 Insurance-based financing
•
The Second (current) Era
• Medical Applications
9 Focus on chronic disease
9 Sub specialization, increased technology →increased costs
9 Prepaid benefits
•
• Public Health Applications
• Population Health Applications
The Third (emerging) Era
9 Focus on optimal health status
9 Need for new operating system
Center for Healthier Children,
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Word
Memory
386
CPU
Center for Healthier Children,
Families & Communities
Word
Perfect
386
CPU
Memory
Word
Plus
386
CPU
Word
Perfect
Memory
386
CPU
Word
Perfect
386
CPU
• Medical Applications
• Medical Applications
• Public Health Applications
• Public Health Applications
• Population Health Applications
• Population Health Applications
Center for Healthier Children,
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Memory
Word
Plus
386
CPU
Center for Healthier Children,
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2
03 New Slides
7/7/2006
Common Operating System: Windows
Inputs into Health & Well-Being
Public
Health
Sector
Medical Care Sector
internet
Pentium 2.6 GHz
Pentium 2.6 GHz
Population
Health
Sector
Pentium 2.6 GHz
• Medical Applications
• Public Health Applications
Civic Sector
• Population Health Applications
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Center for Healthier Children,
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Blue Sky Framework
Components
Current System
Transformed
System
Logic
Change Strategies
Logic
• The Current System
Organization of Health
Producing Sectors
9 Infectious disease control
9 Chronic disease management and prevention
9 Medical Care predominates
Organization & Delivery
of Individual Care
Medical Education &
Workforce
• The Future System
Market
9 Optimizing population health across the life span
9 Disease prevention and health promotion focused on reducing
risks, enhancing protective factors, and enabling health promoting
pathways for individuals and populations
9 Delaying and compressing morbidity (optimizing health across the
life span)
Funding
Planning
Regulation & Governance
Performance Monitoring
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How Risk Reduction and Health Promotion Strategies
influence Health Development
Risk Factors
RR
Risk Reduction Strategies
HP
Health Promotion Strategies
Health Development
Trajectory Without RR and HP
Strategies
Optimal Trajectory
RR
RR
HP
9 Consumers
9 Business
9 Policy makers
HP
• Research
Protective Factors
0
• Communication about needed changes:
• Leadership
RR
HP
Logic – Change Strategies
20
40
Age (Years)
60
80
From: Halfon, N., M. Inkelas, and M. Hochstein. 2000. The Milbank Quarterly 78(3):447497.
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3
03 New Slides
7/7/2006
Blue Sky Framework
Components
Current System
Transformed
System
Organization of HealthProducing Sectors
Change Strategies
• Sectors in the Current System
Logic
9
9
9
9
Organization of Health
Producing Sectors
Organization & Delivery of
Individual Care
Medical Education &
Workforce
• The Future System
Market
9 Strategic linkages across sectors to facilitate integration along
service delivery pathways
9 Workforce growth in public health, population and civic sectors
9 Medical education incorporating concepts of and opportunities to
experience integrated, placed-based care
Funding
Planning
Regulation & Governance
Performance Monitoring
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Center for Healthier Children,
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Blue Sky Framework
System Organization – Change
Strategies
• Coordinate and integrate across sectors
9 Form community pathways
9 Support with IT
• Integrate over the life cycle
9 Support with IT
Medical (dominant)
Public Health (under funded)
Population Health (limited)
Civic (ignored)
Components
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
• Align financing mechanisms with new goals
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Organization and Delivery
of Individual Care
Performance Monitoring
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Inputs into Health & Well-Being
Medical Care
Sector
• The Current System
Public
Health
Sector
Specialty
Care
9 Subspecialty care is medically focused and institutionally centered
9 Increasing technological sophistication (and cost) of Dx and Rx
Population
Health
“Sector”
• The Future System
9 Patient centered, community based, primary care model (increased
use of place-based and non-traditional service locations)
9 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
Center for Healthier Children,
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Primary
Care
Civic
Sector
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4
03 New Slides
7/7/2006
Inputs into Health & Well-Being
Specialty
Care
Medical
Care Sector
Specialty
Care
Public
Health
Sector
Primary Care
Population
Health
“Sector”
Individual Care – Change Strategies
•
9 In communities
9 In primary care
•
Specialty
Care
•
Civic
Sector
Center for Healthier Children,
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Shift emphasis from specialty medical care to
preventive 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
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Blue Sky Framework
Components
Current System
Transformed
System
Market
Change Strategies
• The Current System
Logic
Organization of Health
Producing Sectors
9 Mixed private and public market with no coordinating mechanism
9 Mismatch of private incentives and public interest
9 Consumers lack information needed to make informed choice of
providers
Organization & Delivery of
Individual Care
Medical Education &
Workforce
• The Future System
Market
Funding
9 Embedded, mixed market focused on maximizing the common
good, and organized to support the public interest
9 Consumer choice of providers (i.e., health care providers as well as
facilities) informed by more complete knowledge
Planning
Regulation & Governance
Performance Monitoring
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Government – (Medicare, Medicaid)
Government – (Medicare, Medicaid)
Business
Business
Private Sources
Private Sources
Health
Trust
Health
Plan
Health
Plan
Health
Plan
P
U
B
L
I
C
Health
Plan
H
E
A
L
T
H
Center for Healthier Children,
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Health
Plan
Health
Plan
L
I
N
K
A
G
E
Population Health Services
Center for Healthier Children,
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03 New Slides
7/7/2006
Blue Sky Framework
Market – Change Strategies
Components
• 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
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
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Center for Healthier Children,
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Funding
Funding-Change Strategies
• The Current System
• Upfront investment in realigning the system
• Independent entity to oversee health
financing mechanisms
9 Mixed but uncoordinated public and private sources of funding
9 Limited public health funding (apart from recent influx of
bioterrorism funds)
9 Differential access to population health services
9 Ensure evidence-based funding decisions at the
community level
9Advocate for population health investments
• The Future System
9
9
9
9
Current 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
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“Thinking Big, Thinking Small, and Not Thinking at All”
(Robert Goodin and Ilmar Waldner. Public Policy, Winter 1979)
The Politics of Transformative
Policy Making
“Punctuated equilibria”
(Frank Baumgartner and Bryan Jones, Agendas and Instability in American Politics)
ƒ
ƒ
ƒ
ƒ
ƒ
Center for Healthier Children,
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Manhattan project
National Defense Highway System
Apollo Moon Landing Mission
Reversal on Nuclear Power
Even Social Security
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6
03 New Slides
7/7/2006
John Kingdon—Three Streams
Domestic Policy Mood of the Nation
(Agendas, Alternatives, and Public Policies)
Source: James A. Stimson, Tides of Consent, Figure 3.6, p. 81
75
Policies
Liberalism (Percent)
70
Window of
Opportunity
60
55
50
Center for Healthier Children,
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20
00
19
96
19
92
19
88
19
84
19
80
19
76
19
72
19
68
19
56
19
60
19
64
45
19
52
Pr
ob
lem
s
cs
iti
l
Po
65
Center for Healthier Children,
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Kingdon—The Policy Window and Possible Triggers
Policy
Social
Learning
Effects
Political
Lessons
Pr
ob
lem Systematic Signs
s of Decline or
Change in
Congress (2006?)
Missed
Opportunities?
Center for Healthier Children,
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Framing and Reframing
Stakeholder
Organized
Interests
Interests
e
ns
Past
Policy
Action/
Inaction
Se
Major Crises
(health care system
tipping point?)
Routine
Policy
Experts
Analysis
on
mm
cs
iti
l
Po
Policy
Lessons
(What Works)
Window of
Opportunity
Swing in the
National Mood
Lesson Drawing in American Policy Making
Co
Change in
Administration
(2008?)
Disruption of
Interest Group
Alliances?
Viable Policy
Option
(Blue Sky)
Politicians
(What’s Doable)
Major
Change
© 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).
Center for Healthier Children,
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Visible “Polled”
Attitude
Issue
ƒ Without effective communication, people
default to the dominant “pictures in their
heads”
Model A
ƒ 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
Center for Healthier Children,
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Implication 1
(current dominant)
Model B
Implication 2
Implication 3
Implication 4
Implication 5
Implication 6
© 2006 Frameworks Institute—Susan Bales and Frank Gilliam
Center for Healthier Children,
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Model C
Implication 7
Implication 8
Implication 9
7
03 New Slides
7/7/2006
People Need Values Cues
This Direction Not Work
(Based on George Lakoff)
Frameworks Institute: Most Convincing Values-based Messages
7.9
Interdependence
ƒ Level One: Big ideas, like freedom,
individual rights/responsibilities, justice,
prevention, family, equality, security, and
opportunity
ƒ Level Two: Issue-types, like women’s
rights, the environment, children’s issues,
work
ƒ Level Three: Specific proposals, like the
earned income tax credit, day care,
affordable housing, minimum wage
© 2006 Frameworks Institute—Susan Bales and Frank Gilliam
For 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.
Practical Manager – Step-by-Step
7.9
There 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.
7.8
Prevention
Quality 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.
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
Rights
7.5
Every 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.
© 2006 Frameworks Institute—Susan Bales and Frank Gilliam
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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
ƒ Level One: Interdependence, prevention,
security, equality, and opportunity
ƒ Level Two: Health system infrastructure
ƒ Level Three: Blue Sky Health and Health
Care System Framework and Architecture
© 2006 Frameworks Institute—Susan Bales and Frank Gilliam (amended)
© 2006 Frameworks Institute—Susan Bales and Frank Gilliam
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Center for Healthier Children,
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Visible “Polled”
Attitude
Issue
Consumer
InterInterdependent
Personal cost issue
Reform: “Do me no harm”
harm”
Every one is in this together
The Biggest Political
Challenge
Need an infrastructure
Current system inefficient and unreliable
© 2006 Frameworks Institute—Susan Bales and Frank Gilliam (amended)
Center for Healthier Children,
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Private good
Prevention
Stay healthy
Self financing
Healthy others
mean healthier me
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8
03 New Slides
7/7/2006
Ideological Positions on House Roll Call Votes, 93rd Congress (1973-74)
The Public’s Political Ideology
(Source: Poole and Rosenthal, http://voteview.uh.edu/dwnomin.htm)
(Source: 1972 National Election Study)
38%
80
70
Number of Representatives
40
35
30
25
20
15
10
60
50
All
Republicans
Democrats
40
30
20
10
5
0
Ext Lib
Liberal
Slight Lib
Moderate
Slight Cons
Conserv
0
Ext Conserv
-1
-0.8
Center for Healthier Children,
Families & Communities
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
1
Dw-Nominate Scores (1st Dimension)
Variable 720652, responses only (N=1,157); excluded “Haven’t thought much about it” (N=467) and “don’t know (N=140)
Center for Healthier Children,
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Ideological Positions on House Roll Call Votes, 107th Congress (2001-02)
The Public’s Political Ideology
(Source: Poole and Rosenthal, http://voteview.uh.edu/dwnomin.htm)
(Source: 2000 National Election Study)
3%
70
35
Number of Representatives
30
25
20
15
10
5
60
50
All
Republicans
Democrats
40
30
20
10
0
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)
Center for Healthier Children,
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0
-1
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
1
DW-Nominate Scores (1st Dimension)
Center for Healthier Children,
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80
Understanding Differences Among Public’s Perception
of Needs, the Experts Assessments, and the Political
Assessments
Number of Representatives
70
60
50
40
30
20
10
0
-1
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
Public’s
perceived needs,
priorities
1
Dw-Nominate Scores (1st Dimension)
Number of Representatives
70
C
“Actual
needs”
A
A
D
60
E
50
B
40
Resources,
feasibilities,
policy
30
20
10
0
-1
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
DW-Nominate Scores (1st Dimension)
Center for Healthier Children,
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0.6
0.8
1
LW Green, Inst of Health Promotion Research, Univ. British Columbia, Vancouver, BC V6T 1Z3
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9
03 New Slides
7/7/2006
Summary
Strategies to Reconcile Perceived &
Actual Needs, & Resources
• Importance of a Transformative Approach
9 Shifting & broadening the discourse on health reform
• Incremental
• Comprehensive
• Transformative
Strategic Research
A
A
9 Responsive & Strategic Value
Strategic
Communications
• New Framework to Guide Health System
Transformation
• Engage you in supporting this transformative
approach & moving this forward
(Framing & advocacy
Strategic mobilization
& organizational
Development (state & local)
Adapted from LW Green & MW
Kreuter,1999.
www.chcfc@ucla.edu
Center for Healthier Children,
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Center for Healthier Children,
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Historical and Projected Components
of Federal Spending, 1962 – 2050
CBO Projection of Social Security,
Medicare, and Medicaid
45.0
2.5 Percent Excess Cost Growth
(Simulation 1)
Actual
Predicted
40.0
30.0
Long-term Revenue 18.4%
2.5 Percent Excess Cost Growth
35.0
25.0
Percent of GDP
Percent of GDP
30.0
20.0
18 percent
15.0
Medicaid
10.0
Medicare
25.0
20.0
15.0
Social Security,
Medicare, Medicaid
10.0
5.0
5.0
Social Security
Defense
19
62
19
65
19
68
19
71
19
74
19
77
19
80
19
83
19
86
19
89
19
92
19
95
19
98
20
01
20
04
20
07
20
10
20
13
20
16
20
19
20
22
20
25
20
28
20
31
20
34
20
37
20
40
20
43
20
46
20
49
20
47
20
49
20
45
20
41
20
43
20
39
20
35
20
37
20
31
20
33
20
27
20
29
20
25
20
21
20
23
20
19
20
15
20
17
20
11
20
13
20
07
20
09
0.0
20
05
20
03
0.0
Interest
Other Federal
Spending
Fiscal Year
Year
Source: Congressional Budget Office
Source: See figure 1, page 2 of Restoring Fiscal Sanity 2005
Center for Healthier Children,
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10