Baton Rouge, Louisiana Nov. 12, 2014
2 SUMMARY Louisiana s high rates of obesity and chronic disease, in combination with its high healthcare costs, provided the backdrop for The Atlantic s inaugural Inventing the Future of Health event. The event, which was held on Nov. 12, 2014, in Baton Rouge, convened leading healthcare experts for a series of conversations focused on improving health outcomes for patients and building a stronger and more affordable healthcare system in the state. The event, which was moderated by Atlantic Washington Editor-at-Large Steve Clemons, featured one-on-one interviews with Janet Wright, Executive Director of Million Hearts, who highlighted the applications, devices and technologies that are allowing individuals to self-manage their health as well as best practices for inspiring collective action in local health, and Elliott Fisher, Director of the Dartmouth Institute for Health Policy and Clinical Practice, who talked about healthcare payment reform, the impact of the physical environment on population health and how physicians and healthcare systems can better engage patients in their own care. Clemons also moderated an expert panel representing academia, industry, consumers and providers that featured Peter Katzmarzyk, Associate Executive Director of the Pennington Biomedical Research Center; Warner Thomas, President and Chief Executive Officer of Ochsner Health System; Randy Watson, Director of Insurance of the Caddo Parish School Board; and Clayton Williams, Director of Health Systems Development at the Louisiana Public Health Institute, which looked at healthcare costs and quality and focused on the most pressing health challenges facing Louisiana. Following the public program, a select group of guests participated in a roundtable lunch discussion focused on key takeaways from the event. The conversation was firmly grounded in regional socioeconomic influences, and the group spoke candidly about the challenges facing Louisiana and discussed ways to work together to identify potential solutions. More than 160 guests representing the full spectrum of those involved in healthcare medical practitioners, business leaders, heads of academic institutions, researchers, community organizers, patient advocates, public health officials and others attended the event at the Pennington Biomedical Research Center. In addition, four watch parties were held, allowing viewers across the state to watch a live stream of the event and participate in the program s public proceedings in real time. Overall, 665 people viewed the live stream, including 37 people from outside the U.S. The event garnered more than 375 tweets and the dedicated event hashtag, #ATLFutureHealth, was trending in Baton Rouge throughout the afternoon, as viewers from across the state submitted their questions and comments directly to speakers and panelists through social media.
3 SELF-MANAGEMENT AS A PATHWAY TO BETTER CARE The program opened with Atlantic Washington Editor-at- Large Steve Clemons in conversation with Dr. Janet Wright, Executive Director of Million Hearts, a joint project between the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid that aims to prevent one million heart attacks and strokes by 2017. Data that offers biometric and behavioral information is critical to prevention, explained Dr. Wright, who said she believes that this is the most exciting time ever in cardiovascular disease. Dr. Wright called attention to what can be learned from communities that are seeing positive changes and how individuals and health systems can make changes based on the increasing availability of data and better predictive models. The conversation repeatedly circled back to wearable technologies and mobile applications and the potential behavioral changes that could result from their feedback. Touting his own Fitbit, Clemons asked Dr. Wright for her view on the role of new wearable technologies and their capacity to provide a platform for more consistent patient care. Using the example of diabetics, who are taught to monitor their blood sugar and inject insulin, she contrasted the self-management model with the way we approach blood pressure control, saying: Devices and technology can help with this, devices that we can wear or blood pressures that we can monitor at home, sending those pressures back to the treating provider and making sure that we get timely advice back to the individual. Creating that new loop and that self-management will actually help bring blood pressures down. Dr. Wright also emphasized the impact of community health initiatives. Through her work at Million Hearts, she has seen that the most significant improvements in health outcomes come from community organizations like churches, barber shops, libraries and local establishments where residents gather. Training and supporting community health workers and raising awareness of the powerful ways we can use data, she noted, is critical to empowering individuals to become investors in their own health. FIXING THE SYSTEM: THE NEED FOR REFORM The next group to join moderator Steve Clemons was an expert panel featuring Peter Katzmarzyk, Associate Executive Director of the Pennington Biomedical Research Center; Warner Thomas, President and Chief Executive Officer of Ochsner Health System; Randy Watson, Director of Insurance of the Caddo Parish School Board; and Clayton Williams, Director of Health Systems Development at the Louisiana Public Health Institute. Early in the discussion, Clemons asked Thomas a provocative question. If you were made all-powerful, if you were given a magic wand to change things dramatically, what would you most shift to get a radically different profile when it comes to managing chronic disease? Thomas s answer came quickly: Changing the medical payment system to reward quality care and better outcomes, and giving people incentives to improve their own behaviors and health. The majority of the things, the determinations of health of a population, don t happen in the doctor s office. These are environmental factors, behaviors, genetics, things like that. So we need to pay attention to health literacy. -Clayton Williams Watson pointed to primary care systems as an overlooked opportunity, particularly as more pressure is shifted onto providers to achieve higher-quality outcomes. How can adequate resources be channeled into primary care? I m a believer that the industry needs to reform itself, Watson said. The government is not going to reform us. He said more people need to understand that the current system isn t sustainable. When the money runs out, the provider s going to have to cut cost, and quality is going to get even poorer. We can t get there from here. We can t, he cautioned.
4 Clayton Williams, who works primarily with underserved, uninsured populations in Louisiana, likewise views outdated fee-for-service payment systems as a major hurdle in achieving better health outcomes. He proposed that pay-for-value, or value-based care, systems in which providers are awarded for attaining good outcomes for their patients, are the most effective, and his fellow panelists concurred. This is especially true when approaching the biggest public health concerns in Louisiana, which Peter Katzmarzyk identified as obesity and health literacy. With 50 percent of children in Louisiana overweight or obese, the health system is going to face a double burden in the coming decades, and with a ranking of 49th in the nation in health literacy, there s a long road ahead. The conversation concluded by identifying key questions that need to be asked and addressed if there is going to be significant change in the health status of Louisiana s residents. How can providers target approaches to women and children? What can small businesses which have fewer resources than larger corporations do to make a difference in their employees health? Considering costs associated with selfmonitoring devices and technologies, how can their usage evolve and most effectively be integrated with traditional medical office practices? What role can social media play in this process, and what steps need to be taken to make widespread health literacy a priority? We have a one-size-fits-all system, essentially, and that has to change, Watson insisted. And that means we re all going to have to put ourselves on the line. And again, I think that we have to get away from this adversarial approach and we have to sit down and work together. Think about healthcare. We spend more dollars in healthcare than almost any other industry. And where do you go when you buy a product or a service that you can t research it and look at the price of it, look at the quality of it? We don t do that. We have one-size-fits-all essentially, and that has to change. And that means we re all going to have to put ourselves on the line. And again, I think that we have to get away from this adversarial approach and we have to sit down and work together. -Randy Watson PRIORITIZING PRIMARY CARE: LESSONS LEARNED FROM HIGH- PERFORMING COMMUNITIES To conclude the day s program, Dr. Elliott Fisher, Director of the Dartmouth Institute for Health Policy and Clinical Practice, sat down with Steve Clemons for a one-on-one conversation about accountable care organizations, or ACOs. Citing Dr. Fisher s research into low-resource communities that are performing well on key healthcare indicators, Clemons opened the interview by asking about his findings: why is that the case, and what can be learned from it? We could probably reduce percapita spending by about 30 percent if we were able to mimic the highperforming healthcare systems in the United States that are predominantly primary-care oriented fewer specialists per capita, and patients spending less time in the hospital. -Dr. Elliott Fisher Fisher reflected on the physical and environmental factors that contribute significantly to health outcomes. Remarking that both health and healthcare are locally produced, he called attention to the links between urban design, school quality, community initiatives and other determining attributes that affect health in different environments.
5 Echoing commentary from earlier in the program, Fisher also spoke to the need for payment reform, as well as to the hurdles in changing large, entrenched fee-for-service organizations. The changes, he indicated, will need to come from the top, with payers and medical practitioners agreeing to move toward the new model. Fisher, who coined the term accountable care organization in 2006, recognized BlueCross BlueShield of Massachusetts as sponsoring a leading ACO in the country and an example of a private payers moving in the direction of system reform. The federal government, as would be expected, is harder to change, though Fisher applauded several members of Congress who are working to improve the ACO model. Clemons asked Fisher to identify specific ways Louisiana could spark improvement. Fisher said Louisiana care systems should become further coordinated and integrated, with savings reinvested in programs like early childhood education and obesity prevention. Yes, it is collaboration, but it is recognizing that it s neither the market nor regulation. It s community action toward overcoming important and complex social problems -Dr. Elliott Fisher WORKING TOGETHER: A ROUNDTABLE LUNCH DISCUSSION Following the program, a smaller group of attendees participated in a solutions-oriented roundtable lunch conversation that deepened the discussion among key guests. The conversation focused on Louisiana Baton Rouge in particular and its socioeconomic challenges, with obesity one of the state s top health concerns. Participants noted that obesity can start early, and affects children from a very young age. This is especially prevalent in the poorest areas of the state, where the food children are served both at home and in schools is lacking in nutritional value. Kathy West of Volunteer Health Corps offered insight: You truly cannot underestimate the depth of entrenched poverty, she said. You can t sit up at the top and make these decisions. We have the highest illiteracy [rate] in the country in Baton Rouge, with deeply entrenched poverty and racism overlapped. She emphasized that building health literacy is a steep but necessary hill to climb. Participants agreed that strong educational programs rooted in school and healthcare systems are critical, but differed in their proposed responses. Some, like Perry Russell of Riverside Internal Medicine and Pediatrics, looked to technology as an opportunity for engagement; others, like Frank Smart from
6 Louisiana State University Health Sciences Center New Orleans, turned a critical eye to the concept of seeking solutions in technology. Community Initiatives Foundation s Sr. Judith Brun spoke in support of extension services brought into communities to lead behavioral training: for example, by teaching residents how to cook or use everyday appliances. She also highlighted the benefits that can come from utilizing nonmedical professionals like AmeriCorps volunteers to bring about local change at a lower cost. When it comes to obesity, though, panelist Peter Katzmarzyk pointed out that often obese children in high-risk areas where the condition is prevalent simply look the same as any other child. David Carmouche echoed this sentiment, saying that changing community perceptions of what is and is not healthy will be an important step toward lowering obesity rates. Russell identified reducing the duplication of services as another major step as panelist Randy Watson lamented, when primary care doctors refer patients to hospitals or specialists, they cease to be a part of the process going forward. Instead, each doctor has his own chart, runs his own labs, and throws more money into that patient s care, which is not always the answer. Making it clear to patients that they must have a primary care physician, perhaps even as a condition for getting health benefits, was proposed as a means for employers to drive better care from the front lines. Several participants also brought mental health issues into the discussion, noting that in many communities, mental health WHAT WILL CHANGE THE FUTURE OF HEALTH? KEY RECOMMENDATIONS Emphasize primary care relationships Develop effective ways to share data from applications and devices Engage in community-driven efforts that spark empowerment at the local level Reform payment toward a pay-for-value system Target efforts to enhance health literacy across the state problems must be addressed to have significant impact on individuals, communities and the broader healthcare system. At the lunch s conclusion, participants and hosts alike expressed their gratitude to have been part of the discussion and their commitment to taking additional action toward improving Louisiana s overall health and its healthcare system.