Monday, May 28, 2012

Prevention attention

Along with more federal funding for public health available through the ACA, providers and other private organizations are stepping up investment in c

Prevention attention:Along with more federal funding for public health available through the ACA, providers and other private organizations are stepping up investment in community health initiativesBy Jaimy Lee

Earlier this year, Partners HealthCare awarded nearly $1 million to support health prevention programs in four eastern Massachusetts cities served by the system's hospitals.

While Boston-based Partners has funded some local prevention programs for years, the financial commitment reflects a greater focus by the health system to look at the role prevention can play in lowering costs, notably as Partners moves forward as one of the participants in the CMS' Pioneer model for accountable care organizations.

“Now we recognize that we're accountable in a more direct way for the well-being of populations,” says Matt Fishman, Partners' vice president of community health.

As part of the commitment, the health system promised the Boston-area cities of Chelsea, Lynn, Revere and Salem a $60,000 gift each every year for four years. The funding will enable Salem and Lynn to join Mass in Motion, a state-led obesity prevention effort, while Chelsea's funding will support a community-based coalition, and Revere will use the support to help fund a public-private partnership between the city and an organization called Revere Cares.

It's the first time that Partners, which has said the goal of the $960,000 in funding is to improve access to healthy and affordable foods and physical activities, has supported neighborhood-level or city-level prevention programs in Lynn and Salem, Fishman said.

The 12-hospital system owns multiple hospitals in and around the four cities.

“The important thing is that it's much, much better for the patient, but it's also going to be better for the healthcare system that we're operating as part of,” Fishman says. “There is a greater focus on this kind of activity here than there was five years ago, or even than there was one or two years ago.”

Even with the allocation of billions of dollars for prevention and public health as part of the Patient Protection and Affordable Care Act, prevention has clearly become a key area of investment for healthcare providers.

Hospitals have traditionally been slow to fully take on prevention responsibilities in the communities they serve. However, the shift away from a fee-for-service payment model has led to a change in the way some providers, such as Partners, think about prevention.

This move forward by providers, as well as by private insurers and foundations, to look more critically at the role of prevention comes at a time when state and local governments are dealing with ongoing cuts to prevention and public health funding.

The National Association of County & City Health Officials released a study in October that found 55% of all local health departments had to reduce or eliminate at least one program and 43% lost at least one employee from July 2010 to June 2011.

“Public health faces a number of challenges, including insufficient funding to fulfill its mission, a shrinking workforce, and inadequate investments in health information technology,” the Institute of Medicine said in a recent report.

However, one bright spot for prevention supporters has been the formation of the Prevention and Public Health Fund, the multibillion-dollar fund that was included in the Affordable Care Act.

So far, the fund has distributed $2.25 billion to community prevention, clinical prevention, infrastructure and training, and research and tracking programs. Another $1 billion will be awarded during federal fiscal 2013.

However, the fund has also served as a continual possible source of funding to offset budget deficits in Washington. The funding levels remained intact until February's passage of the Middle Class Tax Relief and Job Creation Act, which cut the fund by $6.25 billion though fiscal 2021 in part to avert the 27.4% cut in Medicare payments to physicians for the rest of this year (See chart).

“It's unfortunate because in the early part of the discussions of the Affordable Care Act, it was the first time prevention had been elevated to prominence in the discussions about healthcare reform,” says Dr. James Marks, senior vice president and director of the health group at the Robert Wood Johnson Foundation.

Two months later, lawmakers proposed to repeal the Prevention and Public Health Fund as part of legislation that would prevent student loan interest rates from doubling. In an April 27 statement, the White House Office of Management and Budget said the proposal was “politically motivated” and President Obama's advisers would recommend that that he veto the bill.

Prevention proponents say that because less than 5% of national health spending goes to public health, the fund is needed to enhance public health and prevention funding. Opponents call it a “slush fund.”

Richard Hamburg, deputy director of the Trust for America's Health, says the administration's statement will make it nearly impossible for the fund to be repealed or defunded in the future.

“The administration has been very supportive of the fund despite the fact that there was a negotiated cut in the fund a couple months ago,” Hamburg says. “They've been very supportive and have defended efforts to completely eviscerate the fund and this would be the most public statement in support of the fund.”

Not-for-profit organizations such as the TFAH say that they and large employers recognized the need for community-based prevention decades ago. Marks, of the RWJF, notes that large companies can often see an improvement in their bottom line within three to five years when they address worksite health promotion.

“Even the most innovative ones are starting to say, ‘It's important for us to help our communities be healthy, too. That's where the family members live. That's where we're going to hire new employees from. It's better for us when they are healthier,' ” Marks says.

There has also been as shift in how the foundation, which awarded about $300 million in public health grants in 2010, assesses programs to fund. Marks says the RWJF has started to look at the outcomes of a body of work rather than what a single grant can produce.

“We're thinking of this in a bigger picture way and I think other foundations are starting to do that, too,” Marks says. “We're reaching out to a much broader array of partners than we ever had before. We see it as crucial for our country that our private sector is strong and that they recognize how important it is for them that our nation's healthcare costs growth are slowing.”

In addition, some hospitals and health systems are starting to “step up,” by helping address public health issues through medical care or community support, Marks says.

“We think that's an important bridge to build between clinical care and public health,” Marks says. “They've been separate in their actions for too long and helping build bridges and connections and seeing how they can be supportive of each other is something we think is important for the long run.”

Partners' Fishman says that the health system expects its financial investment in prevention to serve as a support to federal and state prevention programs, such as the Centers for Disease Control and Prevention's Community Transformation Grants, which aim to reduce chronic diseases, and Massachusetts' Mass in Motion initiative.

It also supports Partners' participation in the Pioneer ACO program.

Increasing engagement in primary care, reducing emergency department utilization and avoiding hospitalizations and readmissions are important. So is ensuring that elderly patients receive immunizations for pneumonia and the flu, Fishman says.

“It's the right thing to be doing in these communities, but it's also the right thing to be doing because the economics of healthcare are now moving in a direction where the expectation is that we're going to do our best to keep people as healthy as possible,” Fishman says.

Allina Health System, a 10-hospital system based in Minneapolis, is also participating in the Pioneer ACO model.

In April, it launched a neighborhood health program for communities in Minnesota and western Wisconsin that provides free health screenings, grants up to $250 to support “healthy neighborhood activities” and social networking tools to support healthy lifestyles.

The total investment for the Neighborhood Health Connection program is about $100,000 in community grants, said Dr. Courtney Jordan Baechler, medical director of Allina Health's Penny George Institute for Health and Healing, a health clinic that also does educational work and research.

It's the first of several health promotion and prevention programs that Allina plans to launch.

The Chelsea, Mass., community will benefit from added investment in the “Healthy Chelsea” initiative, which promotes exercise and better food choices.     
“Overall, there has been a philosophical change and, specifically, an interest (in prevention) because I think we've done a great job within the hospital setting of taking care of real sick patients,” Baechler says. “But our interest is really to keep people healthier longer and be able to have significant expertise in community health and population health going forward.”

In March, the health system reported that it has expanded the scope of the Penny George Institute to include prevention and health promotion and that the facility had been reorganized as a supporting clinical service line for Allina.

Provider investment in prevention is also a trend noticed by Dr. Gordon Norman, chief innovation officer at Alere, a diagnostics and health management services firm.

“In the post-reform environment that we're in right now, the interesting thing that we're seeing is the advent of greater responsibility by hospitals and providers in trying to achieve population health improvements in the populations they serve,” Norman says.

“Many people will go to the same doctor or same hospital or health system for their care over a much longer period of time than they might work for a single employer or carry a single insurance,” he says. “If that is the case, and ACOs are increasingly expected to take risk and responsibility for measured outcomes of the folks they take care of, they may also take a longer-term perspective on doing things like prevention.”

What will be likely is that primary-care physicians, who may have less training when dealing with issues such as obesity and diet, will work alongside care managers and exercise physiologists in an ACO setting, Norman says.

For the insurers and health management companies that have supported employer-based prevention programs, the addition of hospitals as a provider of prevention and wellness programs may provide its own market opportunities.

“Hospitals are now responsible for the totality of issues that impact a patient,” says Dr. Lonny Reisman, Aetna's chief medical officer. “This shift in accountability and responsibility is tectonic in terms of the implications for how hospitals have to look at the world.”

Reisman noted Aetna's own transformation and trials in its approach to prevention, including conducting studies that have found some financial incentive programs such as providing at risk-patients with free medications don't always work. “It's a profound challenge,” he says.

The Hartford, Conn.-based insurer, which Chairman, President and CEO Mark Bertolini often refers to as a health IT company, has invested billions of dollars in health technology during the past decade and is increasingly sharpening its ability to tailor messages to cultural differences among patients.

“Prevention in isolation isn't probably as interesting a conversation as prevention in the context of patient engagement, incentives, accountability by providers and a desirability from a societal perspective in terms of ultimate medical costs and the productivity and health of our population,” Reisman says.

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