Accountable Health Organizations:Harnessing the Potential of Healthy Communities

Healthy Communities:

The Intersection of Community Development and Health

Eduardo Sanchez, MD,MPH,FAAFP

Vice President and Chief Medical Officer

Blue Cross and Blue Shield of Texas

September 28, 2011

What we are facing

Poor health status nationally – getting worse

High medical care costs nationally – increasing

Slipping competitiveness globally

What we know

A healthy workforce = higher productivity + lower medical costs

Fit kids = smart kids

Higher educational attainment = better health + higher income + higher likelihood of health insurance

4Source: IFTF and Center for Disease Control and Prevention, Health and Healthcare 2010, January 2000

How Can We Encourage and Support Behavior Change?

What Drives Health Status and Health Care Costs?

Relationship between Social Determinants and Mortality in 2000

0 50 100 150 200 250 300

Area level poverty

Income inequality

Individual poverty

Low social support

Racial segregation

Low education level

Deaths (1000s)

AJPHAJPH

Place Matters

• Determinant of Diabetes?

• Persons living in low-income communities are 80% more likely to be hospitalized for diabetes or related complications compared with those living in affluent areas.

Source: AHRQ

Personal Choice or Healthy Food Accessibility?

• Low income areas have 1/3 fewer grocery stores than higher income neighborhoods.

• Corner stores and gas stations typically charge 1½ times the price of similar items in grocery stores.

• Not having automobile or adequate public transportation can reduce access to affordable, healthy food.

• Less expensive foods are often high in calories and fat.

• Limited time and knowledge of food preparation can increase demand and consumption of prepackaged or processed foods.

Community Health and Food Access: The Local Government Role; http://icma.org/activelivingCommunity Health and Food Access: The Local Government Role; http://icma.org/activeliving

National High School Graduation Rates, 2003-04

Cities in Crisis, EPE Research Center, 2008

Black White

80.2%76.2%

57.8%53.4%49.3%

NativeAmerican

Latino Asian

Healthy people do healthy things

Healthy Behavior

Eating smart

Being active

Maintain healthy weight

Avoid tobacco

Measures of Health

Healthy weight

Healthy lipid profile

Normal blood sugar

Avoid tobacco

Healthy communities have the elements that enable healthy people

Health Promoting Factors

Accessible, affordable food

• Supermarkets

• Gardens and farmer’s marketsAccessible, affordable venues for activity

• Safe, lighted sidewalks

• Dual use schools

• Parks

• Fitness/Recreation Centers

Approaches to prevent childhood obesity

• Food environment– Raise awareness– Increase consumption of healthful food– Decrease consumption of less healthy food

• Built environment– Raise awareness– Increase physical activity– Decrease screen time

Healthy communities have the elements that enable healthy people

Health Promoting Factors (cont.)

Safe, healthy academically strong schools

Wellness supporting workplaces - jobs

Accessible, affordable primary care (medical home)

Access to “public health” services

Community Development

Retail

• Incentives for supermarkets, fitness centers etc.Housing

• Locate in a healthy community or one that wants to be

• Lighting, sidewalks, fitnessRoads – transportation

• Safe streets for walking and bicycles

• Rationalized mass transit Parks and recreation

• Accessible, safeHealth system – public health, medical care, health plans

Community Development

Health system

Medical Care

• Locate “medical homes” in a healthy community

• Small or not so small business – Employer

“Public health” services

• Compliment medical care

• Jobs and services

• Food safety – retail and restaurants

• Disease surveillance and control

The Role of Health Plans

Support evidence-based policy changes

• Indoor smoking laws• Coordinated school health• Workplace wellness

PCMH (patient-centered medical home)

• Systems thinking – nonclinical opportunities• Wagner’s “chronic care model” – community

engagementACO (accountable care organization)

• Systems thinking – nonclinical components• Public health (population health) consideration

The Role of Health Plans

Charitable contributions (BCBSTX)• CASA• CareVan• MarathonKids• American Heart Association• Organwise Guys• Kaboom

Individual level incentives (BCBSTX)• Tobacco surcharge/NRT (nicotine replacement therapy)• Fitness centers membership card• Blue Points• Metabolic syndrome program

“an expensive plethora of uncoordinated, unlinked, economically segregated, operationally limited microsystems each performing in ways that too often lead to suboptimal performance”

(Halvorson, 2007)

The US Health Care System?

Achieving Health Equity will RequireNon-Clinical Strategies

• Improve coordination of relevant agencies and organizations whose activities address determinants of health (education, housing, agriculture, employment, health)

• Finding ways to increase the availability of healthy, affordable food in underserved communities (encouraging major grocery chains and farmers’ markets to locate insuch communities)

• Promoting community-level interventions for health promotion (tobacco control programs and exercise initiatives)

• School-based strategies to improve graduation rates and reverse obesity trends

(Smedley, Health Affairs)(Smedley, Health Affairs)

PETE supports keeping Humpty from having a great fall

Accountable Health Organizations (AHOs)

Manages the “Investment in Health” portfolio for a community – Health in All Policies

The set of retail, public, social, health (including medical care) services associated with a defined population - accountable for the health status and outcomes for that population.

The providers of services could include a local health department, health plans, employers, primary care providers, specialists, and other health and non-health professionals who share responsibility for the quality and cost of services provided to individuals and communities and for maximizing individual and community health.

Attribution methodologies for accountability (credit for contribution to health and charges to fund and sustain the system).

Makes money by achieving highest health status (= economic competitiveness)

The Accountable Health Organization to get to A Healthy Community

Community Development

Medical CarePublic Health