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

4 Source: 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 AJPH

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;

National High School Graduation Rates, Cities in Crisis, EPE Research Center, 2008 BlackWhite 80.2% 76.2% 57.8% 53.4% 49.3% Native American 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 markets Accessible, 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, fitness Roads – transportation Safe streets for walking and bicycles Rationalized mass transit Parks and recreation Accessible, safe Health 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 engagement ACO (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 Require Non-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 in such 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)

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 Care Public Health