1. transforming health systems in uncertain times
Peter Long, Ph.D.
President and CEO
February 5, 2018

2. key takeaway messages
It is an incredibly dynamic period in health care in United States and California, which means:
Insurance coverage is likely to decline from its highest levels and life expectancy is declining
Care and payment models are changing
Current workforce needs major change across multiple dimensions
Health care contributes a small amount to overall health
Fundamentally different approaches will be required to make significant progress
More questions than answers today

3. blue shield of california foundation
We believe all Californians can be healthy and safe
Our mission: Blue Shield of California Foundation builds lasting solutions to end domestic violence and make California the healthiest state, especially for our most vulnerable neighbors.
About us:
Total Grantmaking since 2002: Over $390 million
2017 Grantmaking:
$25.6 million, 421 grants
Independent Board:
9 Trustees, 5 from Blue Shield of California
Total Number of Staff: 24
Source of Funding: Annual contributions from Blue Shield of California

4. the solutions depend on the questions…
Senate GOP (S 2330); House-passed GOP(HR 4250); Democrats (S 1890; HR 3605)

5. Changes in health insurance coverage over time

6. Why are people uninsured?

7. u.s. life expectancy reflects income inequity

8. What we know
80 percent of health is determined by factors outside of the healthcare system
Every day, we collaborate with forward-thinking partners and seek new solutions to end domestic violence and improve the health & wellbeing of all Californians – especially our most vulnerable neighbors. We use our grantmaking to help create a brighter future. We see what is, imagine what can be, and work together to move California further forward.

9. strategies to improve health care
current situation
strategies to improve health care

10. national academy of medicine workshop on high-needs patients
5% of patients account for nearly half of the nation’s spending on health care
How do we improve care management for this population in an effort to improve health outcomes and reduce costs?

11. themes and conclusions
The high-need patient population is diverse, complex, expensive, and transient.
One size doesn’t fit all. We need to strike a balance between standardized and customized approaches to care.
Segmenting patients is one tool to inform and target care, and should be rapidly tested in real-world settings in conjunction with care models that have been shown to work.
The solutions (e.g., tools, care models, policies) must extend beyond the medical – social and behavioral factors are essential to address.
In order to be actionable, policy solutions must account for existing system constraints and complexities (e.g., integration of medical + social, financing of care models).

12. potential paths forward
More research is needed to bolster the evidence base for care models that work.
There are major policy barriers to broad implementation of what we know DOES work.
In the meantime, action is needed now
Health systems need to work with payers to better identify and target high-need patients and test new practices (i.e., taxonomy).
Payers need to work with health systems so it’s feasible to adopt care models (or specific attributes) that we know work.
Policymakers need to continue progress toward a value-based system, with alternative payment models (including those that work within FFS structure) that support care for these patients.

13. financing approaches: fqhc pilot
FQHC Capitation Payment Preparedness Program (CP3) and Senate Bill 147 (Hernandez)

14. eConsult
Original two counties: Los Angeles and San Francisco
Second phase: Alameda, San Mateo, Santa Clara, Kern, Contra Costa, Monterey, San Joaquin, and San Diego
Foundation funding currently supports eight healthcare systems at varying stages of planning, implementation, and scale-up of eConsult.
Los Angeles County’s Growth in Number of Participating Specialties
eConsult Expansion Across California Counties
Effect of eConsult on Referrals and Treatment

15. ca future health workforce commission
As California ages, grows and becomes increasingly diverse, our health workforce lags further behind the demand
We don’t have enough health providers and we don’t have the right people in the right places with the right training
The California Future Health Workforce Commission was formed to address these issues by prioritizing training, innovation, and diversity in behavioral health, aging, and primary care and prevention

16. systemic barriers to health improvement
Unsupportive policy and payment framework
Uncertainty with evidence base
Different definitions of success
Limited patient, and community engagement
Under-achieving implementation science

17. sources of power in U.S. health care
Federal level: policy & payment
State level: policy, payment & regulation
Local level: community engagement, collaboration & action

18. what would health look like in our communities?
3.0
what would health look like in our communities?

19. coordinated healthcare system community integrated health system
where are we now?
1.0
sick care
system
2.0
coordinated healthcare system
3.0
community integrated health system
Era
1900s-1950s
1950s-present
2000 onward
Health Is
Absence of acute disease
Reduction of chronic disease
Creating capacities to achieve goals, satisfy needs
Care Goal
Improve life expectancy
Reduce disability
Optimize health

20. health transformation framework
1.0
sick care
system
2.0
coordinated healthcare system
3.0
community integrated health system
SYSTEM DESIGN
Health service providers, operating separately
Team-based care within health
Community integrated services, health care as one component
CARE MODEL
Little coordination between in/out patient care, episodic treatment
Chronic condition management, patient-centered care coordination
Health, psychosocial, and wellness care integrated across the life course
DOMINANT
PAYMENT
APPROACH
Fee-for-service
Value-based health payments
Population-based global budgets, linked to multi-sector financial impact
APPROACH TO QUALITY
Variable, low transparency
Consistent, standardize processes and outcomes
Continuous learning and quality improvement
BENEFICIARY LENS
Individual
Patient and family
Subpopulations and communities, equity- oriented

21. our bold goal
To make California the healthiest state in the country, and the state with the lowest rates of domestic violence by leveraging the power of community and innovative solutions

22. our areas of focus Breaking the cycle of domestic violence
Collaborating for healthy communities
Designing the future of health
Breaking the cycle of domestic violence
Collaborating for healthy communities
Designing the future of health

23. 3.0 principles and design strategies
community empowerment and engagement
information and measurement
community integration functions
financing approaches

24. collaboration underpins community health
Source (left): Foundation Center Maps. “Constellation” of Grants to Organizations Based in city of Riverside, CA in support of health, community development, human rights, or human services, (Right) Centers for Disease Control.

25. bringing 3.0 design elements together in communities
California Accountable Communities for Health Initiative (CACHI)
Imperial County Public Health Department, Imperial County
Merced County Department of Public Health, Merced County
Be There San Diego/University of California, San Diego, San Diego County
Dignity Health/St. Joseph’s Medical Center, San Joaquin County
Santa Clara County Public Health Department, Santa Clara County
Sonoma County Department of Health Services, Sonoma County

26. integration beyond health care
Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE)

27. cachi’s origins

28. value-based purchasing drives move to accountable health
If we reward outcomes over volume, mobilizing all factors that affect health will have rewards
There are still unknowns:
which approaches are the most effective?
who should lead these efforts?
what is a sustainable financial model?
Many experiments…few answers
Support from government and philanthropy

29. California is leading the way
continuing to do so will
require us to work together
and develop new ideas
and solutions.

30. unanswered questions
Can we achieve transformation started from the existing system?
Who is included in the system and who is excluded?
How should resources be allocated among systems and within health care system?
What is the optimum balance of intervention at individual and population level?
How can we create the right policy environment to support Health 3.0?
How will we know if we are successful?

31. Peter Long, Ph.D.