1. Achieving Health Care Reform in the U.S.: Toward a Whole-System Understanding Gary Hirsch, Jack Homer, Geoff McDonnell, and Bobby Milstein Health Policy Special Interest Group International SD Conference Boston, Massachusetts, USA July 17-21, 2005

2. Meeting Agenda Background & magnitude of the problem Causal framework and why reform is so difficult Feedback from HPSIG –Illustration of adding stakeholder spheres of interest Moving forward

6. Causal Framework Overview: Stakeholder Roles and Interactions Employers - Health coverage Insurers/Payers (Public, Private) - Reimbursement criteria & rates for risk & disease mgmt and acute care - Number of competitors Providers (MDs, RNs, Hospitals) - Risk & disease mgmt extent and efficacy - Acute care extent and efficacy - Specialty fragmentation - Lobbying of insurers & regulators Patients - Health and risk status General Public - Improvement of living conditions Funds available Citizen involvement Drug/Device Makers - Developing high-tech products for acute care and risk & disease mgmt - Lobbying of insurers & regulators Regulators & Monitors (Public, Private) - Usage guidelines & controls Health Care Costs - Risk & disease mgmt - Acute care - Administrative

7. Population Health Dynamics

8. Growth of High-Tech Medicine

9. Reduced Access and Reduced Quality of Patient Management as Side Effects

10. Higher Costs and Cost Containment as Side Effects--Further Hurting Access

11. Neglected Living Conditions as Another Side Effect of Cost Containment

12. Types of Reform Initiatives Expanding access –Improving coverage to employees, the poor, children –Providing health care resources to inner cities and rural areas Containing cost –Government limits on capacity, service provision, or reimbursement –Employer shift to managed care plans Improving quality of care –State regulation of facilities, professional licensure, Medicaid quality monitoring –JCAHO setting of standards, NCQA evaluation of managed care orgs Protecting health –Risk management, promotion of healthy lifestyles, family planning –Safer workplaces, better housing, safer neighborhoods

13. Why Reform is So Difficult (1) Single-focus strategies are problematic and can generate resistance: Access improvement increases acute care costs, at least initially Cost containment reduces disease management and related investments more than it reduces acute care, so hurts quality of care, and may actually increase costs in the longer term Quality improvement initially increases costs, due to increased regulation and QA activity, or investments in IS and training Health protection requires investments resisted by those who would pay and who see more immediate payoff from funding direct care

14. Why Reform is So Difficult (2) Philosophically “pure” approaches are also problematic: Single Payer addresses both access and cost, but threatens powerful interests Market Competition addresses cost, but could lead to inadequate coverage for many, hurt quality of care, and create disincentives to risk management Managed Competition attempts to strike a balance, but, because it does not mandate managed care for all, allows continued cost increases and loss of insurance coverage

15. Health System Dynamics Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003. Available at http://www2.cdc.gov/syndemics/Presentations.htm

16. Health System Dynamics Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003. Available at http://www2.cdc.gov/syndemics/Presentations.htm

17. Health System Dynamics Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003. Available at http://www2.cdc.gov/syndemics/Presentations.htm

18. Health System Dynamics Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003. Available at http://www2.cdc.gov/syndemics/Presentations.htm

19. Health System Dynamics Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003. Available at http://www2.cdc.gov/syndemics/Presentations.htm

20. Health System Dynamics Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003. Available at http://www2.cdc.gov/syndemics/Presentations.htm

21. Downstream lock-in: Delay in upstream effort guarantees continued growth in affliction prevalence and emphasis on treatment, which further delays upstream effort, as does mounting social disparity. Health System Dynamics Milstein B, Homer J. The dynamics of upstream and downstream: why is so hard for the health system to work upstream, and what can be done about it? CDC Futures Health Systems Work Group; Atlanta, GA; December 3, 2003. Available at http://www2.cdc.gov/syndemics/Presentations.htm