Voices on Value

In conjunction with the release of its 2014 Health Value Dashboard, the Health Policy Institute of Ohio is asking prominent health policy experts from Ohio and across the country to submit brief commentary on the Dashboard and the importance of measuring and improving health value.The Institute plans to periodically post new commentaries in order to further conversation on health value and maintain awareness of the Dashboard. The first commentary is below.NOTE: The purpose of the Voices on Value series is to encourage dialogue on health value in Ohio by providing a forum for diverse viewpoints. The opinions expressed in the commentaries are those of the author alone and do not necessarily reflect the views of HPIO.

Monica Valdes Lupi

Chief of Health Systems Transformation, Association of State and Territorial Health Officials

The Health Policy Institute of Ohio has released a groundbreaking new tool for assessing the population health landscape in Ohio.

The Health Value Dashboard not only provides a snapshot of Ohio in comparison to other states, but establishes health value (the relationship between healthcare cost and population health) as a metric worthy of inclusion in public health analyses and as a target for improvement.
Read more

The Dashboard stands out for being comprehensive, accessible to the public and useful to policymakers. By taking into account factors often overlooked by other state health rankings (such as healthcare costs, as well as the impact of social, economic and physical environment), the Dashboard reinforces the need for organizations performing similar analyses to follow suit.

HPIO’s Dashboard goes a step further by explicitly capturing health value into a metric, setting the stage for similar health value calculations to be incorporated into population health and clinical metric sets.

Preventing disease and injury is one of the most cost-effective ways to improve health. According to Trust for America’s Health[1], spending just $10 per person annually on community-based prevention programs could save the nation more than $16 billion a year within five years, a nearly $6 return for every $1 spent.

Since health value is the relationship between a state’s healthcare costs and population health ranking, it follows that states with high healthcare costs relative to their population health outcomes score lower in their health value ranking. In order to improve their health value, states must address both parts of the equation.

Thankfully, much of the work necessary to improve health value is already underway. The concept of health value has gained traction as many states implement payment and delivery reforms aimed at achieving the “triple aim” by reducing costs while improving clinical and population health outcomes.

In response to increasing health care costs, states have implemented a range of innovative programs: health homes, integration of behavioral services in primary care settings, coverage of non-medical services under home and community-based waivers, utilization of community health aides from outside the traditional licensed medical workforce, Delivery System Reform Incentive Payment initiatives to fund Medicaid delivery system redesign and infrastructure development and value-based payment models that incentivize providers to meet performance metrics and data reporting requirements.

Finally, state and local public health agencies, Medicaid, managed care organizations, and community-based organizations are leveraging partnerships to collaborate on integrating information technology and providing reimbursement and coverage for prevention services.

Integration of information technology is important for assessing, monitoring and improving population health and, by extension, health value. The uptake of electronic health records by private practices, hospitals and other providers has the potential for using clinical data to be analyzed and drive action across multiple levels of care.

Data-driven action facilitates the identification and replication of best practices and also allows for more comprehensive analysis of patient outcomes and support for continuous quality improvement. Many states are developing health information exchanges, which allow healthcare providers and patients to securely access and share a patient’s medical information electronically, thus enabling better coordination between providers and provision of more timely, safer and cost effective services.

Some states also are addressing healthcare costs through public-facing websites that allow consumers to compare procedure prices and patient outcomes across hospitals, thereby increasing transparency and providing consumers with information to help with decision-making. Successful use of health information technology increases health cost transparency, improves coordination of care and improves population health surveillance and research. These benefits lead to better health value: Healthcare that is higher-quality at cheaper cost.

Hand-in-hand with these innovations on the clinical delivery side are related efforts to strengthen public health activities that address the social determinants of health. State and territorial health agencies are paving the way for stronger cross sectoral collaboration with non-health partners to address the built environment, education, housing, and poverty. The call for using a “health in all policies” approach can optimize public health efforts to improve population health by considering contributing factors that impact health and well-being.

As clinical and public health efforts begin to work more collaboratively to improve population health, health value is increasingly becoming a priority at all levels of the healthcare system and public health enterprise. State and territorial health agencies can look at the health value concept as a way to measure efficiency and as a unifying goal all sectors of the healthcare system can collaborate towards achieving. By working together towards achieving health value, we can ensure optimal health for all the communities served by our public health agencies.

Monica Valdes Lupi is the Chief of Health Systems Transformation at the Association of State and Territorial Health Officials. Monica leads a team that includes the following programs: Medicaid Partnerships with Public Health; Public Health Integration; Public Health Informatics; State Health Policy; Health Equity; and coordination of activities for peer groups including senior deputies, public health lawyers, and state legislative directors. She previously served as the Massachusetts Deputy Commissioner and chief of staff for six years. For more information on ASTHO’s Health System Transformation work, please visit http://www.astho.org/Programs/Health-Systems-Transformation/
ASTHO is the national nonprofit organization representing public health agencies in the United States, the U.S. Territories, and the District of Columbia, and over 100,000 public health professionals these agencies employ. ASTHO members, the chief health officials of these jurisdictions, formulate and influence sound public health policy and ensure excellence in state-based public health practice. ASTHO’s primary function is to track, evaluate, and advise members on the impact and formation of public or private health policy which may affect them and to provide them with guidance and technical assistance on improving the nation’s health.

[1] Trust for America’s Health, Robert Wood Johnson Foundation. “Investing in America’s health: A state-by-state look at public health funding and key health facts.” May 2014. Available at http://healthyamericans.org/assets/files/TFAH2014-InvestInAmericaRpt08.pdf

Colleen Spees

Academic researcher, The Ohio State University College of Medicine

Pat McKnight

State Policy Representative for the Ohio Academy of Nutrition and Dietetics

September 2015

Food and health are intimately intertwined.

Aside from tobacco, diet remains the single greatest environmental contributor to health or disease.

Evidence has clearly documented that poor nutritional status and malnutrition are associated with higher hospital costs, longer hospital admissions, increased readmissions and longer lengths of stay.

Indeed, the cost of failing to address obesity, another form of malnutrition, is staggering. In 2008, the medical costs of obesity-related illness in the U.S. were estimated at over $200 billion, and the annual medical costs for people who are obese were, on average, $1,429 higher than those of normal weight. Maintaining healthy food and beverage choices is an important way to reduce the risk of cancer, diabetes, heart disease, hypertension and other diseases. The American Diabetes Association has reported the staggering cost of diabetes – $322 billion a year; or 1 in 5 healthcare dollars.

The Health Policy Institute of Ohio has recently released its Health Value Dashboard, a thought-provoking platform aimed at catalyzing conversation related to the health-related realities facing Ohioans. Although the Ohio scorecard is troubling, there are many evidence-based strategies that can address poor health outcomes and high cost. Addressing poor nutrition is key to achieving health value.

In households with a low socioeconomic status, approximately 80 percent report purchasing low-cost, high energy-dense foods to make ends meet. Chronic exposure to these energy-dense foods contributes to an increased risk for developing diet-related chronic diseases including obesity, type 2 diabetes, disabilities, cancer and cardiovascular disease. If left undiagnosed or untreated, chronic disease can lead to higher rates of disability, unemployment, employee absenteeism and a greater reliance on federal and state assistance. Together, these factors further stress an already-burdened system.

Eating healthy food is good, and doable, even on a budget. The government website ChooseMyPlate.gov has resources for all ages and tips for healthy eating on a budget.

Evidence-based behavioral lifestyle interventions, led by a trained professional such as a registered dietitian, have shown to reduce the risk of conversion from pre-diabetes to diabetes by 58 percent, and a loss of just 3 percent to 5 percent of body weight have resulted in significantly improved health outcomes (that is just 5 to 10 pounds).

Dietitians can be integral members of a healthcare team. Given that medical school curricula still fall short of the minimum 25-hours of basic nutrition education as recommended by National Academy of Sciences, dieticians can plan a key role in identifying and implementing nutrition-based interventions. Registered dietitians are specifically trained and licensed to conduct comprehensive dietary assessments, implement targeted behavioral interventions, provide targeted medical nutrition therapy, and measure outcomes.

Despite clear evidence demonstrating the effectiveness of dietitians in facilitating improvements in dietary behaviors and client outcomes, nutrition counseling is not adequately reimbursed in the current healthcare model. In fact, the ONLY currently billable dietetic services (medical nutrition therapy, or MNT) available through Medicare are for diabetes and renal disease . Some insurance plans and managed care organizations do provide MNT on a limited basis. The good news for Medicaid patients is that dietitian services are expected to be included in Medicaid by the first of 2016. For the 90 percent of cancer patients treated in outpatient settings, dietetic counseling is not reimbursed. In oncology care, the U.S. stands alone in failing to specify and cover the inclusion of a dietitian on the multi-modal oncology healthcare team. Nutritional care can be a challenge for the patient with cancer during treatment and to help them as a survivor

Dietitians can play a major role in disease prevention as stated above. Ample evidence indicates that a healthy diet and physical activity is the KEY to disease prevention. Lack of reimbursement for the expertise of the dietitian in health plans and community health programs limits the role these professionals could plan in population health management

Ironically, the lack of access to nutrition services coincides with a growing body of evidence recognizing the importance of providing nutritional care to optimize health outcomes, improve client quality of life and significantly reduce healthcare costs. Thus, there remains a colossal gap in providing an efficient, accurate mechanism to provide the nutritional and behavioral counseling necessary to improve health outcomes in Ohio. The current system continues to be challenged in its efficacy to provide nutritional counseling to those in need, hence contributing to the growing obesity epidemic. Efforts to close this colossal gap can have a significant impact on Ohio’s ranking on health values.

Colleen Spees, PhD, MEd, RDN, LD, FAND, is an academic researcher on faculty at the College of Medicine at The Ohio State University. Dr. Spees is a Registered Dietitian with advanced degrees in Education, Exercise Science, Health Promotion, and Health Sciences. Dr. Spees’ focus of research involves targeting interventions aimed at providing optimal nutrition for chronic disease in disparate populations.
Pat McKnight, MS,RDN,LD,FAND is the State Policy Representative for the Ohio Academy of Nutrition and Dietetics. She is also Assistant Professor, Nutrition at Mt.Carmel College of Nursing.

Barbara A. Nash

Member of the Ohio Association of Advanced Practice Nurses House Bill 216 Committee

July 2015

How do you know where you are going if you don’t know where you’ve been?

The HPIO 2014 Health Value Dashboard gives us a detailed overview of the current state of the health of Ohioans, and a baseline from which to work to improve the health value for all our residents. Unfortunately, it illustrates an embarrassing bounty of chronic health deficits that plague our state.

For years we’ve been aware of many of these issues, and experts have debated various approaches to address some health disparities.  However, we have made little progress in reducing or closing the gap to significantly reduce our alarming statistics.

Read more

The HPIO Health Value Dashboard forms a vivid graphic, which challenges all health policy makers and providers to commit to innovative and cost effective interventions to raise Ohio out of the bottom quartile of the country on so many metrics.

Richard H. Carmona, M.D., M.P.H., FACS, and the 17th Surgeon General of the United States (2002-2006), is also a registered nurse (RN). I once heard Dr. Carmona speak at a national conference.  He shared his firm belief that of all his credentials, the title of RN was the most valuable.  He maintained that the only way to reduce sickness care costs was to create a true health care system built around health promotion, disease prevention and health literacy.

Carmona went on to say that RNs are experts in these three areas. Moreover, he maintained that RNs and advanced practice registered nurses (APRNs) are undervalued and underutilized in the United States compared to other countries in the developed world.

RNs and APRNs (certified nurse practitioners, clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists) have the education, training, and expertise to impact issues such as high rates of infant mortality, adult and childhood obesity, and diabetes.

Health promotion, disease prevention and health literacy programs cost significantly less than the interventions needed to address the problems and complications that arise from these illnesses. Studies show that nurses can improve outcomes and reduce sickness care costs in the community and in the acute care setting.

Direct access to RNs and APRNs is a means of improving access to health care services that are of high quality and affordable. Studies have shown that nurse practitioners safely and effectively manage chronic illnesses with good outcomes. Certified nurse midwives and nurse

practitioners have demonstrated that they can greatly impact infant mortality rates by following high-risk mothers for a period of two or more years in a case management model. Additionally, certified nurse midwives improve labor and delivery cost models by reducing cesarean rates. The average cost for vaginal births is approximately 50 percent lower than cesarean births.[1]

Many of Ohio’s small rural hospitals could not provide any surgical services if it were not for certified registered nurse anesthetists. In fact, when it comes to reducing costs, certified registered nurse anesthetists provide significant cost efficiencies because anesthesia-delivery models that require physician oversight are likely to be more expensive than CRNA-only models.[2]

The October 2010 Institute of Medicine’s report on the Future of Nursing outlined many objectives that need to be reached by 2020, in order for the United States to reverse the upward spiral of sickness care and its associated costs. One of the main recommendations was to remove the barriers to nurses and APRNs and allow them to practice at the top of their scope and education. Twenty-one states and the District of Columbia have passed legislation modernizing their nurse practice acts to remove barriers to nurses and APRNs.

If practice barriers were removed for Ohio’s APRNs, a RAND Ohio Health Study estimates that the state would have 70,000 fewer emergency department visits for illnesses that would be treated in lower acuity ambulatory settings. The estimated savings for the State of Ohio is expected to be in the millions, utilizing conservative Medicare and Medicaid fee schedule calculations.[3]

The Ohio Association of Advanced Practice Nurses (OAAPN), with the assistance of many other nursing organizations, has spearheaded House Bill 216, which addresses the removal of outdated regulatory restrictions for all APRNs.

Thanks to the HPIO Health Value Dashboard we know where we are. Nursing has the ability to take us where we want to go!

Barbara A. Nash MS, RN, CNS is an advanced practice nurse who was educated at The Christ Hospital School of Nursing, received her BSN from Ohio University, and her Masters in Nursing from The Ohio State University.  She is past president of the Ohio Nurses Association, a member of the OAAPN House Bill 216 Committee, a member of the Ohio Action Coalition Steering Committee and Co-Chair of the Work Group to Remove Barriers, a primary care practitioner and a nurse educator. 

[1] Thompson Healthcare 2007. The healthcare costs of having a baby. Available at: www.marchofdimes.com/downloads/The_Healthcare_Costs_of_ Having_a_Baby.pdf

[2] Paul F. Hogan, P.; Furst Seifert, R.; Moore, C.; Simonson, B. Cost Effectiveness Analysis of Anesthesia Providers. (2010) https://www.aana.com/resources2/research/Documents/nec_mj_10_hogan.pdf

[3] RAND Health. Martsolf, G; Auerbach, D; Arifkhanova, A. The Impact of Full Practice Authority for Nurse Practitioners and Other Advanced Practice Registered Nurses in Ohio (2015). http://www.rand.org/pubs/research_reports/RR848.html

Jennifer Chubinski

Director of Community Research, Interact for Health

May 2015

The Health Policy Institute of Ohio has gone to great lengths to create a dashboard of health value. This well-thought-out and well-researched set of metrics helps provide a North Star to everyone working to improve the health of Ohioans.

I was a part of the large, diverse and engaged group of stakeholders that came together to design the Health Value Dashboard. We argued over the metrics. Are they the right ones? Do they capture what we want to improve in health value?  As someone who wakes up every morning thinking about health data, I can state confidently that they are a strong collection of health measurement metrics that meet the guidelines the advisory group established (see page 17 of the Dashboard), most notably that the data are high quality, consistently available, and easy for the general public to understand.

So what does the Dashboard tell us?  There is really no doubt about the message – We have a lot of work to do!

Read more

Readers will see that simply by flipping through the report and looking for green indicators. These are places where Ohio is among the top quarter of states.

So where is Ohio doing well?  We are among the top states in employer-sponsored health insurance coverage, the percentage of local health departments that have received accreditation, safe drinking water, fluoridated water, and our low percentage of severe housing problems.  That’s it. Ohio is in the top quarter of all states in only 5 indicators of 106. We can do better than this.

I work for Interact for Health, a Cincinnati-based organization that improves the health of people in our region by being a catalyst for health and wellness. We accomplish our mission by promoting healthy living through grants, education, policy and action. In our work, we have found it very powerful to shift from looking at percentages to looking at the actual number of people who would need to change their health behavior or health diagnoses in order to be at the same level as the number one state.  It would be quite over-whelming to do that for all 106 metrics in the Dashboard, but since I do a lot of population-level health tracking for the Cincinnati region, I thought I would focus on some of the population health indicators. (See page 7 of the Dashboard.)

If Ohio wanted to be No. 1 for these indicators we would need the following improvements:

• An average increase of 3.5 years in life expectancy
• 572 fewer infant deaths
• 614 fewer suicides per year
• 1,041 fewer drug overdose deaths
• 40,260 fewer obese high school students
• 98,210 fewer high school youth using any form of tobacco
• 535,321 fewer people reporting fair or poor health
• 686,995 adults doing more aerobic activity and muscle strengthening to meet physical activity guidelines
• 695,917 fewer adults who binge drink
• 714,000 adults with improved oral health
• 1,168,784 fewer adult smokers

Okay folks, with those numbers in mind – what’s possible?  Hawaii, Vermont, North Dakoda, Minnesota, Colorado, West Virginia, Utah and Alaska are doing well in these metrics. Why can’t we?  There are states that have poorer or older populations than Ohio, but still do better in terms of health ranking.

And there are evidence-based policies and programs that, if implement strategically in the public and private sectors, could improve Ohio’s health outcomes and costs. To learn more about these policies and programs, visit HPIO’s Guide to evidence-based prevention.

Now that we have this North Star, what are we going to do about it?

Jennifer Chubinski, MS, directs Interact’s Community Research Program, managing the organization’s effort to improve regional health through original research, improved data access and standardization.  Jennifer leads Interact’s data collection projects such as the Greater Cincinnati Community Health Status Survey, the Ohio Health Issues Poll (OHIP) and the Kentucky Health Issues Poll (KHIP).  Jennifer also works with grant recipients and the community on data collection, management and analysis issues.  

Dr. Craig Thiele

Chief Medical Officer, CareSource

April 2015

Ohioans are less healthy than people in most other states.

That is the stark reality recently revealed by the Health Policy Institute of Ohio in its 2014 Health Values Dashboard.

Ohio also ranks among the lowest in achieving good value for our healthcare dollar.

The Dashboard shows us that moving the overall health value barometer is not dependent on a singular factor. Public health and prevention coupled with physical, social and economic environments are challenges faced by all communities. We are in an uphill battle, but the good news is that there are many roads that lead to short-term and long-term health improvements.

Read more

At CareSource, a leading nonprofit managed care company headquartered in Dayton, we are traveling this same journey. Our milestones are measured as we balance discerning current industry trends, societal challenges and our member’s needs. The Medicaid program is undergoing unprecedented changes across the United States and, as the Dashboard makes very clear, individuals and taxpayers continue to struggle with affordable care and improved health outcomes.

CareSource believes, at the heart of change, comes the vision to put “people before profits.” We made the strategic decision to ingrain this ideal into our culture and updated our mission:  “To make a lasting difference in our member’s lives by improving their health and well-being.” We wrote the organization’s four-year strategic plan on this foundation.

As pioneers in the managed care industry, we have worked tirelessly to build the operational expertise on issues related to eligibility, enrollment, benefit design, quality of care, value-based reimbursement and access.

Designing provider partnerships that encourage and reward quality outcomes and provide Medicaid members with convenient access to care is more than a strategy — it is a key factor to living our mission. Our leadership team has expanded and developed these provider partnerships and has sought innovative solutions to address access challenges facing our membership as it has grown to nearly 1.5 million members throughout the states of Ohio, Indiana and Kentucky.

Telehealth options and opportunities, unique provider models and service locations, expanded service offerings and other new and innovative access solutions are currently part of our best practice research and policy development to support our CareSource members.

The “Ohio’s Greatest Health Challenges” section of the Health Value Dashboard shows that physical health is only one piece of the overall puzzle. Ohio ranks in the bottom 10 percent of environmental factors such as food insecurity, outdoor air quality and secondhand smoke.

In early 2015 we launched Life Services, a division of CareSource that provides a holistic foundation to address the social determinants that impact a member’s health and overall well-being. The mission of Life Services is to make a sustained impact in our member’s lives by effectively addressing the obstacles that impede progress in a member’s journey toward self-sufficiency, improved health and well-being. This innovative program is an outgrowth of the CareSource strategic business plan. We see it as a ladder approach to achieve self-sufficiency.

Given that our members span the life spectrum, we tailor our benefits to their needs, and focus on the stressors that impact their life most.For instance, in May 2014, MyCare Ohio, serving people with both Medicaid and Medicare coverage, launched in 29 Ohio counties over seven geographical regions. With CareSource serving 12 of these regions, we were fully committed to the success of the program. As a key player in this new multifaceted program, CareSource was uniquely positioned to identify challenges, develop solutions and identify opportunities to integrate services and enhance the member experience.

We are already seeing first-hand the value for our members who now have a more coordinated approach to their care, which in turn is providing them with a better quality of life. This first-hand experience managing the intersection of the Medicaid and Medicare programs brings invaluable insight to the policy development and planning for the next generation of public healthcare programs to serve this vulnerable and complex population.

Ohio is my home – I am proud to have grown-up here and to have raised my family in the Buckeye State. In order for future generations to have similar, if not better, experiences, we must continue to improve our overall health policies.

Every time I review the Dashboard, I find a new piece of data that speaks to me and inspires me to find a solution to enable Ohioans to become healthier. The Health Policy Institute of Ohio should be commended for undertaking this endeavor to create a comprehensive dashboard.

Now, it is our responsibility to use the data to make a difference for our citizens.

Dr. Craig Thiele is chief medical officer at CareSource. Dr. Thiele has more than 25 years of clinical leadership experience with an emphasis in integration strategies. He believes the best opportunities for improved outcomes result from aligning objectives and enhancing partnerships. He also serves on the board of the Health Policy Institute of Ohio.

Jason Orcena

Health Commissioner,  Union County General Health District

March 2015

HPIO’s Health Value Dashboard is a tool that can be used to measure a host of system processes and ultimately evaluate Ohio’s application of scientific principals and societal support toward the advancement of public health.

The 2014 Dashboard quantified what many public health advocates know to be true: The portrait of health value and its impact on Ohioans is grim. Part of the gritty reality captured in this snapshot are reflections of twenty years of disjointed public health policies and their subsequent outcomes.

Read more

Public health policy in Ohio has had some shining moments. Under Gov. Voinovich, a concerted effort — coordinated primarily by public health and using population health interventions — led to a sharp decline in childhood deaths due to motor vehicle crashes. Over a ten year period from 2000 to 2010, the then Governor’s Office of Highway Traffic Safety recorded a 45 percent reduction in childhood fatalities in motor vehicle crashes.

Effective public health initiatives involve enforcement, education and policy and this success story demonstrated the best intersection of policy (state laws), enforcement and resources to improve the health of Ohio’s children. In this example, many local health departments served as non-partisan coordinators of the efforts, keeping each partner informed, integrating plans and using their knowledge of the community to best engage the targeted population.

While the programs have been reduced, resources continue to support these efforts, law enforcement continues its commitment, and the legislature has held true to its promise to protect Ohio’s children. The resulting steady decline and stabilization of in-motor-vehicle deaths means that, while it remains a priority, is now surpassed by other threats.

Similarly, under Gov. Taft, Ohio saw a sharp decline in tobacco use initiation by youth through the coordinated efforts of the Ohio Tobacco Prevention Foundation. The OTPF’s success combined strong state leadership with local implementation in the responsible management and distribution of funds from the Tobacco Master Settlement to reduce the burden of tobacco use on both the lives of residents and coffers of the state legislature.

However, unlike the child traffic safety example above, the success of the OTPF’s is not reflected in the Dashboard.

What is the difference? Unlike the traffic safety example, there was no on-going political will to protect the populace’s health. In 2008, Governor Strickland traded the state’s long-term health for a short-term patch on a budget shortfall. The lack of political will to maintain a commitment to broad-based public health programming resulted in the state’s failure to permanently curb tobacco use. As public responsibility for public health diminished, the cost to Ohio was significant in terms of life and prosperity both individually and communally. A 2007 report estimated that, “Ohio’s Medicaid system could save $550 million within five years if all Medicaid beneficiaries who [smoked], quit.”

The two examples highlight where policy and population health interface in regards to the Dashboard. Strong political commitment coupled with a public health infrastructure can improve Ohio’s health value.

Ohio has made some recent gains: The new emphasis on infant mortality, the expansion of Medicaid, new resources for behavioral health, and the new proposal for tobacco tax parity by Gov. Kasich are all valiant efforts to improve population health.

History has shown us that success comes from a broad spectrum of actors working on population health issues. To effectively address infant mortality, for example, interventions must examine the safety of the sleeping environments, the health behaviors of the parents, access to adequate nutrition and access to both prenatal as well as post-partum care.

Coordinating broad, multi-sector interventions is what Ohio’s local health departments were created to do and have proven that they have the expertise to do again. Too often the emphasis for addressing morbidity or mortality has been on more health care spending. While access to care is critical, it is only a piece of the puzzle. Over emphasis in a single sector, or placing success on the backs of one sector, is both unfair and unlikely to result in lasting change.

Access to care is part of the issue, as is payment reform, and support for ancillary services—these are good steps that the Office of Health Transformation has put forward to reform Ohio’s healthcare safety net. While these efforts are important, they represent individual interventions, not coordinated efforts or population health.

Putting more resources in healthcare will not fix a lack of infrastructure, education or policies that reinforce behaviors linked to poor health. It requires the coordination of a multidisciplinary effort. The child traffic safety example above was coordinated by public health, but was supported and involved many sectors and advocates including car manufacturers, non-profit organizations, children’s hospitals, state legislatures and law enforcement.

To improve health value will require a broad spectrum of interventions with multiple partners. For health value to improve in Ohio requires coordination at a local level. It requires knowledge of the communities being served and the integration of service with infrastructure and education support.

Ohio has demonstrated in the past that it can successfully engage the public health system to address population health issues. The Dashboard indicates that Ohio needs to do so again.

Jason Orcena has served as Health Commissioner for the Union County General Health District since 2008. He is currently serving on the Board of Directors for the Association of Ohio Health Commissioners, as the Ohio Public Health Association’s representative to the Board of the Ohio Public Health Partnership and on various committees within his jurisdiction. He also serves on the Board of Directors of the Health Policy Institute of Ohio. Jason holds a master’s in Sociology, bachelor’s in Psychology, and is currently working on his dissertation in pursuit of his Doctorate of Public Health. His dissertation research is examining the impact of local public health shared service networks on the cost of delivery of local public health services.

YOUSUF J. AHMAD

Senior Vice President, System Development at Mercy Health

FEBRUARY 2015

As I read the 2014 Health Value Dashboard created by the Health Policy Institute of Ohio, one thought comes to mind: Thank goodness we have a dashboard. The Institute should be commended for putting rhetoric aside and assembling a fact-based picture of the realities of healthcare in Ohio.

This clear-eyed view is an opportunity for action we cannot ignore.

Looking at the numbers, that opportunity also is a challenge. It’s humbling to see that Ohio is ranked 47th in health value, a combination of healthcare costs and the health of Ohioans. The Dashboard makes plain that we are not getting value for the billions of dollars we spend on healthcare.

Clearly, we have a lot of work to do.

Read more

Access to healthcare is a challenge and has been identified as one of the “determinant” domains by the Dashboard. Getting patients the right care at the right time should be a core competency. The need is particularly acute for some specialized services, including access to high-quality behavioral care, where we rank 42nd. And the Institute’s Dashboard shows that we are dead last – ranked 51st – in public health and prevention.

Even one of Ohio’s strengths — affordability and cost — could be negated by what seem to be inexorable trends in the way people buy health insurance. By 2020, more than 60 percent of the anticipated 9.3 million lives in Ohio will be covered as individuals, not as a group. On the Dashboard, we rank 11th in the country in the percentage of people who work for a company that offers health benefits. But if fewer and fewer companies are able to offer those benefits, that strength will be at risk.

All of these challenges point directly to the dilemma faced by healthcare providers everywhere: We are transforming to providing value-based care while continuing to operate in a fee-for-service world. Can we fundamentally alter our own behavior and continue to provide excellent care for our patients?

At Mercy Health, we are confident that we can do just that. We are Ohio’s largest health system, with 5.3 million patient encounters a year, 32,000 employees and an economic impact of $8.95 billion a year. We are among the top 20% of health systems in the country for quality and efficiency, according to Truven Health Analytics. We provide compassionate, quality care in Cincinnati, Toledo, Youngstown, Lima, Lorain and Springfield, and through partners in Cleveland and Akron.

What are we doing to improve Ohio’s healthcare future?

• We are investing in new services. For example, our Behavioral Health Institute is meeting the needs of patients in the communities we serve, and we are embedding counselors in primary care practices and emergency departments. We don’t make money on this service. We do it because it’s the right thing to do.

• We are leveraging our social service agencies in new ways. We believe in making lives better—mind, body and spirit. We know that families often must pay for food or housing before they pay for healthcare. A few years ago, we added primary care services at our social service agencies. While Ohio is only average in measurements for Social and Economic Environment (29th), we must address the issues of poverty and education with a laser sharp focus.  It also is the right thing to do.

• We are building a high-performing group practice. With 1,300 providers and growing, Mercy Health Physicians is the core of our care network.

• We are innovating. Mercy Health Select, our accountable care organization, now manages care for 75,000 Medicare beneficiaries, increasing quality and lowering cost.

• We are partnering to improve public health. When it comes to public health as a determinant domain, we are ranked 48th in the country for communicable disease and environmental health.  We are partnering with the local public health departments and collaboratively addressing the issues.

• We are joining partnerships that are robust and Mission-based. One example is Health Innovations Ohio, where we have joined with Summa Health System in Akron, Mount Carmel Health System in Columbus, University Hospitals and Health System in Cleveland and Kettering Health Network in Dayton to improve care across the state.

• We are focusing on population health. Health Select, our new clinically integrated network, will allow us to provide the best care to more people, both from our own providers and affiliated physicians who become our partners.

The HPIO Dashboard tells us that we have not succeeded in putting public health needs in the bright spotlight they deserve. The life-or-death issues we face, from the heroin epidemic, to sexually transmitted diseases, to infant mortality, demand that we do better.

As I read the Dashboard, I see that we need to attack public health issues at the root. Look at the map. All across this part of the country, we see the highest rates of smoking, of obesity, of diabetes. This is where we really need value-based care to work, so we can provide the best care to the most people.

We need high-performing, integrated health systems to overcome these very real challenges. At Mercy Health, making lives better and making healthcare easier is what we do every day. We embrace the opportunity.

Yousuf J. Ahmad, DrPH, MHSA, MBA, FACHE is senior vice president for System Development at Mercy Health. He has served as president and CEO of Mercy Health’s Cincinnati market organization and helped advance a variety of system initiatives. He holds a Doctorate in Public Health from the University of Kentucky, a Master of Health Administration and a Master of Business Administration from Xavier University, and Bachelor’s degree in Computer Information Systems from Eastern Kentucky University.