Health Care 2021: A Vision for New York
David Sandman, Senior Vice President and President-designate of the New York State Health Foundation, and Jim Tallon, President of United Hospital Fund, welcomed a sold-out crowd of nearly 400 to the Health Care 2021 conference, held February 9, 2016, at the CUNY Graduate School and University Center. Noting that five years from now, patients might be more engaged in their care, with access to useful technology, readily available pricing and quality measurements, and seamlessly integrated services, Mr. Sandman also noted that, to the contrary, we might be facing a health care system that is even more fragmented than today. Setting the tone for the day, he posed two questions to start the program: “What WILL the health system look like five years from now? And what SHOULD it look like?”
George Halvorson, Chair and CEO of the Institute for InterGroup Understanding and former President and CEO of Kaiser Permanente from 2002 to 2013, presented the keynote address, focusing on the challenges and opportunities of transforming a health system. Drawing upon lessons learned from leading Kaiser Permanente—the largest managed care organization in the country with some 9.6 million health plan members and more than 170,000 employees in more than 500 sites—Mr. Halvorson noted the “opportunity to move into a golden age of care delivery.” He identified two factors critical to achieving his vision: the need to have all information available electronically and the importance of making the right thing to do easy for patients and providers alike.
In thinking about the future, Mr. Halvorson anticipated health care being delivered in four sites. In addition to the expected two (“hospitals and hospital equivalents,” i.e., places where patients sleep, and doctors’ offices, clinics, and the like), he noted the home is the third, which he predicted would be the site of 40 percent of care in the future—care that today is typically delivered in clinics. And he identified the Internet as the fourth site of care—a place for getting diagnoses and prescriptions, tracking patients, and getting second and third opinions, as well as other expert advice—all with significant cost savings. He noted how patients already receiving care electronically are reporting very high satisfaction.
Mr. Halvorson’s keynote had a second focus as well—emphasizing the socioeconomic disparities that persist in early childhood development in the United States and noting that the greatest opportunity for promoting development occurs before the age of three. He expressed the critical need for health systems to work with public health departments, social service organizations, and school districts to ensure that parents understand that emotional and intellectual development is critical even in the first 90 days of life.
Panel 1: Engaged and Informed Consumers and Patients
(From left) David Sandman, Michael Miller, Charles Bell, and Sally Okun
Moderated by Mr. Sandman, the day’s first panel featured Charles Bell, Programs Director of Consumers Union, Michael Miller, Director of Strategic Policy at Community Catalyst, and Sally Okun, Vice President of Advocacy, Policy, and Patient Safety at PatientsLikeMe. The panelists discussed the empowered patient consumer, highlighting the differences among patient populations, and considering the role of the consumer in driving delivery system transformation.
Challenging perceptions that consumers with more “skin in the game” (through higher deductibles and cost-sharing) will make good decisions about their health care, Mr. Miller noted that the general conclusions from RAND studies on the topic were not applicable to key populations—the sick poor and the elderly, the populations that drive most of the costs and utilization. He concluded, “People are terrible shoppers for health care.”
Mr. Bell wryly noted that, to be an “empowered consumer,” it would help to have a lot of time on your hands, have money, have experience in health care finance or billing, and know insurance rules—because then you would have the time to research, learn about, and prevent the “tricks and traps” that undermine consumers’ agency and access to good care. He also emphasized the importance of including patients and their families in discussions about the redesign of health care service delivery and related policy.
Ms. Okun also pointed to the importance of family, since most caregiving is done in the home, and to the need for more attention to family caregivers. She also articulated the difference between “patients”—those seeking amelioration of specific conditions—and “consumers”—those seeking tools to maintain wellness. While it is important to recognize their goals and the types of engagement they need are different, she underscored one important commonality: They all need to feel like the coordinators of their own care.
Panel 2: Technology and Information Sharing
(From left) Amy Shefrin, Eugene Heslin, MD, and Farzad Mostashari, MD
Moderated by Amy Shefrin, Program Officer of the New York State Health Foundation, the second panel featured Eugene Heslin, MD, President of Bridge Street Family Medicine, and Farzad Mostashari, MD, Co-Founder and CEO of Aledade and former National Coordinator of Health Information Technology at the federal Department of Health and Human Services. They discussed a vision for data transparency and technological advancements for both patients and health care providers, putting the arc of innovation into context by also looking at innovations over the past five years.
Dr. Mostashari shared a personal story, recounting when his mother needed knee surgery a few years back. Even with all his professional experience behind him, he could not find data on who “the best knee guy in Boston” was. Unfortunately, the surgery did not go well, and his mother suffered from bleeding, infection, and cardiac complications. He knows today, “I took her to the wrong surgeon.” Today, we have data transparency as we’ve never had before, and he showed how quickly he can find data to compare surgeons on his smartphone. He noted that the data available now, coupled with changes in payment models, which now are incentivizing better care, give hope for the future. But he cautioned that there are three paths for health care providers responding to cost pressures from payers: “You can deliver better care at lower cost. You can create a monopoly so you don’t need to worry about the quality of care. Or you can close the doors.”
Dr. Heslin observed that the experiences of health care providers related to technology are not all the same. While 83 percent of hospitals in New York are connected to a RHIO (a regional health information organization, which facilitates the sharing of health information across providers in a community), only 20 percent of primary care physicians in the state are so connected. He emphasized the importance of building in “expert learning” to help providers when the state mandates new technologies, as well as finding ways to make data flow a common interest between payers, providers, and patients. He and Dr. Mostashari agreed that a key strategy could be prioritizing simple, high-value data exchange, like alerts to physicians when patients are admitted, discharged, or transferred from hospitals.
Panel 3: Providers and Plans in 2021
(From left) Andrea Cohen, Karen Ignagni, Linda Brady, MD, Paloma Izquierdo-Hernandez, and Jeffrey Kraut
Moderated by Andrea Cohen, Senior Vice President for Program of the United Hospital Fund, the final panel featured perhaps the most spirited exchanges of the day as leaders from health care providers and health plans shared different perspectives. The panelists were Linda Brady, MD, President and CEO of Kingsbrook Healthcare System, Karen Ignagni, President and CEO of EmblemHealth, Paloma Izquierdo-Hernandez, President and CEO of Urban Health Plan, and Jeffrey Kraut, Executive Vice President of Strategy and Analytics at Northwell Health. They discussed how the vision for the future of health care involves overlapping and evolving roles as incentives change.
Dr. Brady offered this candid assessment in describing the future of her hospital, which she volunteered is one of 28 on a state watch list for the most financially distressed institutions: “We’ve known since 2007 that the way of the independent hospital was going to be the way of the dinosaur — extinction,” she said. But she added there is “a glimmer of hope” that her hospital will become part of a regional health system in Brooklyn, so that five years from now, it will neither look nor function as it does today.
As the discussion turned to predictions about the future impact of the Delivery System Reform Incentive Payment (DSRIP) program, Ms. Hernandez shared her perspective, representing a Federally Qualified Health Center system with sites in the Bronx and Queens. In particular, she noted that delivery system reform will depend on payers and DSRIP’s Performing Provider Systems engaging community-based providers as true partners and working with them in data-driven ways to achieve positive outcomes. But she also acknowledged the fundamental challenge that DSRIP is really oriented to helping hospitals transform and reconfigure themselves, which makes the broader vision more challenging.
Mr. Kraut described his health system’s rebranding, focusing on its transformation over many years from health care provider to today’s “wellness institution,” which includes CareConnect, its own insurance product that in its second year has more than tripled enrollment. He emphasized the importance of creating health care systems that are sustainable beyond the life of, for example, DSRIP. He also cautioned that value-based payment models based on shared savings might have a short life span, if in short order no more savings can be squeezed out of health delivery.
Ms. Ignagni described her not-for-profit insurer’s leadership in implementing new relationships with providers using innovative value-based payment arrangements, including among its own ambulatory care centers and physicians and its partner hospitals, and how those arrangements leverage the core competencies and capacities of each actor. Praising new data tools that allow plans to better support coordinated care, she cautioned that payment reform itself must not be an end goal, but rather a step along the way to improving quality and affordability of health care. She warned that this will not happen unless systems move beyond upside-only arrangements to share risk, eliminate waste, improve functionality, and incorporate social services.
In one of the day’s most compelling exchanges, Dr. Brady and Mr. Kraut discussed the need for further integration of health care providers, referring to Dr. Brady’s earlier remarks on the need to be part of a system. Ms. Ignagni cautioned, “As someone who gets the bills, consolidation results in significant cost increases.”
Mr. Kraut countered that consolidation was the insurance industry’s fault because insurers paid lower rates to small community hospitals, forcing those hospitals to join with larger systems. “Hospitals started getting together to create scale,” he said. “The marketplace rewards scale. If it wasn’t for consolidation, I dare say four or five of the hospitals in our system would be closed.”
Interpreting the takeaways of the day, Jim Tallon focused attention on the importance of stakeholders coming together to discuss the future state of health care in New York. He pointed to a number of themes from the day—the difficulty of culture change, the changing sites of care delivery, the urgency of system change, technology as a disruptor. He also reminded the audience of the importance of the voices of the many different groups of patients and consumers who access health care. He also reminded the audience of how looking back can make clear how quickly technology can change our system. And he closed by stressing long-term planning to ensure major health institutions are sustainable, accessible, and effective in 2021 and beyond.