The System Is Rigged and Nobody Wins: A Call for Integration

February 18, 2015|11:56 a.m.| Scott Briscoe

Mary Applegate currently serves as the medical director of Ohio Medicaid, but she earned her stripes in primary care practice. Board certified in internal medicine and pediatrics, Applegate previously served the Marysville, OH, community of 22,000 residents, approximately 30 miles outside of Columbus, OH.

At a recent Institute of Medicine (IOM) roundtable on the integration of primary care and public health, Applegate spoke about Ohio's efforts around payment reform and healthcare transformation. Applegate wasn't the only excellent speaker at the roundtable—in fact, her own panel included Theodore Wymslo, Ohio's former state health officer and one of the nation's top leaders on health equity issues—but her talk served to simplify the complex challenge of integrating primary care and public health into easy-to-understand comparisons and examples.

First, the essential information: the IOM roundtable was titled "Public Health and Health Care: Collaboration and Innovation at the Interface: A Workshop," held in person at the National Academy of Sciences in Washington. Archived video recordings, slide decks, and supporting material are all available on the IOM website.

Applegate succinctly explained how we got to our current state: "The system is defined to pay for ill care. [As a result,] the health of the population is going down and costs are escalating." And she notes we've been building this system for more than 50 years, so it's going to take time to shift to a better system.

The key, she says, to turning this around so that we pay less and get better results is alignment. Medicaid's visitation program is a good example of misalignment in action. The visits to expectant mothers have proven valuable in improving the outcome of that birth. But, according to Applegate, there is a missed opportunity-costing millions of dollars a year—by not connecting the visitation program measures to pediatric or obstetric visitation after birth, which are entirely different systems that measure entirely different things reporting to an entirely different agency. For us to have a healthcare system instead of an ill care system, these things must be connected. Applegate notes that when you look, you can see this pattern of misalignment across the existing healthcare system.

In essence the very models we're using to try to achieve health are contributing to poor health. So much of health funding comes in the form of grants, which each have their own goals and measurements - no alignment. It also creates an atmosphere where those in the health profession are left chasing money.

How do you get to alignment?

This is where Wymslo's part of the panel-and frankly the rest of the example-rich panels-come in.

As a brief explanation: Wymslo laid the groundwork for public health and primary care integration in the Ohio health department, and then championed the idea in every meeting and gathering he had, inside and outside the department. The health department facilitated the development of Ohio's Patient-Centered Primary Care Collaborative with insurers, primary care providers, and the state's health and hospital systems, among others. Later, Ohio Governor John Kasich convened a council on healthcare payment reform. Key to the success of the initiative is, among others, the participation of the state's five major insurance providers. The purpose: to change from a fee-for-service model to a fee-for-value system.

Applegate developed five slides that do a terrific job of describing the "fee-for-value" system that Ohio is trying to create. The slides conclude this post, but it's important to note that this was just one of many fascinating examples and ideas describing both the benefits of and how to integrate primary care and public health. In addition to the roundtable, many more resources are available. The ASTHO-Supported Primary Care and Public Health Collaborative is a good start, including the strategic map that was developed by representatives from 28 different public health and primary care organizations as a guide for integration efforts. Duke University's Practical Playbook is another good resource, as is ASTHO's collection of integration success stories.

And now, Applegate's slides that describe the Ohio initiative. Abbreviations to know: PCMH-Primary Care Medical Home, MCO-Managed Care Organization, COPD-chronic obstructive pulmonary disease, PCI-percutaneous coronary intervention. For a slightly larger version of the slide, right click and select "View Image."