Health Affairs

GrantWatch Blog invited the author, vice president of research and evaluation at the Robert Wood Johnson Foundation, to report on a webinar that the funder held this month. 

The fortieth anniversary of the Robert Wood Johnson Foundation (RWJF), a national funder, is a time for reflection on how we at the foundation have done, what we could do better, and how we should do our work in the future. This past week, in a webinar, Bob Blendon, one of the early staff members at the foundation, noted that when the RWJF began, it wanted to bring an evidence revolution to health problems and solutions.

Early leaders of the RWJF funded evaluations both as a way of holding the foundation accountable for its work and as a way of providing information—disseminating innovations that worked. Blendon (who worked at the RWJF from 1972–1987) discussed the foundation’s first great success—the Emergency Medical Services (EMS) Program, which started in 1972 with forty-four sites. The evaluation of the EMS program found that people were getting emergency care faster than before, but people weren’t being taken to the closest, most appropriate hospital. Part of the EMS program’s goal was realized; the other part would take the next decade to fix.  

More recently the RWJF also used evaluation to support the development of health policy.  At the webinar, Jim Knickman (who worked at the RWJF from 1992–2006) described the Cash and Counseling Demonstration and Evaluation, in which elderly and disabled Medicaid recipients were allowed to purchase services from whomever they wanted, including family members, and buy equipment that would assist them, rather than receiving services from a Medicaid-approved agency. In the late 1990s, this was very controversial: policy makers were worried that costs would skyrocket, that family caregivers weren’t trained to do this, and that there would be fraud.

The evaluation conducted by Mathematica and jointly funded by the federal government and the RWJF found that consumers in Cash and Counseling programs were more satisfied and had better outcomes and that there was no fraud. The evaluation assuaged policy makers, and the program was adopted as a Medicaid option in the Deficit Reduction Act of 2005. Today, fifty states have some form of the program, and the Veterans Administration has it available in seventeen states. The key to its success was strong evidence and a partnership with the federal government—thus, improving the likelihood of acceptance. Read the rest of this entry »

The author, director of state health policy at the California HealthCare Foundation, discusses how that funder has been working with California officials to support implementation of various pieces of the Affordable Care Act of 2010 at the state level.

Federal health reform establishes the framework for sweeping changes to the nation’s health care delivery system and financing mechanisms. The task of building on this framework to deliver the promise of expanded coverage, health care system improvement, affordability, and improved health outcomes rests with, and will be the result of, state governments’ decisions and actions.  

Philanthropy is uniquely positioned to partner with policy makers and administrators in states to bring the advantages of the federal Affordable Care Act (ACA) to their residents. Our sector’s independence and long-range view can add perspective and resources as states work through the seemingly endless list of opportunities and tasks related to the federal health reform law.

In California the ACA has already delivered many benefits to Californians and has created numerous opportunities for innovation among health care providers and community groups as delivery system reform pilots unfold. Unprecedented federal support is available to those states that choose to undertake reform activities. While it is tempting to assume that federal funds are sufficient to get the job done, the tasks ahead are enormous and complex, and the quality of their execution has long-ranging consequences.

The California HealthCare Foundation and other California-based health philanthropies have a proud history of sponsoring analyses and projects that support and inform state deliberations and the decision making of California policy makers. The foundation’s portfolio of implementation-related projects reflects our assessment of where we are uniquely positioned to offer balanced and timely assistance to state policy makers and administrators as they take on the myriad tasks associated with the ramp-up. Our colleagues in other California philanthropies are making similar assessments and investments to assure that, as a state, we live up to the aspiration of Diana Dooley, Democratic Governor Jerry Brown’s cabinet secretary for Health and Human Services, to be “the lead car” in implementation.    

Below are examples of the type of work the California HealthCare Foundation has undertaken to inform state policy. They range in scope and complexity, but all are designed to help state policy makers and administrators achieve the goals of the ACA. Read the rest of this entry »

I thought I would start off the week with some people news. I am a bit behind on my reading, but I wanted to let you know about four foundation leaders who were recently named to these lists.

Modern Healthcare 2012 100 Most Influential People in Healthcare list

Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation (RWJF), based in Princeton, New Jersey, came in at no. 50 on the list. The RWJF is celebrating its fortieth anniversary this year.

Drew Altman, president and CEO of the Henry J. Kaiser Family Foundation, based in Menlo Park, California, came in at no. 55 on Modern Healthcare’s list. Altman “founded the current-day Kaiser Family Foundation in the early 1990’s, directing a complete overhaul of the Foundation’s mission, staff, and operating style,” according to a bio sent to me by a staffer. Read his Pulling It Together series of online columns here.

Congratulations to both foundation leaders! Modern Healthcare released its list on August 25.

To provide some perspective, John Roberts, chief justice of the US Supreme Court, came in at no. 1. President Barack Obama ranked no. 4. Kathleen Sebelius, US secretary of health and human services, came in at no. 5. Thomas (“Tom”) Frieden, director of the Centers for Disease Control and Prevention (CDC), ranked no. 46 on the list.

Back story: The awards program invites “readers to nominate and vote for the most influential leaders in healthcare,” the magazine, which started publishing this list in 2002, says. Winners are people in health care “who are deemed by their peers and an expert panel to be the most influential individuals in the industry, in terms of leadership and impact.” View the entire list (photo gallery and text list available there).

Forbes list of the World’s 100 Most Powerful Women 2012

Melinda Gates , co-chair of the Bill and Melinda Gates Foundation, had a very high ranking on this list: no. 4. Read her Forbes profile. Follow Melinda French Gates on Twitter at @melindagates. Read the rest of this entry »

The author, director of health policy at the Missouri Foundation for Health, blogs about a recent report released by the St. Louis–based foundation.

An often overlooked part of the Affordable Care Act of 2010, Section 4302 requires that the US secretary of health and human services “ensure that any federally conducted or supported health care or public health program, activity, or survey collects and reports data on race, ethnicity, sex, primary language, and disability status.” Also, other demographic data on health disparities can be collected “as deemed appropriate by the Secretary.”

In June 2011, the US Department of Health and Human Services announced that the administration planned to begin collecting health data on lesbian, gay, bisexual, and transgender (LGBT) populations in federal surveys.

This is an important step because the biggest barrier in the production of the Missouri Foundation for Health’s new report, Responding to LGBT Health Disparities, was the gaps that exist in health data for the LGBT population. The report is a wide-ranging look at health disparities that impact LGBT Missourians. It includes analysis of available health data for the LGBT population, as well as a range of policy options to eliminate health inequities affecting this population.

In many parts of Missouri and the nation, LGBT people face daily discrimination, and this oppression contributes to the health disparities demonstrated in our report. These inequities include higher rates of obesity, tobacco use, suicide, violence, substance abuse, certain cancers, and heart disease. Read the rest of this entry »

My GrantWatch column in the September issue of Health Affairs, “Mental Health: What Foundations Are Funding,” provides a snapshot of foundation efforts around the country to help people who suffer from mental illness.

A variety of funders are interested in this topic. In my small sampling, it appears that support for integrated health care, in which physical and behavioral health are systematically coordinated, has been gaining in popularity. (The term “behavioral health” often includes treatments for both mental illness and substance use.)

Some foundations are supporting projects on mental health and the criminal justice system. Read about efforts funded by the Bristol-Myers Squibb Foundation (a national corporate funder), the Endowment for Health (a statewide funder, based in Concord, New Hampshire) the New Hampshire Bar Foundation, and the John D. and Catherine T. MacArthur Foundation. (Note to readers: MacArthur no longer has a mental health program, per se.)

In a lengthy section on integration of care, I mention the Robert Wood Johnson Foundation’s policy brief from last year entitled “Mental Disorders and Medical Comorbidity”; a Commonwealth Fund paper on the Affordable Care Act of 2010’s “health home option” for Medicaid enrollees, which promotes “whole-person care”; efforts by the relatively new Empire Health Foundation, which funds in eastern Washington State; the Hogg Foundation for Mental Health, a statewide funder located in Austin, Texas, which has been working on integrated health care since 2006; the Maine Health Access Foundation, which has had some success with its $10 million Integration Initiative, which also started in 2006; and the Sunflower Foundation, a statewide funder located in Topeka, Kansas. Work on integration of care is going on all over the United States, as you can see. Read the rest of this entry »

Editor’s note: Mark Smith is the president and CEO of the California HealthCare Foundation. He also chaired the Institute of Medicine panel that wrote the report–just released today–titled Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.

Smith’s blog post below was first published September 5 on GrantWatch Blog’s “big sister” blog, Health Affairs Blog. Thank you to my colleague Chris Fleming for sharing this post with GrantWatch Blog readers! 

The newly released September issue of Health Affairs contains several thoughtful analyses and proposals about how to change our approach to paying physicians and hospitals. It comes at a time when Washington policymakers begin an annual ritual of Kabuki theater, complete with its hallmark stylized drama and elaborate makeup:  the so-called Sustainable Growth Rate, a recurring threat to cut physician payment in order to restrain Medicare costs. This year the proposed cut is 27 percent. The SGR represents an ongoing approach by some in both the public and private sectors to target physician fees as a lynchpin of cost control.

Is it really a sound strategy to alienate the very people whose cooperation we most need to achieve a more affordable and equitable system?

With the growing realization that the health care system’s costs are unsustainable and represent the greatest threat to the future prosperity of the country, there is virtual unanimity that reducing costs is an absolute necessity. And much of the strategy to reduce costs — from managed care in the 1990s to the SGR in the 2000s — has resulted in considerable pressure on physician income. This pressure has fostered a variety of responses. On the one hand, many leaders of the profession have stepped up to point out ways in which patient care could be improved by decreasing the utilization of low-value and harmful care. Examples include the Choosing Wisely campaign of the American Board of Internal Medicine and the associated Five Things Physicians and Patients Should Question — a partnership with numerous specialty societies and Consumer Reports. And the Archives of Internal Medicine has sponsored an ongoing series, “Less Is More” on the same theme.

On the other hand, there is ample evidence that many everyday, in-the trenches physicians are unhappy, and increasingly burned out, despite being well-paid compared to many others in society. This grumpiness has many sources: growing complexity in biomedical knowledge and organizational relationships, growing expectations for data submission and performance reports, and others. Surely a fair amount of their dyspepsia is related to the perception that their livelihoods are under pressure from forces which they do not understand and cannot control, and that squeezing their incomes is misdirected. There is some validity to that.

Doctors direct most health care spending. They decide, “You’re going to be hospitalized; you need an MRI; you’re going to get a stent; you need a knee replacement.” But despite the fact that they direct this spending, they are not necessarily the principal beneficiaries of it. Read the rest of this entry »

On August 28 I attended the launch of the Gordon and Betty Moore Foundation’s Patient Care Program. This national funder, based in Palo Alto, wants to do transformative work in this area and is prepared to commit $500 million over ten years to do it, if all goes well. Yes, you read that right: that is a half-billion dollars. Foundation staffers came to Washington to make the announcement at the National Press Club.

“Each year tens of thousands of preventable deaths occur in U.S. hospitals, and millions of dollars are spent on complications and patient readmissions that could be averted,” said a Gordon and Betty Moore Foundation press release.

Its new Patient Care Program, a national effort, “seeks to eliminate all preventable harms to patients.” The program will focus on (1) “meaningfully engaging” patients (and their families) in their health care and (2) “developing a systems approach that optimally reconfigures” teams of health professionals, processes, and technology to support that engagement, the press release explained. In this approach, patients and families will be partnering with the health care system. The foundation predicts that by using this approach, health care costs will be reduced. It also believes that health outcomes will improve, and care will be more respectful of patients and their families, as well as those who serve them, the foundation’s president, Steve McCormick, said in the release.

The program will build upon other researchers’ work, collaborate with “like-minded” groups, and award grants for research and clinical projects in the two focus areas.

At the Washington briefing, physician George Bo-Linn, who is chief program officer for the Patient Care Program, noted that, in general, this foundation seeks to stimulate ambitious, large-scale transformation through its funding; achieve significant, measurable, and lasting effects; and make a large financial investment in its areas of focus.

And the foundation wants to make a real difference in patient care. (Bo-Linn also is chief program officer for the Moore Foundation’s San Francisco Bay Area Portfolio of grants, including its ongoing Betty Irene Moore Nursing Initiative and the Betty Irene Moore School of Nursing at the University of California, Davis.)

He pointed out that when patients are well informed, they will usually choose care that is less invasive and less costly. Bo-Linn explained to the audience that excessive and inappropriate care can cause harm to patients. And not offering patients dignity and respect is also harmful, he noted.

He made clear, though, that this supportive health care delivery system that the foundation envisions in its new program “does not hurt patients”! Read the rest of this entry »