by ReThink Health Staff

Our work with the Robert Wood Johnson Foundation tackles the tough question of what it will take for regions to improve health and deliver high-value care at the scale, duration, and intensity needed for long-term, equitable impact. This work approaches health system redesign as a grand challenge, requiring innovation—and integration—across health and health care. Drawing on ReThink Health’s history and experience, as well as on-going learning with partners in diverse sectors, this project will explore a set of hypotheses to focus future regional reform endeavors, refine practical tools and approaches, and launch a learning network to help leaders share what does or does not work with each other and what they’ve gleaned along their respective journeys. The research team hopes to engage with collaborators across the field to test these approaches and harness the potential of innovations along these frontiers. This project, led by the Rippel Foundation as part of its ReThink Health Initiative, is being supported by the Robert Wood Johnson Foundation.

In this interview, Rippel Foundation President and CEO, Laura Landy, and ReThink Health Director, Bobby Milstein, co-Principal Investigators, discuss the project’s context and overall goals.

What led to this project?

Laura262014Laura Landy: The impetus for this project grew from work that we have been doing for several years with leaders who are collaboratively pursuing large-scale change in regions across the country.  And it was no surprise that our colleagues at RWJF had had similar insights.  We recognized that decades of hard work and financial investment in system-oriented initiatives had not influenced health and economic trends as much as we would have hoped.  These disappointing results suggest that we are overlooking or misaligning some core elements or resources, and getting caught in pitfalls that hinder greater progress.  We have come to believe that three intertwined elements are critical to success.  First is a targeted and effective strategy focused on policies that will have greatest impact.  Second is an active, multi-sector group of stakeholders organized into a stewardship structure that can champion and align regional efforts.  And, third is sustainable financing that can seed and support activities and alliances long enough to realize the full impact we aspire to achieve.  A goal is to ultimately shift our culture to create new norms around health and care.  A promising frontier for the field lies in moving beyond decisions about what to do, and pressing on to address the practical—often problematic—questions about how to prioritize strategies that make the most difference, how to pay, and who decides?

Bobby MilsteinBobby Milstein: A related inspiration comes from insights based on the ReThink Health Dynamics Simulation Model.  Although it remains a work-in-progress, thousands of strategists and educators have begun using this interactive, empirically based computer model to play out their own scenarios for the ways we promote health and deliver care in communities.  Again and again, they discover that it is possible—with sound strategies and adequate financing—to dramatically improve the worsening trajectories of chronic disease, rising costs, entrenched inequity, and lost productivity.  In other words, there is good evidence showing that we can make progress across multiple metrics of health system performance.  But to do that, stakeholders must be clear about where to invest and they must sustain those investments long enough to make a real difference.  Not everything has equal impact; some strategies make matters worse; and certain combinations can be especially powerful.  As one example, efforts to coordinate care can produce short-term savings that could then be reinvested to enable healthier behaviors, which in turn will likely promote health, boost productivity, reduce inequity, and save even more money over time.  With its distinctive focus on geographic regions and its wide-angle view of a whole local health system, the ReThink Health Model lets diverse stakeholders test their own “what if…” hypotheses.  Planners see and feel what kind of difference they could make alone and, more importantly, together.   Looking ahead, the Frontiers project will engage an array of partners to understand and test the conditions, opportunities, relationships, and tools that could make these sort of synergistic changes a reality in regions across the country.

Why now?  What is the urgency?

Laura Landy: This sort of effort to press frontiers for the field is badly needed so that we may respond more effectively to the high-stakes, rapidly changing challenges to our health and to our economy.  The overwhelming weight of evidence suggests that the entire U.S. health system will get worse the longer we delay making fundamental changes.  Powerful forces like uncontrolled market dynamics, an aging population, chronic disease progression, rising costs, eroding productivity, unequal treatment, imbalanced investments, discrimination, and wasteful misalignment among stakeholders will likely conspire to deliver a future that none of us want — unless we act now to rethink and redirect the course of change.

Bobby Milstein: In addition, some very pivotal innovations are beginning to flourish and we may be on the precipice of a genuine movement for health, driven simultaneously by federal and state policies, as well as by shifts occurring at the grassroots in regions across the country.  Changes in the wake of the Affordable Care Act have already begun to expand insurance coverage, alter economic incentives by paying providers for value instead of volume, institutionalize shared-savings agreements, and require hospital community benefit investments to be openly aligned with data from public health system assessments and in harmony with the priorities of local stakeholders.  Moreover, there has been a sharp increase in the formation of integrated health and health care enterprises, accredited public health agencies, multi-stakeholder coalitions, health improvement collaboratives, and other tables where people are focusing on larger, system-oriented solutions.  Dozens of novel financing structures are also emerging that had scarcely been considered even five years ago.  Some examples include accountable care organizations, collective impact organizations, social investment funds, venture capital investments, employer-based initiatives, prevention and wellness trusts, social impact bonds, and a variety of other mechanisms.

Laura Landy: Of course, the impact and spread of these emerging innovations is still limited.  There are many challenges.  The relationships are complicated.  Language differs.  Visions are not aligned.  Competition for resources abounds.  There is rarely a shared strategy for change, nor the organizational capacity or resources to implement it.  When confronted with changes, challenges, and opportunities of this magnitude, rethinking how to approach solutions becomes even more critical as a prelude to concerted action.  We are continually refining tools and approaches to help innovators clarify their intentions, connect more deeply, see how they are situated in a wider system, and embrace their own roles as change agents within it.  With all that is going on in health care finance and delivery today, now is a very fertile moment for that kind of new thinking that may well be a decisive step in being able to harness the potential of the frontiers that are within reach. These are precisely the reasons that we created ReThink Health, and our work supported by RWJF is helping us bring it to the next level of effectiveness and spread.

What makes this project unique in terms of RWJF’s involvement?

Laura Landy: This project is an ideal example of RWJF’s dedication to creating a culture of health.  Together we conceived and launched this project more than a year ago.  This type of cross-foundation engagement reflects the importance that all of us at Rippel and RWJF place on developing integrated, system-wide solutions: a stance that is now even more apparent in RWJF’s reimagined vision around a culture of health.  In supporting this project, both of our foundations affirm the idea that we must work simultaneously to enhance population health and deliver high-value health care to all who need it.

How are you going to achieve this daunting task?

Bobby Milstein: It is definitely a challenge.  But ReThinkers, by definition, are drawn toward the most thorny and pragmatic predicaments. Veteran practitioners recognize the paradox of pursuing system-wide solutions through fragmented, short-term investments.  And we see the limitations of attempting to nourish a culture of health without somehow engaging all stakeholders as stewards of our common health system.  The Frontiers project will reframe aspirations and search for integrated, system-wide strategies that are fueled with serious, sustainable financing and steered by broad-based stewardship teams that have the authority and legitimacy to act on behalf of the whole. The good news is that we are not alone.  Many colleagues are confronting these same challenges and pursuing complementary paths.  We are forming strong alliances with like-minded leaders and learning together.

Laura Landy: As this project proceeds, we will be listening for and refining the most compelling hypotheses to guide the next generation of action-centered learning.  Over the next several months, we will elicit insights from health professionals as well as colleagues from other fields such as energy, safety, and maintenance, where many of the same issues have been the focus of impressive innovations.  We will convene local stakeholders along with some of the main champions in the field, facilitate interactive learning labs, map the structure of stewardship and financing networks, and study examples of promising endeavors under way in the U.S. and abroad.  We have also created an online learning network that will soon be openly available as a forum for innovators who want to explore ideas and exchange work in progress, including the measures they use to chart progress over time.

Bobby Milstein: Across all of these engagements, we will constantly think ahead and question what kind of novel financing and stewardship structures have yet to be recognized, as well as where the resistance, opposition, and sticking points may arise.  Our core team and an expanding circle of allies are well-positioned to define these frontiers for the field, offer practical tools, and eliminate some of the most common excuses that stand in the way of attempting daring experiments to enhance our collective understanding and accelerate innovation.

Are there places now that are showing promise?

Laura Landy:  Yes.  Creative work is going on in places like Oregon, Ohio, Georgia, Minnesota, Colorado, Vermont, Arkansas, and others.  Community development investors are starting to see how intimately connected health and health care costs are to their goals of creating livable environments and thriving local economies.  Similarly, we are starting to see major hospital systems embrace their role in keeping the population healthy and out of the emergency room.  They are also focusing on how to deliver greater value when health care is needed and lead payment reform efforts that will drive change.  These are all critical not only to their business model but to the future health and prosperity of their entire region.  Part of what we’re trying to do with this project is to consolidate hard-won lessons from these innovators and accelerate action on the most promising innovations.  In the end, we want to show that it is possible to create the conditions for better health in every region across the country.

The personal views and opinions expressed in this blog (and in any comments) are those of the original authors only, and do not reflect the opinions of The Rippel Foundation or ReThink Health. Neither The Rippel Foundation nor ReThink Health is responsible for the accuracy or validity of any of the information contained in the blog or any comments. All information is provided on an “as-is” basis.

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