Sustainable Financing, Stewardship, Strategy Using Systems Change to Create a New Health Ecosystem July 11th, 2016 Laura Landy President & CEO Share Post We’re all well aware of what’s wrong with our healthcare system—costs are going up, health status is declining, value is poor. But there is a solution: we must create a new health ecosystem, which approaches health much more broadly. We can no longer focus only on specific diseases, body parts, or populations. Why? Because health care contributes only 10% to health. Genetics is a big factor at around 30%. The remaining 60% is the result of behavior, environment, and social circumstances—things we can change. This new ecosystem must incorporate all of the interdependent factors that contribute to health, and we must restructure the relationships between these factors. In 2007, The Rippel Foundation launched ReThink Health in response to this systems challenge. At ReThink Health, we are working to show that systems change is both necessary and possible, and to fundamentally shift the norms and standards that leaders use in their decision making. We are a think tank, convener, collaborator, consulting firm, coaching team, tool development shop, and influencer—combined. Much of our work focuses on the regional level—essentially self-defined marketplaces—with a goal to accelerate the efforts of cross-sector coalitions, policy makers, and others to get beyond improvement of the current system, to get beyond collective impact, and to work in the hard, disruptive, and necessary space of transformation. To this end, we have worked with leaders in 70+ regions across the country, helping them see the systems they are part of and how they can be more effective agents of change. We also convene our peer organizations—we call them catalysts—so that we may collaborate with others who share our vision, and we participate in key forums for change at the Institute of Medicine, the Public Health Institute, Robert Wood Johnson Foundation, and others. Admittedly, however, it can be hard to describe our day-to-day work in concrete terms, so here are a few illustrative examples: In Minnesota, when the state legislature asked the department of health to explain how incarceration affects the health of individuals, families, and communities, the department asked ReThink Health for help. In early 2016, we led two workshops with representatives from public safety, economic development, education, health, human services, and the broader community. The workshops resulted in a “map” of the system—shared with the legislature—demonstrating how incarceration can have long lasting, detrimental effects on economic opportunity, educational achievement, family unity, and housing stability—the very conditions that shape health. Moreover, these conditions were found to be reinforcing; that is, once begun, the impact of incarceration on health spreads and deepens over time. In 2011, when ReThink Health began working with the Pueblo Triple Aim Corporation (PTAC) in Pueblo County, Colorado, the county had among the worst health outcomes in the state and questioned how they were investing their resources. Using ReThink Health’s Dynamics Model, essentially a health system in a computer, the PTAC’s leaders identified new ideas that could yield a much more positive and sustainable future for Pueblo’s residents. This plan helped PTAC attract significant funding to support its agenda. The 2016 County Health Rankings revealed that progress is being made, including a nearly 50 percent reduction in preventable hospital readmissions among seniors and significantly reduced teen/unintended pregnancies. Like many hospitals and health systems in the United States, Dartmouth-Hitchcock Health (D-H) is grappling with a rapidly changing environment. In 2013, ReThink Health used its Dynamics Model to engage the D-H Board and senior staff in a strategy discussion. As a result, D-H created a “population health innovation fund,” which is financed with 30 percent of the investment returns that exceed budget targets. This fund has grown to more than $14.5 million since its inception. One of the first of its kind in this country, this fund is a model for how existing health care resources can be invested differently to yield greater value. The impact of efforts like these could be huge over the next 10-20 years, especially if they can be scaled. We are excited for the work ahead. Will you join us? This blog post is a summary of Rippel Foundation President Laura Landy’s remarks during a panel on “Promising Approaches to Systems Change” at the Social Impact Exchange‘s recent Conference on Scaling Impact. 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. Join the Conversation Jack Homer Great stuff, Laura. But I think we need to be careful about “health care contributes only 10% to health”, etc. The squishiness of this claim is discussed by Harvard’s Austin Frakt (2012) at http://theincidentaleconomist.com/wordpress/how-much-does-health-care-contribute-to-health/. He notes that this statistic is based on McGinnis et al (Health Affairs 2002), which was actually talking about how inadequacies or failures of health care are responsible for 10% of deaths. That is a very different statement! For a better sense of the contribution of health care, Frakt cites Cutler et al (NEJM 2006), who conclude that improvements in health care are responsible for about 50% of increased longevity of the past century; http://theincidentaleconomist.com/wordpress/to-what-extent-is-health-care-responsible-for-our-longer-lives/. Now, both of these are statements about deaths, and deaths are not the same as disease or poor health. But I’m not aware of any estimates of the contribution of medicine to mitigating poor health. So, in lieu of that, we’ll have to take deaths. The confusion, as I see it, is about medicine as it stands today, as opposed to medicine as it advances. If you consider only medicine as it stands today, then, yes, elimination of failures can contribute only 10%. But if you consider medicine as it advances, then it can contribute 50%. All in all, putting these things together, here’s my recalculation of potential contributors to better health: advances in medicine (50%), eliminating medical errors (5%), improvements in behavior (25%), improvements in environment (10%), and improvements in genetic counseling (10%). Charlotte Gay Stites Thanks for this interesting blog. I agree that with burgeoning cost of health care, we need to look for new models. In spite of spending far more than any other country in the world, the US has poorer health outcomes. It is time to invest in maintaining wellness rather than managing chronic diseases. Many conversations about our healthcare system revolve around adult care and disease management, but many of the chronic diseases begin in childhood and are rooted in lifestyle behaviors leading to obesity as well as Adverse Childhood Experiences. It is time to invest upstream to prevent diseases before they begin, to invest in promoting healthy behaviors, improving educational readiness and success to improve long term health. In Louisville, KY, we are working to open the Smoketown Family Wellness Center, a scalable model that provides medical care for children in a community-based setting with healthy lifestyle support for the entire family, empowering parents with the tools they need to raise healthy children. We will partner with existing programs to bring resources and services to families in the neighborhood setting, creating a culture of health. Robert Kambic Laura, if we think of health care as including behavior, environment, and social circumstances, as you suggest, we come up with “Public Health.” The Johns Hopkins Bloomberg School of Public Health (I am retired faculty now working for Medicare) is celebrating its 100th anniversary. During its existence the School has addressed all of the issues you mention as needed for health. When I began my MSH at the University Of Pittsburgh School Of Public Health in 1970 I think there were less than ten such schools in the US. Now they are ubiquitous. There has been a recent move to use the term “Population Health.” I think that one is able to distinguish Population and Public Health by considering that Public Health subsumes all facets and aspects of health, wellness, and illness whereas Population Health seems to me to be more confined to illness and curative medical science. That is where the dollars are; and the dollars come from insurance including Medicare and Medicaid. Clean air, clean water, sanitation, proper nutrition, decent housing, jobs, transportation, etc. are really not counted into the healthcare dollar equation and all have suffered extensively under recent state and federal budgets. In my opinion the American public has lost sight of the importance of the broad aspects of Public Health; they do jump to it when faced with a novel threat such as Zika or Ebola not realizing that these emerging infectious diseases are just a part of a larger problem. Having worked a bit with your ReThink colleagues I applaud what they are doing across the country. Continue with the organizing efforts. From a science perspective trying to decide how much of “health,” “illness,” and “death” is addressed by various aspects of healthcare is complex and fun to argue about; yes of course it is also a serious endeavor. The American Healthcare system is extraordinarily complex if we include all of the aspects discussed herein, including spending. Check the article Lynn, Straube, Bell, Jencks, Kambic. ‘Using Population Segmentation to Provide Better Health Care for All: The “Bridges to Health” Model” The Milbank Quarterly, Vol. 85, No. 2, 2007 (pp. 185–208).