The Users' Guide to the Health Reform Galaxy

Recess for better health

Jim Marks, senior vice president and director of the Health Group, encourages us to turn to the playgrounds to build prevention efforts and reclaim recess to help improve children’s learning and well-being. This post first appeared on The Huffington Post. As another way to improve children’s health, read Jim Marks’ thoughts about the importance of attacking “cereal killers” in the grocery store to help reverse childhood obesity here.
 
When it comes to improving the health of Americans, we normally talk about what happens in a doctor's office.

And when it comes to improving education, we usually focus on what happens in the classroom.

But what if we looked outside of the classroom and the doctor's office? In fact, what if we just looked outside?

It turns out that there's one place you can go to improve learning and health at the same time: the elementary school playground. A growing body of research suggests that playing games like kickball or four square at recess may be the secret to a successful school day and building a lifetime of health.

Kids today are getting fewer and fewer minutes on the playground for recess -- the average is now down to about 22 minutes each day. Facing pressure to meet academic and other requirements, many schools have cut back on recess and some have eliminated it entirely, thinking that this can help them with their academic mission.

However, this trend toward sacrificing recess may produce the exact opposite result and hurt academic performance. In fact, according to a new Gallup poll of elementary school principals, the vast majority surveyed linked having recess to academic achievement, and two-thirds reported that students listen better and are more focused in the classroom after they have had recess. Principals also overwhelmingly saw recess as key to their students' social development.

How Maine Used Its Clout to Press for Higher-Value Health Care

Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, recounts how a big health care purchaser applied its considerable leverage to insist on public reports about hospital performance. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

What does a heavyweight look like in the fight for high-value health care? Take a look at how the state of Maine has used its muscle as the administrator of health plans for 34,000 employees, retirees and their families. It is an especially noteworthy story since the health care reform bills before Congress include a number of provisions to encourage the use of quality measures and value-based purchasing.
 
Maine’s State Employee Health Commission, responding to a call from the state legislature to contain health care expenses, developed a new health-benefits plan in 2006. No ordinary plan, its goals included engaging employees and retirees in the health care process, improving quality of care and encouraging providers to publicly report their performance information.

The upshot has been a value-based purchasing strategy based on public reports developed by the employer-led Maine Health Management Coalition, which works closely with the Robert Wood Johnson Foundation’s Aligning Forces for Quality grantee, Quality Counts, and the state government’s quality-improvement initiative, called the Maine Quality Forum.

Obama's Budget Includes Modest Increases for Public Health and Prevention

Jeffrey Levi, executive director of Trust for America's Health, writes about advancing the agenda of prevention and public health in tough economic times.

In a time of very tight financial constraints, we all need to be realistic about our expectations. In the context of a freeze on overall domestic non-defense/security discretionary spending, the Obama Administration did show its commitment to a strong public health system that focuses on prevention. Obviously, we'd love to see big increases for public health; however, this budget, combined with large investments about to be released under the American Recovery and Reinvestment Act (ARRA), will significantly increase the capacity of communities to respond to pressing prevention needs.

But the question of health reform still looms large. Unless we take action to improve the health of Americans, we'll lose an important opportunity to rein in health spending. Treating chronic diseases is
one of the biggest drivers of health care costs,  and until we focus more on prevention in a sustained and comprehensive way, we're never going to get these costs under control.

Teaming Up to Improve Care of Diabetes Patients in Minnesota

As Congress and the president figure out their next steps on national health care reform, we want to continue shining a light on local laboratories of reform. Here, Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, writes about the effort to encourage high-performing health care providers in the Land of 10,000 Lakes.

Quality reformers have a mantra: You can’t improve what you don’t measure. But in Minnesota, the local team that the Robert Wood Johnson Foundation tapped to manage its Aligning Forces for Quality initiative, also knows you can’t lose weight by just standing on the scale. You have to act on what you learn.

The Foundation’s grantee, Minnesota Community Measurement, operates the scale. Its HealthScores project gathers performance data from Minnesota health plans as well as 300 medical clinics statewide. But it is part of a multi-pronged action team that is driving change in Minnesota by helping providers improve on their performance and then rewarding them when they do.

'Bending the Cost Curve' by Tackling Overuse of Diagnostic Imaging

Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, examines how some communities are using evidence-based  guidelines to rein in a conspicuous source of health care overspending. This post is part of our continuing effort to shine a light on local laboratories of health care reform.

If you look closely in Aligning Forces for Quality communities, you can see how local laboratories are grappling with some of the most vexing delivery issues in health care. And there is probably no more vexing issue than overuse of health services—an issue that has figured prominently in the health care debate as Congress and the president wrestled with the question of how best to control costs.

Dartmouth researchers have estimated that as much as 30 percent of health care spending is for care that doesn’t improve people’s health—and don’t just take their word for it. Thompson Reuters came out with a new study last October attesting to the reasonableness of this estimate.

Diagnostic imaging, especially when it involves lower-back pain, is one case drawing the attention of overuse detectives. Lower-back pain is the fifth-most-common reason Americans see a doctor, and the common use of expensive imaging technology to diagnose it has become controversial. For more than a decade, guidelines for treating lower-back pain have recommend delaying imaging use for most patients because their backs typically get better, and their pain often subsides, within a month. A recent study published in Health Affairs took a look at the relationship between the supply of MRI machines, and their use for lower-back pain. Surprise, surprise: The researchers found “a clear relationship between MRI availability and MRI use for low back pain patients.”

Hat Tip to Emergiblog, the Life and Times of an ER Nurse

Head over to Emergiblog for this week’s Grand Rounds – the LOL Edition, a collection of medblog posts complete with accompanying “Lolcats” and “kittehs." This week's overview includes a post from our very own Susan Hassmiller about the importance of recognizing nurses as health reform leaders.

The Wisdom of Crowds?

David Colby, vice president of research and evaluation, writes about what you, our readers, selected as the most influential articles funded by the Robert Wood Johnson Foundation last year.

In December, we asked the public to vote on the most influential articles funded by the Robert Wood Foundation in 2009.  It was our second effort to draw outside feedback into our Year in Research process. What do you think about the wisdom of the crowd?  Did the crowd miss important articles or themes?  Did the Foundation miss funding some important articles?  Please join the discussions by posting your thoughts and comments below.

The articles receiving the most votes in 2009 are:

• Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems;
• What Newly Licensed Registered Nurses Have to Say About Their First Experiences;
• A Closer Look at the Economic Argument for Disease Prevention;
• Association Between School Food Environment and Practices and Body Mass Index of U.S. Public School Children;
• Geographic Variation in Public Health Spending.

The wisdom of which crowds?  Last year, my picks and the picks of our readers were different. Last year, the picks of the nation and those from inside the Beltway were different. This year, the picks of single article voters and those who voted for more than three articles were different. Those who voted for more than three articles chose:

• A Closer Look at the Economic Argument for Disease Prevention;
• Association Between School Food Environment and Practices and Body Mass Index of U.S. Public School Children;
• Geographic Variation in Public Health Spending;
• Slowing the Growth of Health Care Costs - Lessons from Regional Variation;
• What Does It Cost Physician Practices To Interact With Health Insurance Plans?

Now you’ve seen the full results of the poll, I would love to hear from you about the crowd’s choices and our process. 

Prevention - An Impetus for Moving Health Reform Forward

Jeffrey Levi, executive director of Trust for America's Health, writes about how strong public support for expanded disease prevention programs could help jumpstart the legislative process. This column first appeared in Huffington Post.

As we turn the page to the next stage of debates around health reform, we should remember there is a whole lot in the current Senate and House bills that is popular, already in close agreement, and could be the impetus for moving forward.

The prevention and wellness sections of the bills could help do just that.

A public opinion survey released in November 2009 by Trust for America's Health (TFAH) and the Robert Wood Johnson Foundation (RWJF) found that disease prevention is one of the most popular parts of health reform. In fact, 71 percent of Americans favor an increased investment in disease prevention.

Investing in disease prevention receives majority support from across the political spectrum (85 percent of Democrats, 59 percent of Republicans, and 68 percent of Independents) and across the country (72 percent in the Northeast, 73 percent in the South, 71 percent in the West, and 69 percent in the Midwest), according to the poll, conducted by Greenberg Quinlan Rosner Research and Public Opinion Strategies.

Call to Action: Tapping Nurses' Leadership and Expertise

Susan Hassmiller, senior adviser for nursing at the Robert Wood Johnson Foundation, writes about the need for nurses to be full partners in reforming the health care system and improving patient care.

There’s image and there’s reality, and the two are not the same where nurses are concerned.  Nurses are seen as trusted, caring, compassionate, skilled health care providers. But that image doesn’t fully capture the reality of the roles nurses play in our health care system, which are much more extensive, substantive, pivotal and robust. 

Today, the Robert Wood Johnson Foundation and Gallup are releasing an unprecedented survey of 1,500 opinion leaders that provides insight into what we need to do to ensure nurses’ place at the decision-making table—and to give health reform every chance to succeed. In many ways, the  two objectives are inextricably connected.

For years, nurses have come out on top of Gallup’s annual poll of most trusted professionals. It’s a truism that the public trusts nurses. But this survey goes deeper. It finds that diverse opinion leaders—including those in insurance, health services, government, industry and academia—say that nurses should have more influence on health systems and services. 

Addressing the primary care workforce shortage to come

Deanna Okrent, senior health policy associate with the Alliance for Health Reform, writes here about a predicted shortage of primary care providers to treat a larger pool of insured Americans.

With the prospect that an additional 31 million Americans may gain insurance coverage under national health reform, many warn there may be too few primary care providers to treat them. 

Following enactment of reform in Massachusetts -- a state often studied to help inform the current debate -- increased demand for primary care led to longer waits for medical appointments and unmet needs for some types of care.  This may have been the result of pent-up demand from previously uninsured individuals. In a May 2009 paper on health reform in Massachusetts, Sharon Long notes that this demand is expected to stabilize as people have coverage for a full year and longer.

Many predict a similar phenomenon after national reform is implemented.  A contributing factor is the declining interest in primary care as a professional goal. Far fewer medical graduates entered residencies in family medicine and internal medicine in 2009 than they did in 1999. Among the reasons graduating physicians choose specialties and subspecialties over general practice are: 1) their large educational debts and  2) the relatively low compensation of primary care physicians, which means it takes longer to pay back that debt. 

Robert Otto Valdez makes Christmas appeal to the U.S. Senate

Robert Otto Valdez, PhD, executive director of the Robert Wood Johnson Foundation Center for Health Policy at the University of New Mexico, channels FDR and Jimmy Stewart to make the case for expanding Medicare to achieve universal health coverage.

I was reminded the other day watching “Mr. Smith Goes To Washington” that
sometimes you just need to say what needs to be said until the Senate hears what is
right. This is right: We all have a right to life and liberty. These are founding principles
of our nation; they define our social contract to one another. And one cannot have life
and liberty without good health. ALL those living and working in the USA must have
access to quality health care and healthy communities, lest we break the social
contract itself. The Senate’s debates on health insurance reform must restore our
nation’s social contract in accord with these principles.

President Franklin Delano Roosevelt commented that “the test of our progress is not
whether we add more to the abundance of those who have much; it is whether we
provide enough for those who have too little.” The Senate would be wise to heed
these words as they debate health insurance options for our nation. History shows
that private enterprise and the profit motive do not ensure the well-being of every
individual - public commitment is essential to achieve our ideals as a society.

We would do well to recognize our own history with the Social Security program,
the cornerstone of our nation’s economic security. At first, coverage was
limited to only a few. Only gradually, over several decades, was the program
expanded to its present nearly universal form. Today, it is recognized as our nation’s
most important anti-poverty program, the major or only source of income for many
seniors.

I'm dreaming of a white paper ...

David C. Colby, vice president of research and evaluation at the Robert Wood Johnson Foundation, shares his favorite health reform policy papers in the spirit of regifting.

While many of you might already have visions of sugar plums dancing through your heads, I (not surprisingly) have health reform on my mind.  That doesn’t mean I am not in the holiday spirit. In fact, I propose a “white elephant” holiday gift exchange here at the foundation. ‘Tis the season of regifting.  The best part of the gift exchange is how it highlights that value is truly in the eye of the beholder.  Many recycled gifts are still perfect gifts.

In that spirit, I want to regift to you some of this year’s health reform policy papers that are as good as stocking stuffers today as when they were released last February, April, June or October. I started with 12 gifts of policy analysis, but with Hanukkah wrapping up tomorrow, feel free to pick your favorite eight…

America’s Uninsured Crisis
Released in February by the Institute of Medicine (IOM), this report addresses three key questions: (1) What are the dynamics driving downward trends in health insurance coverage? (2) Is being uninsured harmful to the health of children and adults? (3) Are insured people affected by high rates of uninsurance in their communities?

Crossing Our Lines: Working Together to Reform the U.S. Health System
In June, three wise men, former Senate Majority Leaders Howard Baker, Tom Daschle and Bob Dole completed The Leaders’ Project on the State of American Health Care, a two-year consensus-building process resulting in a plan for reforming America’s health care system.  This report outlines their key recommendations.

How Do We Pay For Health Reform?
Conducted by Urban Institute researchers and released in July, this analysis reports that savings from many popular health reform ideas would finance the lion’s share of the cost of comprehensive health care reform. The authors also conclude that a combination of revenue options would provide more than enough money to fill the gap between the cost of reform and the savings resulting from it.

How Does the Quality of U.S. Health Care Compare Internationally?
This analysis from the Urban Institute, which we released in August, looks at the evidence on how quality of care in the United States compares to that in other countries and highlights the implications for health reform.

How Will the Uninsured Be Affected by Health Reform?
In this four-part series, released in August by RWJF and the Kaiser Commission on Medicaid and the Uninsured, the Urban Institute’s Lisa Dubay and Allison Cook calculate how many uninsured people could gain coverage through a health reform scenario that draws on proposals being discussed on Capitol Hill.

Bending the Curve
Released in September, this report is not about making candy canes. Compiled by the Engelberg Center for Health Care Reform at the Brookings Institution, the paper proposes that health care reform should include comprehensive efforts to achieve higher-value care. The report was co-signed by a distinguished group of scholars and policymakers: Joseph Antos, Ph.D., (American Enterprise Institute for Public Policy Research); John Bertko (Brookings Institution); Michael Chernew, Ph.D., (Harvard Medical School); David Cutler, Ph.D., (Harvard University); Dana Goldman, Ph.D., (RAND Corporation); Mark McClellan, M.D., Ph.D., (The Brookings Institution); Elizabeth McGlynn, Ph.D., (RAND Corporation); Mark Pauly, Ph.D., ( University of Pennsylvania); Leonard Schaeffer (University of Southern California); and Stephen Shortell, Ph.D., (University of California, Berkeley).

Is Massachusetts Reform Working for Doctors?
This study, published in the Oct. 21 issue of the New England Journal of Medicine, finds that 70% of practicing physicians in Massachusetts support health reform three years after its passage in 2006. We partnered with Blue Cross Blue Shield of Massachusetts Foundation to fund the research, which was designed and conducted by researchers at the Harvard School of Public Health.

Trust for America’s Health Prevention Poll
The poll, conducted for RWJF and Trust for America’s Health by Greenberg Quinlan Rosner Research and Public Opinion Strategies, indicates the majority of Americans support disease prevention investments as a part of national health reform. Poll findings were released in November.

A State Policymaker's Guide to Federal Health Reform
These three documents released by the National Academy for State Health Policy (NASHP) last month identify the most challenging health policy issues that states are addressing; describe the tools they have at their disposal and how federal health reform may affect those tools. It also describes the support they would need to implement federal health reform legislation.

County and City Health Departments: The Need for Sustainable Funding and the Potential Effect of Health Care Reform on their Operations
This report, released earlier this month by Health Management Associates, analyzes the effects that substantial funding cutbacks from local, state, and federal sources have had on already-strapped local health departments.

Leveling the Field - Ensuring Equity Through National Health Care Reform
Bruce Siegel, M.D., and Lea Nolan, M.A., from the Center for Health Care Quality, The George Washington University School of Public Health and Health Services, published this piece in the Dec 3 edition of the New England Journal of Medicine. The paper discusses how health reform legislation would reduce racial and ethnic disparities by extending coverage to disadvantaged groups.

The Cost of Failure to Enact Health Reform: Implications for States
Released at the end of September, researchers from the Urban Institute used their Health Insurance Policy Simulation Model to estimate how coverage and cost trends would change in every state between now and 2019 if the health system is not reformed.

Wishing you a happy and healthy holiday season. May all your policy papers be white!