10 Years Watching the New York Health System: The Good and the Bad

[Note: This will be my last blog post as the President and CEO of the New York State Health Foundation; on March 1, 2016, I will be the Robert Derzon Chair in Health and Public Service at NYU. Sign up here to receive e-mail notifications of new posts.]

After 10 rewarding years, I step down this week as President of the New York State Health Foundation and join the faculty at New York University. In other places, I have reflected on my experiences running the Foundation, but here I thought I would reflect on the ups and downs of health care and public health in New York State.

As president of a foundation helping to support medical care innovation, healthy living, better health policy, and more attention to the real health needs of New Yorkers, I have had the privilege of watching our health system evolve and try to improve. Some of what I observe, I am super-impressed with. Other aspects of what has happened over 10 years, I find disappointing.

Here is my scorecard (and I urge you to think about your own scorecard of positives and negatives and share some ideas in the comments section below!):

A Positive: The success of the ACA in expanding insurance coverage
This is clearly a home run. More than 2.8 million New Yorkers have signed up for health insurance coverage as a result of the Affordable Care Act. And, more than half of those are Medicaid enrollments. In the past, it has been extremely challenging to get Medicaid-eligible New Yorkers to actually sign up for coverage, so this is an especially welcome development.

A Negative: The consumer-friendliness of the ACA and the medical care system overall
Expanding coverage is only half the battle! I've tried to help loved ones navigate the enrollment process, and it's so challenging. And once people are enrolled, it's hard to know how to use the health insurance they have: Which providers are in-network? How much will I have to pay out of pocket? Which surgeon should I use for my back surgery? Patients just don't have access to the kinds of information they need to make good decisions about their care.

A Positive: The growing focus on supporting people to lead healthier lives
We have known for a long time that medical care is only a small part of what makes us healthy or sick, but it seems that only in the last 10 years has there been real momentum to push for changes outside the medical care system. Now, we are seeing money and energy to encourage healthy eating and physical activity through community interventions and policy change. And we are seeing interest not only from the health care and public health worlds, but also from those working in education, housing, business, transportation, community development, parks and recreation...the list goes on and on. People are seeing that all of these areas affect the health of our communities. This focus on a "culture of health," as the Robert Wood Johnson Foundation calls it, is a welcome development.

A Negative: The blunt use of co-payments and the high cost of health care for consumers
We still have not figured out how to encourage high-value care and discourage low-value care in a meaningful way. High co-payments amount to an annual tax for people who are chronically ill and who are most vulnerable. Health care is unaffordable for too many working New Yorkers; it makes no sense that people earning $50,000 a year might spend $20,000 on health care. Other industries (automobiles, airlines, computers) manage to offer quality products at a range of price points, but we have not attended to this issue in health care.

A Positive:Innovation spurred by State government to slow the costs of our large Medicaid program
The impact of the Medicaid Redesign Team, which led to the $8 billion waiver and now the Delivery System Reform Incentive Payment (DSRIP) program, has been so important in focusing attention on getting our health care spending under control. The introduction of spending caps, a clear goal to reduce avoidable hospital use by 25% over 5 years, experiments with care management and health homes, and more attention to the care delivered outside of the hospital setting are all going in the right direction. Kudos to our State government and a broad set of health care leaders for making the Medicaid Redesign Team work so effectively.

A Negative: The unfulfilled promise of integrated medical records
Even more than 10 years ago, HEAL NY (the Healthcare Efficiency and Affordability Law for New Yorkers) was established with the intention of investing up to $1 billion in State funds to improve health care delivery, with a focus on establishing interoperable health information technology (in English, this means health records that the full range of health care providers treating a person can share in an electronic way). In addition, in 2009, New York State received substantial federal stimulus dollars to improve health IT. These investments did spark some success, and we have seen momentum with the New York eHealth Collaborative (NYeC) in fostering innovation, pushing for electronic health records, and developing the Statewide Health Information Network of New York (SHIN-NY). But after all this time, and hundreds of millions of dollars, we still lack a widespread, integrated medical records system in New York State.

A Positive: Rapid expansion of access to primary care
I have often said that community health centers are the jewels in the crown of our health system, providing high-quality care and serving as a critical safety net. With New Access Point funding through the Affordable Care Act, dozens of health centers throughout the State have been awarded approximately $380 million to expand capacity and serve hundreds of thousands more patients. A statewide plan developed by the Community Health Care Association of New York State (CHCANYS) identified opportunities for sustainable growth of health centers to provide more than 1 million additional patient visits each year. And, just last year, Mayor de Blasio announced the $20 million Caring Neighborhoods initiative, which will expand primary care services for more than 100,000 New York City residents in underserved neighborhoods.

A Negative: The inability of health care providers and payers to share important information with patients
This relates a bit to the complexity of our medical system I described above, but the lack of transparent information is a huge challenge. If patients are supposed to be at the center of our health care system, they should have access to the information they need to make good decisions related to price and quality. New York's all-payer claims database, long planned, is still not off the ground. Such a resource would bring together encounter and payment data from Medicare, Medicaid, and commercial insurers and could be a tremendous resource for price transparency, quality oversight, policy research, and health systems transformation. FAIR Health is developing an online shopping tool for New Yorkers that will provide meaningful price and quality data. But there persists a reluctance among providers and payers to share these types of information in ways that help consumers make the best decisions for their health and for their pocketbooks.

A Positive: The positive energy of medical care providers preparing for new payment approaches
For too long, the way we pay for health care has perpetuated perverse incentives: the volume of care has been rewarded over the quality and value of care delivered. But there is tremendous momentum for that to change. New York State has set formal goals that 90% of all Medicaid payments and 80% of all commercial payments be made under value-based arrangements. Catalyst for Payment Reform's New York Scorecard on Payment Reform shows that we are making some progress. Although most payments still rely on a fee-for-service model, a significant share of payments is "value-oriented," with one-third of payments designed to boost the quality of care patients receive. This approach is also consistent with the growing focus on population health and disease prevention; providers recognize that new models of care will allow them to (and be paid to!) help patients stay healthy and manage their chronic illnesses.

A Negative: The slow emergence of disruptors we need so urgently
Although we have seen some exciting innovations in health care (the emergence of ZocDoc, Oscar, CityMD, and a range of apps focused on both wellness and medical care), there has not yet been what I would consider a "blockbuster disruptor" that can spur others to be creative. To truly improve our health system, we need something with the scale and drama of Uber, or Facebook, or Google. Adequate numbers of innovators simply haven't arrived on the health care scene. And I would guess that we need folks from outside of the usual players in health care to be truly disruptive, to turn what's broken about our system on its head. And, for sure, disruptors will make those of us who have worked in health care for many years get more creative also!

Clearly, we have a lot to be proud of; New York has always been and continues to be a leader in health care. But there is still more important work to be done. I look forward to keeping an eye on progress through a different lens as I start my new job!

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