Moving Forward in Minnesota
By Sanne Magnan, M.D., Ph.D.
Lately, I have been thinking a lot about the future—the future of public health, the future of health care, the future of health in Minnesota. We have just entered a new decade, and there is so much change going on around us. We need to look at where we are—and where we are heading. And I have to admit, as I look forward, I cannot help but be concerned. But I am also hopeful. One of the biggest changes—and sources of uncertainty—is the recently passed federal health care reform law. Here in Minnesota, we are working to understand the impact this new law will have on our state. Minnesota has long led the nation in tackling significant health reform, and we hope the federal government will look to us as an example. But many questions remain.
For example, How will the new law affect insurance coverage in Minnesota? Our state has long been a leader in covering the uninsured; but that has started to erode. In 2009, 9.1 percent of Minnesotans were without health insurance, up from 7.2 percent in 2007. And, in 2009, only 57 percent of Minnesotans had health coverage through an employer—down from 63 percent in 2007. The federal health reform law is estimated to cover roughly 60 percent of uninsured individuals across the country, but we do not yet know exactly how this will affect our state.
Even as we expand coverage, we have to find ways to contain health care spending, which continues to rise at an unsustainable rate. Total health care spending in Minnesota rose nearly 70 percent between 2000 and 2007, from $19 billion to nearly $36 billion. The Health Economics Division at the Minnesota Department of Health estimates that if left unchecked, health care spending could rise to $78.5 billion by 2018.
Increasing health care spending is not the only issue causing concern. Our unhealthy behaviors are leading to alarming trends. Almost two-thirds of Minnesotans are overweight or obese. Tobacco use is declining in the state, but still nearly one in five adults smokes.
Minnesota’s place in the annual America’s Health Rankings continues to slip. In 2009, we were ranked the sixth healthiest state in the nation, down from the third healthiest in 2008 and the healthiest in 2006. Although we ranked first in health outcomes last year, we ranked only seventh in such health determinants as the prevalence of obesity, smoking, and binge drinking; air pollution; and the number of children in poverty. This is an indication that our health outcomes may decline over time.
The demographics of our state are changing. By 2020, the number of Minnesotans who are older than 65 will outnumber school-aged children. Health care spending jumps dramatically for people older than 55. Furthermore, our state’s population is becoming more diverse, and we face significant disparities in key health indicators.
These numbers are sobering. So many challenges face us at a time when our resources are dwindling. Is it possible for us to effectively address them? I believe it is. What gives me hope is the work we are already doing in Minnesota.
State Health Reform
We are currently working to reform our health care system and transform the health of Minnesotans in a comprehensive, meaningful way. For the past two years, we have been busy implementing the reforms that the Legislature passed and the governor signed into law in May 2008 that together make up “Minnesota’s Vision for a Better State of Health.”
If you look at the federal health reform law, you will see many things that Minnesota is already working on such as prevention, wellness, quality and value measures, health care homes, and administrative simplification. For example, Minnesota has been working on quality measures for a long time, and we hope that our work can be used to influence the national quality strategy.
We also have been working to reform health care payment to encourage better care instead of simply more care. By creating the Centers for Medicare and Medicaid Services (CMS) Innovation Center, the federal health reform law has set the stage for movement toward payment reform on the national level. We have seen signals from CMS that the center will be looking for an unprecedented level of learning from and collaboration with states. Minnesota has proven to be a leader in health reform, and I hope that CMS will continue to look to us as a laboratory for innovation—and for our vision.
That vision is broad and far-reaching. We are seeking to move upstream to invest in public health, expand health care market transparency, redesign care delivery, reform payment, and engage consumers. We are pursuing Minnesota’s “Triple Aim,” adapted from the Institute for Healthcare Improvement, to simultaneously improve the health of the population, the patient experience, and the affordability of health care.
Moving Upstream
We know we must do more in public health if we want to truly improve the health of Minnesotans. Experts estimate that health care contributes only about 20 percent to our overall health. Healthy behaviors contribute 30 percent, socioeconomic factors 40 percent, and our physical environment 10 percent.
A significant amount of money goes into clinical care. We really need to invest more upstream, in the modifiable determinants of health including tobacco use, diet and physical activity, education, employment, community safety, and the built environment. Our Statewide Health Improvement Program (SHIP) is moving upstream to tackle tobacco and obesity, the leading preventable causes of illness and death. SHIP is a model for community-led, community-oriented changes in policies, systems, and environments to support healthy choices for individuals. But we must do more to reach all of our communities and address the diverse set of factors that most affect health.
Enhancing Health Care Value
We also need to promote value—higher quality at a lower cost—in our health care system. The United States spends trillions of dollars on health care annually—more than any other country—yet our health outcomes are mediocre in relationship to the dollars invested. One way we are trying to improve the value of health care in Minnesota is through the provider peer grouping initiative. Allowing providers, payers, employers, and consumers to make more informed choices about health care is an important way to expand market transparency.
We are the first state in the nation to create a statewide provider peer-grouping system that looks at risk-adjusted quality in comparison to risk-adjusted costs. By being transparent with the development of provider peer grouping, we have worked hard to include many perspectives, and we are committed to creating a solid, credible product that providers and the community can understand and trust. This approach will be important in light of federal reform, which incorporates value-based purchasing for Medicare providers and will include a value-based payment modifier in the Medicare physician payment methodology by 2015.
Redesigning Care Delivery and Payment
Our current payment system is broken, and incentives are misaligned. Providers are paid based on the amount of care they provide instead of the value of that care. And many consumers do not feel empowered to take an active role in their own health care.
Through innovations such as health care homes, we are supporting a redesign of care and a redesign of payment. The focus is patient- and family-centered primary care, so now more than ever, patients can become partners with their providers. The care coordination payment for certified health care homes will pay providers for the work of coordinating patients’ care as well as for regular visits and tests.
During the implementation of health reform, I have seen remarkable leadership in the medical and health community. In the midst of taking care of patients and populations, clinical leaders have stepped forward to redesign care and redesign payment. This could be compared to building an airplane while flying it. But you are showing the way to improve population health, improve the patient experience, and improve affordability. Your leadership is critical to Minnesota’s success.
As I look back on all that we have accomplished over the past two years, I am heartened. I know we have much more work ahead of us and we must continue to explore the ways in which federal health care reform will affect our efforts in Minnesota. But I am hopeful for a future in which Minnesota’s vision becomes a reality, both here and throughout the United States. I am hopeful that soon we will all live in a better state of health. MM
Sanne Magnan is Minnesota’s Commissioner of Health.