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What COVID-19 teaches us about health and human services integration by Melissa Riba

Melissa Riba, Director of Research and Evaluation

For much of the last year, CHRT has been working with The Kresge Foundation and other national partners to better understand and advance the concept of health and human services integration.

At CHRT, we are focusing our health and research transformation lens and our expertise in systems change to learn about the challenges and opportunities that occur as organizations work to connect historically separated systems to improve the health and socio-economic opportunities of communities. Throughout this work, we are mindful of the critical importance that racial inequities play in individual and community health and well-being.

Working on health and human services integration during and through the COVID-19 crisis, our team is learning at an accelerated pace. Our awareness of barriers and policy issues are heightened as we see the real-world impact of this pandemic.

Here’s what we’re learning:  

Our most vulnerable citizens are at greatest risk: The negative effects of this pandemic are falling disproportionately on our most vulnerable citizens—people who struggle to earn enough to live on; to maintain a roof over their heads; to stay clean and sober; to maintain their mental health; to feed themselves and their families; to be safe from violence—all while trying to keep safe from a deadly virus for which there is no vaccine or cure.

The pandemic is exposing and exacerbating racial inequality: In Michigan, 40 percent of COVID-19 deaths are among our African American residents, yet they are only about 12 percent of the population. Why is that? Health, and alternatively, vulnerability to a devastating virus, is not something that happens in isolation. It is impacted by historical and structural inequalities that have been shaped by racist policies and practices and the lack of economic and social mobility that came along with them.

The ability to share data safely, securely, and meaningfully is key: In order for health and human services systems to effectively address the complex, multi-faceted needs of individuals, information needs to flow across systems, programs, and agencies. Such information can help to identify which individuals and families need extra support and can support ‘no-wrong door’ approaches for them by using universal enrollments, assessments, and protocols.

Tele-health has expanded, but it is re-exposing our digital divide: Until recently, expanding tele-health existed mostly on health care wish-lists. Now it has been thrust to the forefront of health interventions. As CHRT senior analyst Karen Teske points out in a timely April, 2020 publication, since the beginning of the year 80 additional services are now billable through Medicare for telehealth with a certified clinician. But even as we see tremendous progress, we ae mindful that disparities in access to high-speed internet determine how effective tele-health is as a means to deliver care and services—rural communities, lower income households, and older individuals are far less likely to have the high-speed internet that makes effective use of this innovation possible.

Right now, and far into the future, we need our health and human services systems to:

  • Share information, reduce duplication, and create and maintain an organizational culture that puts people at the center.
  • Address health while at the same time addressing the social determinants of health, racial inequalities, and barriers to social and economic mobility.
  • Implement more culturally competent, trauma-informed practices and ‘no wrong door’ approaches to ensure people can get the services and resources they need, when they need them, delivered in ways that elevate, rather than marginalize.

Across the country, more and more organizations are examining and talking about their integration work, but we are coming to recognize that true integration is often difficult to achieve.

While consolidating offices or administrative tasks and collaborating on individual programs may be part of an integration framework, achieving real health and human services integration means unwinding entrenched systems, reintegrating the cultures of organizations, the data systems they use, the funding streams they require, and the governance structures they depend upon—all while recognizing that social determinants are inseparable from the health and wellbeing of people and communities.

Another existential threat to the Affordable Care Act in the midst of the COVID-19 pandemic

Having health insurance is essential to getting early diagnosis and treatment.  And if we’ve learned one thing during this coronavirus crisis, it’s that early diagnosis and treatment isn’t just important for the individual affected, it’s important for all of us. That’s why I was so troubled this week when, during a press conference, President Trump reaffirmed his support for a Texas lawsuit—set to be reviewed by the U.S. Supreme Court this year–that threatens to eliminate the entire Affordable Care Act.

The Affordable Care Act just turned 10 years old.  The Act’s successes are well documented – the steep reduction in the numbers of uninsured Americans from 15.4% in 2009 to 9.5% in 2018; the fact that coverage is now available to those with pre-existing conditions who were unable to get it before; the fact that preventive services are now covered in full with no cost-sharing for consumers; and the fact that fewer people report not getting needed medical care because of cost than they did before the ACA.  That last fact could not be more important as we face the most critical public health issue of our lifetimes – the coronavirus.

The Texas lawsuit I’m referring to—the one that President Trump supports—was filed in February 2018 by 18 Republican Attorneys General and 2 Republican Governors who challenged the constitutionality of the Affordable Care Act in light of the 2017 tax bill that eliminated the tax penalty for individuals who did not enroll for minimum health coverage under the ACA.  The plaintiffs argued that without the penalty, the mandate was unenforceable as a tax, and that since the entire ACA relied on the mandate, the law itself should be struck down. In December of 2018, a federal judge in Texas agreed with the plaintiffs and determined the entire ACA to be invalid

Many of the judge’s legal rulings were criticized by both conservative and liberal legal scholars. And the case was immediately appealed. But the Trump administration sided with the plaintiffs and supported the ACA being struck down in its entirety.  In December 2019, the appeals court determined that the individual mandate was unconstitutional but made an inconclusive ruling on the constitutionality of the rest of the ACA. And earlier this month, the Supreme Court agreed to take up the case in its next term.

There is no question that the Texas lawsuit poses an existential threat to the ACA. And, there is also no question that that threat could not come at a worse time. The full story of the coronavirus is yet to unfold.  But, one thing that the coronavirus makes clear: health care coverage is a public health measure.

With a disease as infectious as the coronavirus, we need public health measures to protect us all.  The coronavirus doesn’t skip infecting people just because they are uninsured. And uninsured people are just as likely to infect others as are people with insurance. It is essential to all of us that people who are sick get tested early to both save their lives and protect others from being infected.

Unfortunately, financial barriers keep people from seeking need medical care. The first phase emergency measures that Congress put in place to address the coronavirus acknowledged how much cost can be a deterrent to care by making sure that there would be no copays for people getting tested

One issue the Congressional measures did not address is the fact the thousands of Americans who get the coronavirus will now be considered to have a “pre-existing” condition. The emergency measures don’t need to address that issue because the ACA is in place today and Americans with pre-existing conditions are protected from losing health coverage because of the ACA. But, if the Trump administration has their way, the ACA will go away; the health care system will face further chaos and there is no certainty that a replacement will be put in place to protect the millions likely to be infected with this virus over time. There is simply no doubt that the ACA is essential to our fight against the coronavirus. Now is the time to be expanding the ACA, not throwing it away.

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Nancy Baum on what backbone organizations do, and why they matter

At CHRT, we devote much of our time to policy analysis, research and evaluation, and project management.  More recently, as our emphasis on collective impact has grown, CHRT is expanding our role as a backbone organization. So what does it mean to be a backbone organization, and why does it matter?

One way to conceptualize a backbone organization is that its goal is not to work one-on-one with individuals or organizations, but to create a broader understanding of what a community needs and provide capacity to address those needs in the community. Backbone work is accomplished working among multiple organizations in a community, rather than between two entities, as might occur in project management or traditional consulting work.

Until very recently, foundations and other organizations historically hadn’t funded the infrastructure necessary for this type of coalition work. Now, as government agencies and NGOs increasingly recognize the interconnectedness of multiple factors affecting the health of people and communities, support for the work of backbone organizations is growing. Backbone work provides both infrastructure and context for mission-based organizations, and can help focus efforts taking place across entire communities and among those community organizations.

CHRT’s work with the State Innovation Model (SIM) is one example of the role a backbone organization can play in facilitating collaborative efforts to reach shared goals across regions and organizations. CHRT’s job with the SIM is, in part, to help develop key strategies and provide capacity to align resources so that regional partners – social service and health organizations in two counties – can achieve their specific missions as service providers while working together to focus on the needs of their shared clients. In the case of the SIM, care management services are provided to individuals who have high health and social needs to help them achieve their health goals and to reduce reliance on emergency departments.

As we collect and aggregate partner data locally we can start to see what the need is at a community level and measure collective impact of our joint work. We can also disaggregate the data in nuanced ways to pinpoint specific challenges key populations face and identify best practices that help our partners better address those specific needs. Similarly, in the process of facilitating the collaborative approach, we learn how to help the organizations we work with more effectively carry out their complementary work. The vantage point and capacity of a backbone organization helps local organizations that individually deal with housing, or food insecurity, or complex health care to talk to each other, collaborate, and work more efficiently together for the good of the individual.

The perspective and expertise of a backbone organization also extends beyond the ability to connect and synergize mission-driven organizations with differing core competencies. As collective work becomes more effective through better insight into process and practice, backbone organizations like CHRT also help ensure that funders understand what the partners are addressing in their community, what’s working, and where further efforts should be focused. Backbone organizations can provide expertise in budgets, offer administrative capacity and resources, create summary documents or presentations, and implement convenings to make it easier for foundations and legislative allies to support regional collaborations and tout the results of ongoing public, private or non-profit investments.This level of backbone work provides the partners with crucial resources to make the case for longer-term sustainability. 

To learn more about CHRT’s backbone work, policy analysis, research and evaluation click here.

The gift of simplicity means a lot. It means even more in the midst of coronavirus.

Erin Spanier, Marketing and Communications Manager, Center for Health and Research Transformation (CHRT)

When it comes to business, simplicity is the rule. 

Amazon lets you buy with a single click. The App Store lets you do it with a print. And you can sign up for discounts at your favorite stores with an email address–no name, no phone number, no hassle.

But when it comes to government–particularly when it comes to government aid for people and families in poverty–simplicity is too often the exception. 

I recently learned that Michigan is trying to buck that trend. And as a professional communicator watching from the sidelines as coronavirus threatens the livelihood of hourly workers and business owners across the state, that makes me proud to be a Michigander.

Last summer, the Michigan Department of Health and Human Services launched a “Simple Gifts’ contest for its staff. The department-wide competition encouraged staff members to submit ideas that would make it less challenging for Michiganders to apply for government aid. 

Some 331 entries were submitted to streamline and improve the application process for healthcare coverage, emergency housing, food assistance, cash assistance, and other basic aids for those who are struggling financially.

Jennifer Bellini, an eligibility specialist from Ingham County, suggested updating verification checklists with plain language to make it easier for clients to understand requirements.

Stacy Kiger, an eligibility specialist from Genesee County, suggested making a computer and printer available at each county office so clients could print off the documents and forms they needed to complete their applications. 

Angela LaLonde, a registration support staff member from Iosco County, suggested implementing live chat on the MiBridges website for quicker responses to client questions. 

Emily Luther, a family independence manager from Macomb County, suggested adding an option to pay by phone to the toll-free line for MiChild, a health insurance program for Michigan’s working families. 

The suggestions went on and on. And they were good ones. Really good.

In January, more than 30 Michigan Department of Health and Human Services employees were honored for their winning ideas at a celebratory lunch at the George W. Romney Building near the State Capitol. 

“We aim to simplify everything we do and the winning Simple Gift ideas advance that goal,” said MDHHS Director Robert Gordon at the luncheon. “We will implement as many as we can as quickly as we can.” 

Already, the state has simplified asset tests for several assistance programs, and I hope to see more of these ideas implemented in the weeks ahead.

Luke Shaefer, director of Poverty Solutions at the University of Michigan, warns that with virus-related social distancing policies “many low-earning hourly workers don’t have the option to work remotely, and this unexpected change in income will exacerbate challenges for families working hard to make ends meet.”

Small food and financial supports could go a long way toward helping those families weather this time. But to apply, families will need to navigate paperwork, procedures, and protocols that have been tooled, retooled, and complexified by generations of administrations. 

Streamlining these applications, and making sure they can be completed quickly and easily online or over the phone, would be a win for everyone–government and workers alike.

Building a business case for sustainability–why you need one, and why this is the time to get started

Marianne Udow-Phillips, Founding Executive Director, Center for Health and Research Transformation (CHRT)

Community based organizations providing important social services–supportive housing, food security, mental health, substance use services and the like–are often challenged to maintain programs over time. Without an ongoing revenue stream, many human service oriented organizations struggle to keep important services available in the community. In this context, when we talk about sustainability, we’re talking about ensuring that organizations that provide effective human services can keep those services going and scale them to magnify their impact.

It’s common for foundations and government entities to fund pilots. But foundations rarely fund programs for more than a few years. How then do community based organizations that have implemented programs–programs with demonstrated results–continue those programs on an ongoing basis? 

America spends a great deal on health care–more than any other country in the world–and in an ideal world, those dollars would support the programs that improve health, regardless of whether those are flu shots, nutritional supplements, counseling sessions, supportive housing, or financial coaching. Unfortunately, that’s not the case. The health financing system we have in this country generally focuses on funding the medical delivery system and not broader services that might actually make a bigger impact on health. 

However, there are signs that the historical approach to funding health care in the U.S. is beginning to change. In 2019, Medicare added a new opportunity for Medicare Advantage plans to pay for services related to the social determinants of health. Medicare’s decision opens the door for new and sustainable funding for organizations providing these needed and evidence-based services. Many private payers follow Medicare’s example, as does Medicaid. So, new opportunities for sustainable funding are definitely on the horizon.

At CHRT, we help clients navigate these realities to achieve sustainability. We help them develop robust evaluation protocols; analyze the data they’ve collected to ascertain the impact in terms of quality, customer experience, and cost; then build a compelling business case for payers. Ultimately, we help clients think about projects objectively, analyze their impact, and demonstrate the value to the payers and providers that have the power to keep them going. 

In health care costs, Michigan is doing something right

Editor’s Note: This column was published in Bridge Magazine.

Variation in health care spending between states has been well documented for decades by many researchers, most notably, those who produce the Dartmouth Atlas of Health Care. The reasons behind this variation in spending have generally been less understood and much debated.

Our center wanted to understand this variation better, particularly to see how Michigan stacked up. To do that, we compared health care spending (particularly the largest part of health care spending: hospital costs) between states with different health policies. We chose two neighboring states, Indiana and Wisconsin, because they share similarities – as well as some significant structural and policy differences – to Michigan.

What does our study comparing health care spending in Michigan, Wisconsin and Indiana tell us?

We are doing something right in Michigan. And there is much that Indiana and Wisconsin can learn from Michigan when it comes to health care spending.

Our study’s findings were simple, yet complex. Health care spending overall, and hospital costs in particular, is lowest in Michigan, followed by Indiana and highest in Wisconsin. Hospital costs make up about a third of health care spending and these costs are considerably lower in Michigan than the states we looked at in the study. Wisconsin hospitals’ operating and total hospital margins far exceeded national benchmarks, while Michigan hospital margins were generally below those benchmarks.

The complexity of this comparison lies in trying to answer the question, “What causes these differences?” While cause and effect is difficult to analyze and there are numerous complex environmental differences between the states, certain differences are likely contributors to this variance.

First, Wisconsin is the most fragmented health insurance market in the country, with 10 health plans having at least 5 percent of the market. In contrast, both Indiana and Michigan have one dominant health plan. As found in other studies, having a dominant health plan is probably an important part of what keeps health care costs lower in Indiana and Michigan compared to Wisconsin. When a health plan has large market share, they have more leverage than small health plans in price negotiations and likely more impact from innovative cost strategies.

Second, Michigan is one of 36 states with Certificate of Need laws. Wisconsin and Indiana are not. Over the past several years, Michigan policy makers have debated the value and impact of these laws, which regulate a hospital’s (and sometimes, other providers’) ability to build new facilities and/or to purchase expensive new equipment.

The question is whether or not these laws are beneficial in terms of health care spending. Some argue that they give certain providers monopoly power and as such, could increase health care spending. Others believe that these laws are important tools to control overuse of services since health care doesn’t operate like most markets.

The research on Certificate of Need is not conclusive. Some research has shown that there is no effect on health care costs from these policies. But, there are also studies that show that these laws have a favorable effect on health care costs, particularly hospital costs.

There is continuing debate on the value of state Certificate of Need laws, but it is hard to believe that repealing or weakening these laws in Michigan would have a beneficial impact on health care spending. Fundamentally, our mix of market structures and state policies appear to be favorable when compared to Indiana and Wisconsin.

Michigan’s approach to health care financing along with regulation of costs is something to build on, not abandon.

After two years, hard to call ACA anything but a success

Editor’s Note: This column was published in Bridge Magazine.

It is hard to believe that as the Affordable Care Act turns five on March 23, it continues to be as controversial as it was on day one. The U.S. House of Representatives has taken 56 votes to repeal all or some of the landmark health care reform law, most recently in February. Earlier this month, the U.S. Supreme Court heard another ACA case with significant and far-reaching implications for the law’s future. Governors and legislatures across the country are continuing to debate whether or not to expand Medicaid. And legal and policy debates about contraceptive coverage and other components of the law are ongoing with no end in sight.

Yet against great odds, the ACA is having a profound effect on coverage and care across the country and in Michigan.

The second year of the ACA’s individual health insurance market coverage expansions came to a formal close on February 15. The first year of the Medicaid expansion in Michigan ends on March 31.

What has been the ACA’s actual impact in Michigan?

The answer is in the numbers. While there have certainly been negative effects for some individuals and businesses, it is hard to argue that the ACA’s coverage expansions, health system reforms and economic impacts at large have not positively affected hundreds of thousands in our state (and will be a topic of discussion at our Center’s March 26 symposium).

One has only to add up the numbers:

In Michigan, about 272,000 people received individual coverage through the Health Insurance Marketplace in 2014, blowing through all predictions made at the federal level. In 2015, Michigan exceeded 341,000 covered through the Marketplace. In 2014, 87 percent of these individuals have received a subsidy (making the upcoming U.S. Supreme Court case on this issue profoundly important). Many now covered on the Marketplace were able to get health insurance for the first time.

By early March, more than 579,000 people received coverage under the Healthy Michigan Plan, the state’s expanded Medicaid program, exceeding the state’s first-year enrollment predictions in just 10 months. The vast majority of these individuals were also uninsured before the expansion.

Data shows that despite some predictions otherwise, employers have not dropped coverage as a result of the ACA. In fact, employer-sponsored coverage continues to be the way most U.S. employees get their health insurance coverage. In 2014, 71.4 percent of non-elderly employees had employer-sponsored insurance nationally, up slightly from the 71.2 percent who had it in 2013.

As a result of these coverage changes, Michigan’s uninsured rate dropped by half between 2012 and 2014, based on CHRT’s most recent survey of Michigan adults. It does not appear that patients are experiencing access problems as nearly 9 out of 10 survey respondents (87 percent) reported that it was not difficult getting a primary care appointment.

Michigan has received almost half a billion dollars in federal funding for grants and demonstration projects since the ACA’s inception. These funds have gone to efforts such as increasing access to care at federally qualified health centers, expanding early childhood home visitation programs, and implementing new models of innovation like the grant recently awarded to the state for $70 million to test a variety of approaches to improving coordination of care and innovations in reimbursement.

Hundreds of providers across the state are testing new models of reimbursement and care integration under the ACA through initiatives like Accountable Care Organizations and bundled payment demonstration projects. The federal government extended one of these initiatives, the Michigan Primary Care Transformation Project, for another two years because it demonstrated first-year savings of $148 per beneficiary for Medicare alone.

In light of these real, tangible and measurable accomplishments, it is hard to understand why the focus by some in Washington continues to be on getting rid of the law rather than strengthening it.

There is no question that the ACA is complicated and needs changes to fully achieve the goals it set out to accomplish. But in just five years, the law has given hundreds of thousands in our state a chance they never had before: access to health care.

Let’s not lose that focus as we go forward in 2015 and beyond.

How personal advocacy influences autism policy

Co-authors

  • Marianne Udow-Phillips, director of the Center for Healthcare Research & Transformation
  • Dr. John F. Greden, founding chair of the National Network of Depression Centers and executive director of the University of Michigan Comprehensive Depression Center

It will take leaders like Lt. Gov. Brian Calley, who are willing to speak up about their personal journey, to move public policy in a way that will make the difference for the more than 1 million people in Michigan who suffer from other depression, bipolar illnesses and other mental disorders.

In 2012, Michigan passed significant legislation to expand insurance coverage for children with autism spectrum disorder, a group of developmental disabilities that can impair a person’s behavior and social and communication skills. A little more than two years later, it appears that implementation of the legislation has challenges—but also considerable promise—for achieving its goals.

While it is too early to see the legislation’s full impact, there are important lessons in the law’s passage for mental health advocates who want public policy to go beyond autism according to a recent report from the Center for Healthcare Research & Transformation, “Autism Spectrum Disorder in Michigan.”

The debate on autism coverage had been an active and contentious one when Gov. Rick Snyder was first elected governor in the fall of 2010. Bills to expand coverage for autism spectrum disorder were considered and defeated in 2010 because of cost concerns expressed by health plans and groups representing employers.

The legislative climate changed, however, when Snyder assumed office in January of 2011 because a father with a young daughter with autism also assumed an accompanying legislative leadership position that year.

Lt. Gov. Calley, who had long advocated for expanding autism services, served as a powerful advocate for finally moving this legislation forward—a key missing piece in advocates’ efforts to broaden the legislation past autism.

Those willing to speak about their own or their family member’s illness have always moved public policy—whether it is securing disease-specific research funding in the budgets of the Centers for Disease Control or the National Institutes of Health, or expanding coverage of certain types of services included in the Affordable Care Act. Calley’s voice for advocating for autism coverage in Michigan follows this tradition.

At the time of the autism coverage debate, mental health advocates argued that the legislation should have been expanded to cover all mental disorders. Relative to other mental health disorders, autism spectrum disorder is relatively rare and advocates argued that the legislation should benefit all of those suffering from mental health disorders.

Autism spectrum disorder is estimated to affect a little more than 1 percent of children compared to an estimated lifetime prevalence for mood disorders among adults approximating 20 percent.

Despite the overall greater magnitude in prevalence, disability, and financial costs for depression, bipolar illnesses and other mental disorders, advocates for broadening the legislation beyond autism failed. While several factors contributed to this failure, notable was the lack of a leader with as powerful a voice and as personal a story as Calley in the autism debate.

Mood disorders or other mental health diagnoses like schizophrenia continue to carry with them a stigma that autism simply does not. Parents and public figures are not afraid to speak out and organize for better services for individuals with autism. Autism is not seen as a failure of the child’s will or failure of the parent. Rather, it is generally seen as a developmental brain disease that requires coverage and research to improve treatment.

In contrast, while mood and other mental health disorders are also brain illnesses influenced by environmental events, they too often are erroneously seen as a failure of the individual or family. Stigma persists. That stigma results in a reticence by leaders in sharing their personal stories and engaging in advocacy that can move public policy.

The implementation of the autism legislation in Michigan has not been entirely smooth.

Wait times range between one month and two years because there are still too few providers or approved specialized centers that can diagnose and develop treatment plans.

But there is no question that the legislation is changing how care is delivered and financed for many Michigan children, and new approaches to training practitioners and providing treatment are being established. Importantly, the autism legislation provides a platform to strengthen the delivery system and build additional approaches to help these children and their families.

Mental health disorders continue to take an incredible toll on individuals, families and society at large. More funding for research and dissemination of best practices is desperately needed. The payoff would be profound.

We must save lives by stopping this silent killer

Co-authors

  • Marianne Udow-Phillips, director of the Center for Healthcare Research & Transformation
  • Theodore J. Iwashyna, M.D., Ph.D., Research Scientist, Center for Clinical Management Research, Ann Arbor Veterans Affairs Health System; Associate Professor of Internal Medicine, University of Michigan

Today in the United States, more than half of all hospital deaths are from something that most people have never heard of: severe sepsis. That is the medical term for an overwhelming infection. Many more people die of sepsis than die of prostate cancer and breast cancer combined. From 2000 through 2010, deaths from sepsis increased by 17% while deaths from other causes, such as heart disease and cancer, actually declined. Indeed, the rise in hospital deaths from sepsis is in part because of a decline in the death rate from these other diseases: people are surviving other serious diseases, but in a weakened condition that makes them more vulnerable to sepsis. Today’s challenge is to do more to recognize and treat sepsis earlier—when it is most treatable.

The rise in the proportion of deaths in hospitals from sepsis calls for public health and public policy action. Michigan can become a leader in sepsis diagnosis and treatment, including setting statewide standards of care.

Sepsis is caused by an overwhelming immune response to infection. Immune chemicals released into the blood in response to infection trigger widespread inflammation that leads to blood clots, leaky blood vessels and damage to vital organs. In the worst cases, the heart and lungs can weaken, organs can fail and patients can go into septic shock and die.

Sepsis is most commonly caused by bacteria that have infected the lungs, abdomen or urinary tract. Prompt diagnosis and treatment (usually with antibiotics and large amounts of intravenous fluids) is essential to survival. Once shock has set in, even a single hour delay in appropriate treatment can mean a 7% rise in mortality.

Policy leadership is essential to both increasing research and disseminating best practices in diagnosis and treatment. We need to fund pilot projects and evaluate innovative models of sepsis care in Michigan hospitals. These models need to integrate the emergency department, intensive care unit and other inpatient units to ensure patients get the right care wherever they are. Policymakers can convene hospitals, insurers, EMS and consumer groups to develop systematic, coordinated responses to severe infections.

Policy leadership has always been important in advancing public health and treatment of disease. As an example, our state’s policy leadership built the statewide trauma system we have today. In 2001, the Statewide Trauma Care Commission was created and concluded that Michigan’s trauma system was sorely lacking. By 2004, the Michigan Trauma System Plan was created.Patients across our state are benefitting every day from this coordinated approach to reducing deaths from trauma—the Centers for Disease Control and Prevention has held up Michigan as a model of success.

What the state did for trauma systems, it can do for sepsis. The development of the comprehensive trauma system in Michigan was a 20-year journey. We cannot wait that long to improve the care of patients with sepsis. It is time to start now.

Obesity in Michigan: What Can We Do?

Editor’s Note: This column appeared in Bridge Magazine.

In 1990, 14.1 percent of Michigan’s population was considered obese. Twenty years later, that rate was at 30.3 percent and has stayed fairly constant for the last few years. Michigan is one of the 10 “fattest” states in the country – one of the few northern states in the top 10. This is one measure where it is not good to be in the top 10.

Obesity contributes significantly to many health issues, especially cardiovascular disease, cancer and diabetes. It is not surprising, then, that Gov. Snyder has chosen obesity as a major area of focus and a key health indicator on the Michigan Dashboard. It is essential that we understand this issue and do something about it in our state.

The issue of obesity has long been of concern to public health professionals and while there is uniform agreement that this is a national (indeed, a global) problem, what to do about it has been an issue of much greater debate. Michael Bloomberg is famous for his attempts to tax sugary beverages and ban supersized drinks while serving as New York City mayor. Snyder has promoted his “4 by 4” plan, which calls for maintaining a healthy diet, exercising, obtaining an annual physical and avoiding tobacco use and exposure. While these ideas may have merit at addressing obesity (though evidence does not generally support an annual physical exam), the causes of obesity are complex and the solutions less clear than they are for other health behavior related issues such as smoking.

The importance of this issue, combined with the lack of clarity on what to do about it, led us at Center for Healthcare Research & Transformation (CHRT) to take a look at detailed health risk assessment and claims data available to us from Blue Cross Blue Shield of Michigan to see what we could discern.

Our findings show that those who are severely obese (those with a BMI of 35 or higher) have considerably more health problems than the moderately obese (those with a BMI between 30 and 35). Severely obese individuals had many more health issues, and had average annual health care costs of $7,117 per year – 50 percent higher than costs for the moderately obese and 90 percent higher than those with a healthy weight. Those who were moderately obese were two to three times more likely to have multiple chronic conditions or serious health conditions, along with higher health care costs, compared to those with a healthy weight.

What do these findings tell us?

Well, first of all: It may be important to distinguish between levels of obesity rather than trying to develop a one size fits all approach. For those who are severely obese, it is essential that health professionals and community leaders do what we can to help them lose weight. And, for those who are moderately obese, it is essential that we do what we can to help them from progressing to become severely obese along with trying to help them to lose weight.

There is good news in our findings as well. Fifty percent of both the severely and moderately obese reported that they were actively trying to manage their weight. And, more than one-third of both the moderately and severely obese were “confident” that they could be successful.

Motivation and confidence are tremendous assets to build on. And, fortunately, we do know that there are strategies that work. Two strategies have evidence-based support: bariatric surgery and intensive behavior therapy.

Bariatric surgery is one of the only treatments that has shown the ability to reduce body weight by 20 to 60 percent. But today, in Michigan and nationally, many fewer people get bariatric surgery than are clinically eligible.

Intensive behavioral therapy (IBT) for obesity is one of the few primary care-based approaches to obesity shown to work. Indeed, the U.S. Preventive Services Task Force found that 12 to 26 sessions could produce significant reductions in weight. The evidence was strong enough for this service to be included as one of the required preventive care services (with no patient cost-sharing) in benefit plans under the Affordable Care Act. Unfortunately, there is currently no agreed upon definition or criteria for what constitutes IBT in Michigan and many people may not have access to high-quality services in this regard.

While there are many interventions related to obesity that have popular support, if we are truly going to tackle this issue and reduce both the related human suffering and health care costs, shouldn’t we focus on the things we do know work and make sure they are widely available in Michigan at high quality and reaching the population they are intended to serve? With a population that appears as motivated as those in our study, shouldn’t we all work together to give them the kind of help that has been shown to make a difference?