The answer: a multi-stakeholder effort, such as the Atlanta Regional Collaborative for Health Improvement, or ARCHI. Launched in 2011, the collaborative has brought together local government officials, philanthropies, health care systems, public health authorities and others to chart a strategy that could lead to lasting improvements in the community’s health.
ARCHI has big plans: to improve the quality and efficiency of the local health care system; lower the rate of growth of overall health care spending; and redirect the savings to other purposes that could lead to a growing economy, and, in turn, better health of the population. Although a long road lies ahead, ARCHI nonetheless offers a template for other communities that want to take collective action to improve health.
ARCHI grew out of a stark reality: Like much of the country, Georgia has faced rising rates of chronic illness, disparities in health access and outcomes, and growing health care costs. Local Atlanta-area foundations wanted to tackle these problems by investing more in the safety net – for example, federally qualified health centers. Meanwhile, as a condition of retaining their federal income tax exemption, nonprofit hospitals, locally and nationally, have to comply with requirements under the Affordable Care Act to undertake community health needs assessments and adopt community health improvement plans every three years, or pay a penalty. As such, they’ve acquired new responsibilities to improve the health of the entire community, not just that of the patients coming into their hospitals.
To guide these and other health reforms in the region, three local organizations – the Atlanta Regional Commission , the United Way of Metropolitan Atlanta, and the Georgia Health Policy Center –led the creation of a new multi-stakeholder collaborative. They also engaged ReThink Health, an arm of the Fannie E. Rippel Foundation that works with local communities to redesign their health systems.
Bobby Milstein, a director of ReThink Health and a visiting scientist at the MIT Sloan School of Management, led a team that gathered data and built a computer simulation model of Atlanta’s health system. The model showed that the price tag for health care services in Atlanta was already running at about $11 billion annually – and that the region was on track to spend nearly $450 billion through 2040 unless alternative policies were put in place.
The ReThink Health model allows for testing some of those alternatives, in the form of 25 different evidence-based interventions. For example, communities can see what the effect would be of expanding primary care capacity, reducing environmental hazards, or converting from fee-for-service to capitated payment for health care providers.
In Atlanta, a group of nearly 80 stakeholders – including everyone from members of the local faith community to insurers, as well as officials from the Atlanta-based Centers for Disease Control and Prevention (CDC) – used the model to evaluate the options in a daylong session in November 2012. After sifting through the choices, nearly 9 in 10 stakeholders voted to select a scenario labeled “Atlanta Transformation,” with a specific set of interventions designed to play out through the year 2040. “We went from not having a clue what our priorities would be to having our 28-year agenda in one day,” says Karen Minyard, the Georgia Health Policy Center’s director.
Summarized in a 44-page document called the ARCHI Playbook, the scenario features a number of components that are designed to interact with each other, magnifying the effect of each intervention. One foundational intervention is an extension of insurance coverage to the area’s uninsured under the Affordable Care Act (however, because Georgia hasn’t expanded Medicaid, the gains would be limited to commercial plans for those eligible). The coordination of health care would also be greatly improved – for example, through enhanced primary care, leading to such outcomes as fewer avoidable hospital admissions. Enhanced care coordination would save money quickly and yield hundreds of millions of dollars in savings over the 28 years.
These cost-saving effects would be amplified in combination with still other interventions. All health care payers, public and private, would shift at least half of the population of patients from volume-inducing fee-for-service plans to value-based payment, with providers able to share in any savings achieved. And an array of interventions to enable “healthier behaviors” would create conditions to reduce smoking, alcohol, and drug use, as well as improve diet, nutrition and exercise among the local population. These would be paid for in part by an “innovation fund” put up by local stakeholders, in the amount of $500 million over five years (approximately 1 percent of total health care costs for the first five years).
Over time, as savings in health care spending accrued, the expected gains would be recycled into investments that would lead to broader benefits in the local economy and improved population health. For example, financial and other assistance to help children of low-income families complete high school and college would improve their access to higher-paying jobs, expand the economy through greater productivity, and produce improved health status, since higher incomes and levels of education are linked to better health. The result would be a “virtuous cycle” that, by 2040, was estimated to produce an 11 percent drop in the share of the local population living below twice the poverty level, and a five percent drop in the overall death rate.
ReThink Health’s Milstein, who has been involved in about a dozen similar exercises around the country, says that ARCHI’s “Atlanta Transformation” scenario is impressive in its simplicity and clarity, and the fact that the stakeholders landed on it so quickly is all the more so. “They realized just how pernicious poverty is to people’s health,” he says. “It was fascinating to see how rapidly they moved to a willingness to make a collective investment. You had people stepping out of their normal role, rejecting business as usual, and trying to build something greater, together.”
Today, the quarterly meetings of ARCHI regularly draw about 65 participants, and more than 40 organizations have formally signed on as ARCHI members. An initial pilot project will attempt to put the playbook plan in place in disadvantaged areas such as College Park, near Atlanta’s Hartsfield-Jackson Atlanta airport. The United Way has slated $3.6 million in grants to help boost school performance, improve local housing, and expand access to primary care. A mobile van dispatched from a local federally qualified health center is now delivering primary care to community residents, many of whom remain uninsured.
Plenty of barriers must be overcome before the broad vision set forth by ARCHI can be achieved. As of now, it’s not clear which organizations will contribute to the $500 million innovation fund. Kaiser Permanente of Georgia and four local hospitals and health care systems — Grady Health System, St. Joseph’s Health System, Piedmont Healthcare and Emory Healthcare –have signed partnership agreements with the collaborative. However, although four other local hospital and health systems have attended meetings of the collaborative, they have not yet committed to the strategy. If they remain on the sidelines, it’s possible that the projected savings from care coordination and value-based payment would be greatly reduced.
Still, the fact that the collaborative has made this much headway offers cause for hope. Minyard of the Georgia Health Policy Center notes that some stakeholders involved in the ReThink Health process invoked the Iroquois Nation principle that any deliberation must consider the impact on the “seventh generation” — that is, on tribal descendants who would be affected 140 years or so hence.
If the Iroquois could focus that many years into the future, noted Judith Monroe, MD, a CDC deputy director who sat in on the deliberations, surely contemporary Atlantans could focus on the next 28.