Changing Health Care from the Bottom-Up: Local Initiatives Hold Promise

Recognizing the difficulty of national health reform in the current political environment, the Harvard Interfaculty Program on Health Systems Improvement (PHSI) launched the Harvard Forums on Health initiative in 2003 as a vehicle for learning about successful local innovations that address the nation's most pressing health care problems. The just-released report of that effort, "A Strategy for Health Care Reform: Catalyzing Change from the Bottom Up," reflects "glimpses of hope" in what the PHSI sees as the native ingenuity and creativity of communities around the United States. By outlining what government, providers, consumers, businesses, and other stakeholders can do to lead innovative health reform efforts, the report seeks to "capitalize on that local potential and to use it as a springboard" for efforts to solve national health care problems. The report provides a blueprint of steps communities can take that will promote universal health coverage within 20 years and address problems related to quality, affordability, value, and population health.

Over the next five years, the PHSI recommends the creation of a national clearinghouse to identify and disseminate information on promising local innovations and urges policymakers, foundations, and others to invest in and evaluate local reform efforts to assess what does and does not work. Policymakers and stakeholders at the federal, state or local level should adopt consensus goals that describe what the desired health care system should look like and develop local and state level initiatives that further those goals

Beginning in five to 10 years, PHSI calls on the federal government to stimulate grassroots innovation through matching funds for local health reform experiments. Local stakeholders would commit to achieving quantifiable, five-year goals, and the federal government would contribute half of the necessary funds. During this time, the federal government would develop national health care goals related to coverage, quality, value, affordability and population health to be achieved over a 20-year period and support state plans that aim to achieve these goals.

Within 15 to 20 years, successful state-based programs would be implemented throughout the United States, with continued funding and guidance from the federal government. Through "trickle-up experimentation," states will have the benefit of years of testing and evaluation.

"A multi-staged, bottom-up approach holds the most promise for building towards fundamental reform, says PHSI Director David Blumenthal. "It's a characteristic American way to spark complex social change. Given the current political situation in Washington, we don't hold much hope that leadership will start there."

For a copy of the report "A Strategy for Health Care Reform: Catalyzing Change from the Bottom Up" visit PHSI's website at www.phsi.harvard.edu.

David Blumenthal: Why Embrace a Bottom Up Approach to Health Reform?

States and localities are eagerly watching as Massachusetts girds to adopt a new law expanding coverage to 550,000 uninsured residents. PHSI Director David Blumenthal explains the importance of stimulating local health system reform, the role of Harvard in promoting this activity, and how PHSI will foster state and local experimentation.

Q: PHSI's new report promotes the idea of catalyzing change from the bottom up. Why focus on local reform instead of nationally imposed reform?

DB: Most of the time when we do something nationally, it's after trial and error experiences at the local and state level. We think this is not only a correct strategy but a politically pragmatic strategy. History shows that this is the way major social change happens here. Just look at welfare reform. It started in the states and was tested there before it spread nationally. We don't believe the federal government is going to act at this time, but we have an obligation to propose a strategy that will lay the groundwork for federal action in the future.

Q: Is the Massachusetts universal coverage law emblematic of this?

DB: It is emblematic of how states can and will lead in trying to solve national problems that affect their populations. Massachusetts' effort will provide essential lessons for future reform – about what works and what doesn't, what states can do and what only the federal government can do.

Q: Is this effort to spur action on an important social issue unique to Harvard?

DB: There are others that play leadership roles in their community. But Harvard is strongly positioned because of its intellectual capacity in health care. I don't know of another university that has taken on such an ambitious agenda in the policy arena to facilitate change. Universities have an obligation to play a more assertive role in solving the nation's most complex social problems and to take more risks to move what they know into practice.

Q: What will the PHSI do to advance its agenda?

DB: We are exploring how to facilitate and catalyze local health system reform. We also are looking for other university and local partners and we are trying to raise funds to help us do that.

Q: What will PHSI offer communities pursuing reforms?

DB: We will offer concrete practical advice on what they can do to improve the efficiency and quality of their health care systems. We will take what we know and translate it into actionable plans for change. Our objective is to provide those with the political will and governing structure some goals that make sense and ways to achieve them without recreating the wheel.

Q: How will PHSI contribute to helping reform health care in Massachusetts?

DB: We hope to collaborate with the various stakeholders in the state to track, monitor and assist with making the experiment as successful as possible. And, we hope to be a conduit for sharing its lessons more broadly.

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Project Updates

Gauging IT Adoption among CHCs: National Survey Underway

Prompted by the November 8, 2005 policy meeting on community health centers and HIT adoption organized by the Interfaculty Program, Harvard researchers, working with colleagues at George Washington University and the National Association of Community Health Centers, have launched a national survey of 1,000 community health centers (CHCs) to measure the extent to which they are adopting IT. Alexandra Shields, Director of the Harvard/Massachusetts General Hospital Center on Genomics, Vulnerable Populations and Health Disparities, says the survey is the first attempt to document where CHCs are in developing IT capacity and what barriers they face in instituting it. Results from the survey should be available by summer. To sensitize lawmakers on the issue, NACHC, working with PHSI and others held a briefing on Capitol Hill on May 12, where CHCs shared their views on bridging the digital divide. "The challenge for safety net providers is they don't have the margins to facilitate this kind of capital investment," says Shields. "This survey can help us understand how far behind they are in developing this capacity and what inputs are needed to facilitate wider adoption," she adds. Meanwhile, the federal government is about to launch a similar but much more comprehensive national survey on IT adoption among CHCs.

New Research: Does pay for performance work?

A new analysis by Harvard's Meredith Rosenthal and Richard Frank reveals there is "little evidence" to support the effectiveness of paying for quality. Their review of published literature on the merits of bonuses tied to measures of quality of care appears in the April 2006 issue of Medicare Care Research and Review. The authors conclude that despite assertions to the contrary, "the empirical foundations of pay for performance in health care are rather weak." Their findings could be attributable to the small size of bonuses studied and the fact that payers usually account for only a fraction of the targeted provider's panel.

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For more information on the projects and events described in this newsletter, or to unsubscribe, please contact us at phsi@harvard.edu.



New PHSI Report David Blumenthal Interview CHCs and HIT Adoption P4P and Quality	Spring 2006 Changing Health Care from the Bottom-Up: Local Initiatives Hold Promise Recognizing the difficulty of national health reform in the current political environment, the Harvard Interfaculty Program on Health Systems Improvement (PHSI) launched the Harvard Forums on Health initiative in 2003 as a vehicle for learning about successful local innovations that address the nation's most pressing health care problems. The just-released report of that effort, "A Strategy for Health Care Reform: Catalyzing Change from the Bottom Up," reflects "glimpses of hope" in what the PHSI sees as the native ingenuity and creativity of communities around the United States. By outlining what government, providers, consumers, businesses, and other stakeholders can do to lead innovative health reform efforts, the report seeks to "capitalize on that local potential and to use it as a springboard" for efforts to solve national health care problems. The report provides a blueprint of steps communities can take that will promote universal health coverage within 20 years and address problems related to quality, affordability, value, and population health. Over the next five years, the PHSI recommends the creation of a national clearinghouse to identify and disseminate information on promising local innovations and urges policymakers, foundations, and others to invest in and evaluate local reform efforts to assess what does and does not work. Policymakers and stakeholders at the federal, state or local level should adopt consensus goals that describe what the desired health care system should look like and develop local and state level initiatives that further those goals Beginning in five to 10 years, PHSI calls on the federal government to stimulate grassroots innovation through matching funds for local health reform experiments. Local stakeholders would commit to achieving quantifiable, five-year goals, and the federal government would contribute half of the necessary funds. During this time, the federal government would develop national health care goals related to coverage, quality, value, affordability and population health to be achieved over a 20-year period and support state plans that aim to achieve these goals. Within 15 to 20 years, successful state-based programs would be implemented throughout the United States, with continued funding and guidance from the federal government. Through "trickle-up experimentation," states will have the benefit of years of testing and evaluation. "A multi-staged, bottom-up approach holds the most promise for building towards fundamental reform, says PHSI Director David Blumenthal. "It's a characteristic American way to spark complex social change. Given the current political situation in Washington, we don't hold much hope that leadership will start there." For a copy of the report "A Strategy for Health Care Reform: Catalyzing Change from the Bottom Up" visit PHSI's website at www.phsi.harvard.edu. back to table of contents David Blumenthal: Why Embrace a Bottom Up Approach to Health Reform? States and localities are eagerly watching as Massachusetts girds to adopt a new law expanding coverage to 550,000 uninsured residents. PHSI Director David Blumenthal explains the importance of stimulating local health system reform, the role of Harvard in promoting this activity, and how PHSI will foster state and local experimentation. Q: PHSI's new report promotes the idea of catalyzing change from the bottom up. Why focus on local reform instead of nationally imposed reform? DB: Most of the time when we do something nationally, it's after trial and error experiences at the local and state level. We think this is not only a correct strategy but a politically pragmatic strategy. History shows that this is the way major social change happens here. Just look at welfare reform. It started in the states and was tested there before it spread nationally. We don't believe the federal government is going to act at this time, but we have an obligation to propose a strategy that will lay the groundwork for federal action in the future. Q: Is the Massachusetts universal coverage law emblematic of this? DB: It is emblematic of how states can and will lead in trying to solve national problems that affect their populations. Massachusetts' effort will provide essential lessons for future reform – about what works and what doesn't, what states can do and what only the federal government can do. Q: Is this effort to spur action on an important social issue unique to Harvard? DB: There are others that play leadership roles in their community. But Harvard is strongly positioned because of its intellectual capacity in health care. I don't know of another university that has taken on such an ambitious agenda in the policy arena to facilitate change. Universities have an obligation to play a more assertive role in solving the nation's most complex social problems and to take more risks to move what they know into practice. Q: What will the PHSI do to advance its agenda? DB: We are exploring how to facilitate and catalyze local health system reform. We also are looking for other university and local partners and we are trying to raise funds to help us do that. Q: What will PHSI offer communities pursuing reforms? DB: We will offer concrete practical advice on what they can do to improve the efficiency and quality of their health care systems. We will take what we know and translate it into actionable plans for change. Our objective is to provide those with the political will and governing structure some goals that make sense and ways to achieve them without recreating the wheel. Q: How will PHSI contribute to helping reform health care in Massachusetts? DB: We hope to collaborate with the various stakeholders in the state to track, monitor and assist with making the experiment as successful as possible. And, we hope to be a conduit for sharing its lessons more broadly. back to table of contents Project Updates Gauging IT Adoption among CHCs: National Survey Underway Prompted by the November 8, 2005 policy meeting on community health centers and HIT adoption organized by the Interfaculty Program, Harvard researchers, working with colleagues at George Washington University and the National Association of Community Health Centers, have launched a national survey of 1,000 community health centers (CHCs) to measure the extent to which they are adopting IT. Alexandra Shields, Director of the Harvard/Massachusetts General Hospital Center on Genomics, Vulnerable Populations and Health Disparities, says the survey is the first attempt to document where CHCs are in developing IT capacity and what barriers they face in instituting it. Results from the survey should be available by summer. To sensitize lawmakers on the issue, NACHC, working with PHSI and others held a briefing on Capitol Hill on May 12, where CHCs shared their views on bridging the digital divide. "The challenge for safety net providers is they don't have the margins to facilitate this kind of capital investment," says Shields. "This survey can help us understand how far behind they are in developing this capacity and what inputs are needed to facilitate wider adoption," she adds. Meanwhile, the federal government is about to launch a similar but much more comprehensive national survey on IT adoption among CHCs. New Research: Does pay for performance work? A new analysis by Harvard's Meredith Rosenthal and Richard Frank reveals there is "little evidence" to support the effectiveness of paying for quality. Their review of published literature on the merits of bonuses tied to measures of quality of care appears in the April 2006 issue of Medicare Care Research and Review. The authors conclude that despite assertions to the contrary, "the empirical foundations of pay for performance in health care are rather weak." Their findings could be attributable to the small size of bonuses studied and the fact that payers usually account for only a fraction of the targeted provider's panel. back to table of contents For more information on the projects and events described in this newsletter, or to unsubscribe, please contact us at phsi@harvard.edu.