Faces of Public Health: NY State Health Commissioner Nirav Shah

Apr 3, 2013, 10:15 AM

Nirav Shah, NY State Health Commissioner Nirav Shah, NY State Health Commissioner

Today, New York State Health Commissioner Nirav R. Shah, MD, MPH, released the 2013-17 Prevention Agenda: New York State’s Health Improvement Plan—a statewide, five-year plan to improve the health and quality of life for everyone who lives in New York State. The plan is a blueprint for local community action to improve health and address health disparities, and is the result of a collaboration with 140 organizations, including hospitals, local health departments, health providers, health plans, employers and schools that identified key priorities.

Dr. Shah, the architect behind today’s prevention agenda, was confirmed as New York State’s youngest Commissioner of Health two years ago. The state’s governor, Andrew Cuomo, had three critical goals: reduce the state’s annual Medicaid growth rate of 13 percent, increase access to care and improve health care outcomes.

Shah, a former Robert Wood Johnson Foundation Physician Faculty Scholar and Clinical Scholar, has already made important inroads in all three goals and the prevention agenda builds on that. NewPublicHealth spoke with Dr. Shah about prevention efforts already underway in the state, and what it takes to partner health and health care to achieve needed changes in population health.

NewPublicHealth: How does improving the social determinants of health help you achieve your goals in New York State?

Dr. Shah: New York’s Medicaid program covers 40 percent of the health care dollars spent in the state. We were growing at an unsustainable rate, and we needed a rapid, but effective solution. So, we engaged the health care community, including advocates, physician representatives, the legislature, unions, management, and launched a process that enables continuous, incremental, but real change toward the Triple Aim—improved individual health care, improved population health and lower costs.

Collectively, these efforts resulted in a $4 billion savings last year in the State’s Medicaid program, increased the Medicaid rolls by 154,000 people, and resulted in demonstrable improvements in quality throughout the system.

NPH: What opportunities do you see for public health and health care to work together in New York State?

Dr. Shah: That’s the essential component to making all of this health care reform work. We know that $0.90 to $0.95 of every health dollar goes toward healthcare and only 5 percent goes toward prevention and population health. We must move that ratio because we know the investments we make on the front end—keeping people healthy—have a far greater impact on improving lives and lowering costs as opposed to back end investments in sick care, in treating people once they’re already ill and have a chronic condition. That public dialogue has really begun, and people understand it. I was very pleased when a hospital CEO, who also heads a large Accountable Care Organization (ACO) in New York, came up to Albany to see me and asked what he could do about childhood obesity. He knows that one year, five years, 10 years down the line, when he is responsible for the health care costs of that individual, investing in preventing pediatric obesity now is going to do well for his population and cut costs dramatically.

That same CEO now calls everyone a customer rather than a patient, because he realizes that lobbying for the schools to keep the gyms open on evenings and weekends, paying for the extra janitor, creating bike lanes in the community, and including healthy options in cafeterias have a much larger ROI than the old way of doing things. Another good example is the Montefiore Medical Center in New York City, which is one of the pioneer ACOs in New York State that has invested heavily in school-based health care centers. They know that school-based health helps reduce admissions for pediatric asthma tenfold, and it helps reduce teenage pregnancy by 47 percent. The investments they’re making are an example of the broader system, they’re championing the message that it’s about health, not health care; that it’s about wellness and prevention, and not about MRIs and CAT scans.

NPH: In what ways do you think New York State is a leader in efforts to improve population health?

Dr. Shah: We’re very lucky in New York to have a governor who understands the importance of public health and prevention relative to the payment system and the synergies that are possible. We are one of just seven states where Medicaid resides within an umbrella organization that also includes public health. So, we attribute our achievements in savings and improvement toward the Triple Aim in the last year to the fact that we have that broader perspective beyond the health care delivery system. We understand the importance of the social determinants of health, and we guide every action toward the Triple Aim. Clearly, taking into consideration that broader health perspective has been the secret of our success.

We have asked the Centers for Medicare and Medicaid Services to allow NY to use $10 billion in projected federal savings from our reform efforts to continue the great progress we’ve made. Projects include the nurse/family partnership, where we would commit more than $120 million of Medicaid dollars to have home visits by nurses to first-time moms in the Medicaid program throughout pregnancy and for two years after, because we know that every dollar spent is going to save $5.70. Savings would extend beyond Medicaid to include education, juvenile justice, and certainly health care costs—across 20 different areas that have been studied for 33 years in randomized trials, many funded by RWJF.

We have many other areas—such as water fluoridation, pre-diabetes screening and intervention, asthma home visits, and lead abatement—where traditional public health functions can be taken on by health care delivery systems as they become accountable care organizations. These functions represent the low-hanging fruit that will help save money, improve quality, and improve population health. That model we’ve proposed is a generalizable and sustainable model under health care reform that the entire country can follow. If a state as complex as New York can do this, it’s possible anywhere.

NPH: Can you give an example of how public health and health care investments resulted in savings?

Dr. Shah: We invested $1 million into a collaborative called the Gold STAMP Program, where nursing homes, hospitals and even EMS [emergency medical services] providers work together around reducing pressure ulcers [also called bedsores]. That $1 million resulted in a $28 million savings in the Medicaid program. Most importantly, that investment reduced the number of patients who had pressure ulcers by thousands in just one year. We realized a 28-fold return on investment just financially, not to mention the significant human benefit of reducing pressure ulcers among vulnerable patients.

We’ve reduced our rate to about 7.7 percent for pressure ulcers—the national average is between 6 to 8%. Our goal is to get to where Kaiser Permanente is—0.55%, which is why we’re working with Kaiser to continue to improve our systems.

NPH: How else have your efforts translated into reductions in cost?

Dr. Shah: Our Medicaid program went from a $53.5 billion program growing 13 percent a year to, in very short order, a program that now grows at 4 percent annually. We drove down costs by committing to a cap on growth. And, we saved $425 million last year in our pharmacy spend.

We know we can move the bar on Medicaid costs through health homes. In fact, we’ve already enrolled more than 20,000 people who suffer from two or more chronic conditions into these health homes. In this model, for the first few years, $0.90 of every dollar we spend comes from the federal government to invest in care coordination to effectively build bridges among hospitals, nursing homes, primary care, and home care for chronically ill patients. Ultimately, these bridges will be used by all patients to improve care and lower costs. The lack of coordinated care that results from the traditional siloed approach leads to unnecessary and costly readmissions. We know, more than ever before, what works to improve health care quality, enhance population health and reduce costs—and we’re using this knowledge to transform the entire system.

NPH:  What are some of the other innovative ways you’re looking to improve health and reduce costs?

Dr. Shah: Through New York State’s cardiac registry, which documents all of the cardiac surgery and percutaneous coronary angioplasties (PCIs), we found that 23 percent of all elective PCIs in the state were inappropriate according to national guidelines. In a year we’ve already decreased rates of inappropriate PCIs to less than 10 percent. This result is a big deal, as it illustrates the immense power of data. When you have high-quality, audited data, you can take the deep-dive to drive significant, positive change.

Another important example is the Choosing Wisely campaign, which identified 135 different tests and procedures that 17 medical societies have said doctors should no longer perform because they may actually harm, rather than help, patients. One example: reduce elective pre-39-week C-sections. Should babies be born early—purposely—simply because it may be more convenient in some cases than full term? Of course not, yet it happens up to 45 percent of the time in some hospitals, which leads to very costly NICU stays and bad outcomes for both the mother and the child. We are working closely with the American College of Obstetrics and Gynecologists, providers and patient advocates to determine how stop this unnecessary, dangerous and costly practice.

We’re taking a multi-pronged approach including, in some cases, mandating proven solutions and ideas - and in others, making it clear that many of the legacy practices or outdated and ineffective approaches will discontinue. At the same time, we build trust with and inspire the community to develop solutions.

NPH: You have often spoken about the business community as a vital partner in improving the public’s health. Why is that community so important?

Dr. Shah: As Jim Marks, Senior Vice President of the Robert Wood Johnson Foundation says, companies are deciding where to site their factories based on obesity rates, not on the tax rates or the availability of cheap electricity. Why? Because these firms know that where there are high obesity rates there are high health care costs, and those costs represent the biggest variable between profitability and lack thereof. It’s clear to companies like GE, IBM and a growing list of others that investing in the health of their workforce improves productivity and reduces absenteeism. We’ve been able to leverage those realities and partner in meaningful ways to help inform insurers’ decisions regarding covered services and to present a unified voice around the benefits of physical activity and the importance of interventions that truly impact population health.

Success depends upon having access to good data. Our solution is the New York eHealth Collaborative (NYeC), a non-profit organization that’s improving health care through health information technology and health information exchange.

The Collaborative is leading the continued development of the Statewide Health Information Network New York, which is a seamless connection of all the electronic health record data from Buffalo to Brooklyn, regardless of the system one uses.

We’ve positioned the business community front and center in the effort. Last October, we worked with NYeC and the Partnership for New York City Fund to create the New York Digital Health Accelerator, a $4.2M program to drive health IT innovation and create jobs. It’s the largest-funded health IT accelerator program in the U.S., and is projected to create some 1,500 jobs over five years. In the first round of the program, a dozen venture capitalists funded eight companies (each one getting roughly $300,000) to build apps for the network supporting health homes. The eight companies were selected out of a pool of 250 companies from 27 states and across 10 countries. That’s the kind of innovation and excitement happening now around healthcare transformation in New York.

NPH: And how are businesses using health IT to improve public health?

Dr. Shah: Last year IBM announced a collaboration with the Center for Disease Control and Prevention and the PublicHealth Data Standards Consortium to standardize the exchange and use of public health information to improve health care quality and coordination of care. The synergy is critical for major public health events such as controlling a major outbreak of whooping cough or tracking circulating flu strains is critical to public health. However, inconsistent and delayed public health reporting because of a lack of standardized electronic reporting often creates inconsistencies and duplication of efforts.

IBM Research scientists are creating templates for public health case reports that could work with electronic health record systems, allowing critical information in the proper format to be easily shared among local, county, state and federal public health agencies to speed response times to public health issues. The expectation is that the coordination and surveillance of public health information across organizations will aid in understanding and potentially preventing the spread of threats to population health by automating the process and ensuring consistent access to data anywhere in the country. This technology is being piloted with public health information systems in Delaware, New York State, and San Diego.

>>Read more on New York's efforts to reform the state’s costly and controversial Medicaid program on RWJF.org.

This commentary originally appeared on the RWJF New Public Health blog.