Department in its transformational journey to provide veterans with easier access to both v. A. Care and private sector care. He oversaw the v. A. s community of care network, which includes half a million providers, academics, and community networks. Treating about 1. 5 million patients annually, a significant improvement that was done in terms of providing access to care and increasing access to care for veterans. He has a nationally recognized expert in hiv medicine and healthy quality. He has published over 150 chapters and papers in leading journals. He has made important contributions to the understanding of patient care andt in Health Individual and environmental factors boardligh yehia he is certified in medicine and infectious diseases. He received his bachelor and medical degrees here at the university of florida. He completed his residency at Johns Hopkins john hopkins hospital. He also holds a masters in Public Policy from Princeton University and masters of science in Health Policy research from the university of pennsylvania. Please join me in welcoming dr. Baligh yehia. [applause] can you hear me ok . It is really a pleasure to be here today. Bringing together my undergrad and my medical School Training here at the university of florida. My work with the v. A. It is a little bit of a homecoming. Im looking forward to our conversation today. Couplewant to share is a of thoughts about how health care is changing in America Today and really draw on lessons from the department of Veterans Affairs and how other Health Care Systems and networks can use those lessons to drive forward positive change or patients and providers for the population at large. How do you take ideas and put them and implement them into practice and lead change in health care . This up for us tonight and talk about what is changing in health care and how do you think about that as the context for our conversation today about how to lead change in Health Care Systems and networks. The first, is to think about how a population is changing. You know that our population is aging and as part of that, more and more of our patients have multiple, chronic conditions. Ins data from the 2010, about one third of americans had more than one chronic condition. Over the last five years, it has been a 4 increase. Until 2000om 2006 10. When you walk into a doctors office, that means you are more than likely to have more than one condition that the doctor has to take care of and he has to work with more specialists to coordinate that care. We are seeing that multiple chronic conditions are on the rise. Also know that over the overtime, to manage those individuals, we have to rely on more than one provider or specialist. This graph shows you that both in the primary care world and the Specialty Care world, the likelihood that that patient would leave the office with a referral to see another off to see another doctor has been rising over the years. There are multiple providers involved in the delivery of health care. Not just one primary care provider or when specialist. We also know that health care is now delivered in multiple settings. ,ou can walk to a Grocery Store a pharmacy, and you might be able to receive a flu shot or someone might be able to check your blood pressure, or even prescribed medications for you. That is very different than what or 15 or 20g 10 years ago. The era of clinics or hospitals has been expanding. Telehealth or how you communicate your need through a smart phone or through a computer at your house or health care not available before. The venues where you can receive health care are also changing. What does that mean . I wanted to give one example, thinking about opioids which i know is on the minds of a lot of our clinicians these days. We have seen over the last couple of years, the number of opioid prescriptions, and this is data from medicare, that are prescribed by more than one provider is on the rise. In 2010, only about 40 of medicare an official ares, about one Million People that they looked at, had a prescription from one provider. Prescriptions had from more than one provider. People who had four providers prescribing, the likelihood that they would receive prescriptions was over 70 of the time. That is a problem. Those medicines are dangerous. That is exactly what happened, bad Health Outcomes. The more subscribers you have prescribers you have, the more likely you are to get admitted to a hospital. This is a case in point of more providers, more settings, more chronic conditions, and this is one example of what we want to make sure that we all avoid and prevent as we think about these changes in health care. One thing that has been around for a long time that has not received the attention that it deserves is thinking about the social determinants of health. If you look at the graph on the lefthand side, you can see that health care, someone comes to see me in the clinic, the contribution that i make is only about 10 . R genetics, behaviors at social, economic, and legal situation all of that has a much bigger impact on their health and wellbeing than a prescription i might write in my office. That is important when we think about improving the health of the population in our communities across the country. That means we do not just need better medicine and treatment, we have to think about getting out there into the communities to make sure that we can address what we call the social determinants of health. One way of doing that is something called the health in all policy. Every policy we pass, whether it is at the local or national level, will have some impact whether it is transportation, and how quickly you can get between your home and a doctors appointment, whether it is agriculture, environmental policy. All of that impacts the health of our community. The cdc and others have been promoting health and all policies. Think about the Health Impact of the various policies that local, up to the national government, might be working on before you actually pass them. Thees without saying cost of health care in treating these multiple chronic conditions is on the rise. We can compare and contrast here and 2010, the cost of treating patients with five or more chronic conditions. Again, it is interesting when you look at the proportion of Health Care Dollars that we spend for those individuals with multiple conditions. Makeup thatmingly burden of cost. I will give you an example. For those individuals with five or more chronic conditions, they only represent about a percent or 9 of the population, but they make up 35 of the Health Care Cost than americans spend on the dollar every year. What we need to do is focus on how we can better coordinate that care and manage those chronic conditions. That will help the cost curve. The last couple of points i wanted to make a four we get into the meat of our conversation is the rapid change or the rapid pleas of change in health care. We have talked about multiple settings. Multiple providers. Multiple chronic conditions and the cost of those conditions. Health care has been changing rapidly and the last couple of years. This is not just something that has been happening over a decade. Here is an example for the movement of volume value. Right now, any Health Care Providers in the country get rewarded by what we call fee for service. They get paid for their time. But, they do not necessarily get paid for the outcome they are delivering. The Health Outcome that we want. O see in our patients you can see that in 2016, the centers for medicare and medicaid services, 30 of their payments to doctors that year were based on value. Which is a large increase. And only going to grow over time. Once the ways they can deliver that Value Proposition is Accountable Care organization. They have been growing rapidly. The graph shows growth from 2011 to 2017. We now have many apos across the country. That covers 10 of the population. That is a huge increase in five years. You can think about not only the changes occurring but how fast the change is occurring. Here are two other examples. Is on fda drugs approved. You can see the sharp line there over the last decade. The number of new drugs approved for the treatment of health care has been rapidly rising. Interestingly, for hospitals and the health care system, they are consolidating. You may see hospitals merging more rapidly. Health care is becoming more and lessnetworked and less and individual hospitals going at it alone. Howus think about that and the peace of change and the amount of change that is occurring today. As leaders in health care, as policymakers and clinicians, how can you adapt to that environment . How can you create positive impact for patients, their families, in your community . Myt i wanted to do is use experience at the v. A. About two weeks ago and i was deputy undersecretary there and we focused a lot on the veterans Choice Programs. Exampleuse that as an on how various leaders in health care can drive change. Was014, the v. A. Experiencing a lot of access issues. It was all over cnn, fox news and the newspapers. Accesseterans could not the care that they needed in a timely fashion. As a result of that crisis, Congress Passed what we call the choice act. Provided thely department of Veterans Affairs with 15 billion, 5 billion to internal structure including hiring doctors and nurses and 10 billion to partner with outside providers to deliver health care. From the very beginning, the program had a number of challenges. One, it had a 90 day implementation period. That is a very short time period. Care e that to try tri care. It was a very constrained timeframe. Two, thinking about the department of Veterans Affairs about 150ere hospitals. A lot of Different Health professionals across the country from hawaii, alaska, florida, new york how do you coordinate and communicate with all of those different providers. Had you get them on the same page and move things forward . The choice law passed had a lot of different requirements. It required the department to behave in a different way than it had behaved before and different than other programs it had. There were issues there. It differs. Things had to be different. You had to be able to adapt to that. Next, communication. There are about 22 million veterans that live in the u. S. 9 million of them are enrolled in the v. A. Had to get aon card. It looks like a Health Insurance card. Not all of those veterans were eligible to receive those benefits which created a lot of confusion. You got something in the mail that said you could get a benefit, but you really couldnt because you had to meet certain criteria that were stipulated. How do you communicate with patients across the country and let them know what the benefits are. And how do you communicate that the criteria that you used and how they changed from daytoday. And lastly, the infrastructure. Withovement at the v. A. The Choice Program is how do you leverage the principles that the Health Insurance companies had themany years, but that department did not have fully fledged. There were issues with infrastructure. That is a little bit of a challenge that the v. A. Faced. When i walked in i came to the Department Three years ago and started working as the assistant deputy and then the deputy undersecretary two years ago, these were some of the headlines i was faced with about the veteran choice card being smoke and mirrors, having problems, the Choice Program leaving veterans frustrated. Again, of all of these different headlines about the issues that existed with the program. We will talk a little bit about the process we went through to create positive change but i will tell you upfront that all of the stories are not rosy today either. There has been a lot of Forward Momentum and positive movement but, we still have a way to go to get the program and the concept internal and external, working well. I am one of those people that likes to simplify things. When i was reflecting on how we went about creating change, i thought about what were the things that our team did that really started to move the ball . Byy can really be summed up , active, continuous transformation. I will go over each of those words. Hopefully, when you leave our conversation this evening, you have a principal or framework you can use in your own circumstances of how to create change in health care. The first active. The future gauging state. The future engaging state. It is common for someone to come in and say they have all of the answers. This is what we have to do. Typically, that is a way to create a feeling program. You really need to listen to your stakeholders, to your community about what they need. Wasfirst thing that we did start to think about how to make improvements in the Choice Program and in Community Care through actively engaging our stakeholders. Our facility at the department does this in its own right across the board. The first thing you could do is identify who should you talk to. V. A. Community care team thought we need to talk to veterans, first and foremost. They are the center of everything that we do. We have to talk to v. A. Staff and clinicians. Not just the nurses and the doctors but also the administrators, the clerks, the schedulers. We need to talk to those that represent the interest of veterans across the country that may represent pieces that we dont. And the community of Health Care Providers. We need to learn from other institutions about what works for them and apply it to the department. We went through this process of actively engaging and learning from all of these different stakeholders and then listening. That was really important. Take the feedback and put it to use. The snap is see in we held a couple of roundtables and a couple of listening sessions. We had our team that went across the country. They were in those geographies anyway and they set up listening sessions and ways to walk through the process and learn about what was going on. This was very important. We conducted interviews, conducted datagathering exercises. That was key. We did not come in preconceived, fully baked. We gathered information along the way. What we heard throughout this process was here are our issues. We grouped them into six different categories. Eligibility. At that time, our veteran patients did not know if they were eligible for the program or not. Which doctors to go to. Did they need to pay anything. There was a lot of confusion about do i have this benefit or not . The referral process was confusing. The rich the referral process is when you go from point a to point b. Everyone of these programs had a different way of doing that. Maybe one way you walked in with a piece of paper. Maybe another, you had it through an electronic portal or a phone call. It was very confusing for people to manage. Which way and my supposed to do this . Care coordination was challenging. We talked at the beginning of our time today about multiple providers. This is the perfect example. Not only are we making sure that ourselves,te within but how do you work with other providers outside of yourselves . Community care networks. One of the things that we learned early on was how critically important it is to be communityers for your partners. And that means making sure that they have all of the information they need and for veterans, making sure that they have providers that meet their needs and their communities. Provider payment. This is key. Well or onot pay time, no one wants to work with you. Asheard a lot of frustration we listened to Different Community providers in groups. They said we are not able to get our accounts receivable or our bills paid on time and we may not be able to participate if we dont do that. Lastly, customer service. All of these different programs created confusion. How did you provide this service not only to veterans but also the providers. We laid it all out there. Here are all of the challenges we are hearing today. What we did when i walked in we wondered where should we start . How should we tackle it . What our team decided to focus on was we will focus on the things important to the veterans and we will start to work on those things first. We used a process called journey mapping. When you map the journey of a patient through a specific experience. We looked at all of the different touch points. We looked at eligibility. The referral process. Coronation. Providers in the network. Provider payment. And then customer service. To making sure that we touched veterans. It was easy to get distracted. We wanted to make sure that everything aligned to the important touch points that our veteran patients told us are valuable to them. Next, we talked about continuously evolved capabilities. That is a lot of words. Is not as that change one and done thing. You do not just implement a new program or technology. You have to constantly evolve. The Health Care Marketplace is constantly changing. The needs of providers and patients are constantly evolving. You want to make sure that your constantly building capabilities to allow you to succeed in the future. It is so easy to do a project here and there but they do not come together for the greater good. We thought about how can we use capabilities to link vision and action . Wow, think about there is all this stuff to do. I will work on this and i will work on that. If it is not coordinated, you will see the impact. We wanted to decide on where we wanted to get to. Toch points were important veterans. Capabilities feeds feed into that. It might sound simple. It actually takes a lo