Robert Wood Johnson Foundation’s Risa Lavizzo-Mourey: The Challenges Facing Health Care Reform

The landscape for health care in the U.S. continues to shift since the Obama administration passed the Patient Protection and Affordable Care Act last year. Several questions remain unanswered, including how to expand health coverage, what are the potential minefields for doing so, and what are the best ways to ensure that the system performs well. Meanwhile, Americans are becoming increasingly unhealthy, despite spending more on health care than any other nation. To address these issues, Knowledge@Wharton spoke with Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation, which focuses its efforts on improving the country’s health care.

Lavizzo-Mourey will be a speaker at the upcoming Wharton Leadership Conference 2011, titled “Leading in a Reset Economy and Uncertain World,” which will take place on June 22.

An edited transcript of the conversation appears below.

Knowledge@Wharton: How has the Foundation’s mission shifted since the Obama administration passed the Patient Protection and Affordable Care Act last year?

Lavizzo-Mourey: Our mission really has not changed. Since the inception of the Foundation — almost 40 years ago now — our mission has been to improve the health and health care of all Americans. So we have not deviated from that. We have long supported expansion of insurance coverage, access to affordable care for all Americans, investments in prevention and expansion of primary care among all of the professions — nursing, physicians, etc. And as a private foundation, we really don’t take a position on specific pieces of legislation. Now, that said, the Affordable Care Act is the law of the land, and we are working to help those … who are looking to implement the law to do it as effectively as possible.

The law does give a lot of leeway to states to develop exchanges and ways of approaching higher value in quality care. And we, obviously — based on our mission to improve health and health care for all Americans — are committed to trying to make that happen as effectively as possible. So we are looking to help all states — red states, blue states, anyone who is interested in using an evidence-based approach — to implement better quality care, to lower costs, to make [health care] available to more people.

Knowledge@Wharton: Speaking of evidence, research has shown that in Massachusetts, broader health care coverage has not led to dramatic overuse of the system or sky-rocketing hospital costs. Can the same results be achieved in other areas of the country? Or maybe even in the country as a whole?

Lavizzo-Mourey: Massachusetts clearly has been at the forefront of helping us understand and test how to achieve a reformed health care system. And [it has] demonstrated an ability to expand coverage. The costs, as you say, haven’t sky-rocketed. But they also have not decreased. What is important for us to keep in mind, I think, is that Massachusetts, because of its demographics and high education level … does not necessarily represent all states. And what we are committed to doing at the Robert Wood Johnson Foundation is learning from Massachusetts, but then also expanding that learning to other states, which will collectively represent the way other states are going to have to implement the Affordable Care Act.

So, we’re looking to fund states like Alabama and Colorado and New Mexico, Tennessee, Minnesota, Maine — among others — which complement the kind of demographics, politics and leadership that Massachusetts has, so that at the end of the day, we have a broad-based understanding of how to actually improve health and health care in this country.

Knowledge@Wharton: And what would you say are the biggest potential stress points for expanding health care to those who are currently uninsured?

Lavizzo-Mourey: Simply put, I think the issues are cost and value. When you look at what has to be done to expand health care coverage, we are looking at adding 50 million Americans to the health insurance rolls. And that is coming at a time when state budgets are constrained, when people are looking to develop ways to address the fiscal conditions in the states that tax the ability of Medicaid and other programs like CHIP to continue to enroll and expand coverage. At the same time, we know that value — that is, the quality of care that is delivered for the cost in this country — is not what it could be. We have great medical care, but we don’t always deliver the highest value care. As a result, the challenge that people implementing health care reform are facing is how to expand coverage [while] trying to do it in a cost-constrained environment, and one that is not always conducive to delivering the highest value care.

Knowledge@Wharton: What would you say are the best ways to ensure that any health care system performs well? Based on the research the Foundation has sponsored, for example, what have you learned?

Lavizzo-Mourey: I would list a few things that I think are critically important to ensuring that the health system performs well. First and foremost is a focus on the patient, the consumer, the person who’s actually getting the care. The second is information — having timely information about the quality of care and the cost of care — that is transparent and maximally available to people who are making decisions, both individuals and organizations.

We’ve learned that an emphasis on teams and the ability of teams to collaborate and coordinate care is essential to delivering high quality health care. Our payment system needs to be reformed. We currently pay for health care that is delivered on a piece by piece, service by service basis. And coordinating the care is therefore not something that there’s an incentive to do. Reforming our health care system so that we encourage teams, accountability and coordination is, I think, going to be essential.

And then two more. An emphasis on the population’s health is important. We know that so much of what determines how healthy you are is not happening in the medical care system per se. It’s very important to get high quality medical care when you’re sick. But keeping people healthy requires that we focus on the population’s health — the things that help them live in healthy communities, eat well and stay focused on their health. That will be critical to ensuring that the health system performs well.

And then, finally, we know that our health care system is fraught with racial and ethnic disparities that can be reduced if we pay appropriate attention to improving the quality of care for particular groups that are not receiving the highest quality care — and make a special, concerted effort there.

Knowledge@Wharton: The Foundation’s site notes that Americans are not as healthy as we could and should be, despite spending more on medical care than any other nation. Why is that so?

Lavizzo-Mourey: Well, I think that’s a very complicated picture and there’s no single answer to that question. People like to look for a silver bullet or one easy answer. But the fact of the matter is that it’s a host of [factors]. The most comprehensive assessment of this recently has been [from] the Institute of Medicine’s Round Table on improving the quality of care in this country, which has underscored things like the unnecessary services that we have in this country, the services being inefficiently delivered, the fact that we have a pricing system that sometimes leads to the prices being too high, excessive administrative costs and missed opportunities to — as I’ve mentioned before — improve the health of the population through prevention.

When we look at improving our health, I think we’ve got to take that set of concerns and underlying causes for why we’re not as healthy as we should be given the amount we’re spending, and invest in all of those [areas] in a comprehensive way.

Knowledge@Wharton: I noticed also on your website that one of your key initiatives is to focus on childhood obesity. Can you talk a little about that? How complicated an issue is that to tackle?

Lavizzo-Mourey: It is an important issue for us because the rate of increase in childhood obesity over the last 20 years has just been striking. It has increased two to four times, depending on which age group and demographic of children that you look at. We also know that kids who are overweight or obese as teenagers will remain — or have an 80% chance of remaining — obese as adults and therefore have the complications of obesity at an early age in their adulthood. And that leads to increased health costs. It leads to morbidity and, in some cases, premature death. So it is a public health problem that rivals tobacco use in terms of our ability to change the health of the nation by changing a risk factor.

Now, it’s complicated to address it because there are so many factors that contribute to childhood obesity. But it boils down to needing to help our kids make healthier choices — and helping their families make healthier choices — by balancing the energy equation. Helping them take in healthier foods — lower calorie, less energy-dense foods, but high in nutritional value — and offset that by greater amounts of physical activity. So, we are investing in the places where kids typically spend their time and trying to make those as healthy as possible — making sure that the schools are serving only healthy foods, that they are promoting physical activity during school and after school; making sure that the communities, particularly those where kids who are at risk live, have healthy environments, environments that allow them to walk and bike and play [safely]. And we try to do something about the amount of screen time that kids have, because that not only keeps them from being physically active, but often bombards them with messages that aren’t particularly healthy about what to eat and how active they are. We’re trying to take a prevention approach.

Knowledge@Wharton: Looking ahead, where else do you feel the Foundation will need to focus its efforts?

Lavizzo-Mourey: We’re going to continue to focus on the core areas that we’ve focused on for the last seven or eight years. Obesity, as I’ve just spoken about, but also improving the quality and value of health care. It’s clear that the Affordable Care Act will not be implemented to the full extent that it can unless we improve the quality and value of health care. And we’re going to need to make sure that the work force that delivers that care and works in public health systems and outside of the hospitals and clinics is the right work force to improve the health of Americans.

Knowledge@Wharton: How has failure in some programs helped shape what the Foundation does? I noticed that was addressed in your annual report. And I thought it was an interesting thing to address, because not many organizations do address it. Can you speak a little bit about that?

Lavizzo-Mourey: One of our guiding principles is that we will continuously improve. And so we look at all of our programs and try to learn from them. We don’t necessarily think that only the programs that have failed can teach us. We think that all of the programs that we’ve had can teach us. We have had some spectacular successes like the national 911 system — and we’ve had some investments that didn’t spark the changes we envisioned. What we try to do in every case is reflect on the factors that were successful in a program, and those that were less successful.

Knowledge@Wharton: You will be speaking at the upcoming Leadership Conference. I was curious to know, on a personal level, what’s the biggest challenge you face in your current role as President and CEO?

Lavizzo-Mourey: Well, I’m very much aware that as the president of a foundation, a private foundation, we are stewards of private funds that must be used for the public good, and that it is important that we have a clear view and approach to improving the health and health care for all Americans. So for me, staying focused and strategic when there are so many other important areas that would be worthy of us working on is one of the most difficult things that we have to do. And at the same time, we have to make sure that our strategies are evolving and morphing in accordance with the new evidence and the changing environment.

So, that’s certainly one of the major challenges that I face. Another [challenge] that is particularly important in these times is that health is, at its core, apolitical. It requires that we seek improvements from all sectors of our society if we’re really going to improve health — the business community, our political leaders, our scientific leaders and the like. And as the political environment has changed over the last five or six years, it has become increasingly hard to maintain a non-partisan, apolitical approach to this important topic — improving health.

So that challenges us to stay above the fray, to make sure that our research is balanced, that the way we talk about our work is non-partisan — and that we continually reach out to all sectors to work with us in delivering results that we all can be proud of.

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