Health Reform Keynote Address
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The document discusses the challenges facing the U.S. health care system, emphasizing the need for transformation driven by the Affordable Care Act. Key themes include the integration of population health, social determinants of health, and innovative models for care delivery to improve overall health outcomes and reduce costs. It highlights ongoing initiatives and the critical need for hospitals and health systems to engage with their communities to address health disparities.
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Hospitals’ New Roles in Population Health
New requirements under ACA on tax-exempt hospitals and
health systems
To retain 501(c)(3) [tax exempt] status, organization must
conduct a ―community health needs assessment‖ at least every
three years
Must adopt implementation strategy to meet the community
health needs identified through the assessment
Penalty: $50,000 excise tax for each year that a tax-exempt
hospital subject to these provisions fails to satisfy requirement](https://image.slidesharecdn.com/dentzer-131025101247-phpapp02/85/Health-Reform-Keynote-Address-28-320.jpg)
Health Reform Keynote Address
- 1. + Reform, Health System Transformation And the Implications for Health, Hospitals and Health Care Systems By Susan Dentzer Senior Policy Adviser, Robert Wood Johnson Foundation University of Missouri Health Policy Summit October 25, 2013
- 2. + This Presentation at a Glance The United States face a number of health and health care challenges – one reason for the Affordable Care Act System transformation is being accelerated by the law but will extend far beyond it Pursuit of the Triple Aim: Challenges in health, health care and health care costs Key aspects of reform and transformation and the implications for hospitals and health systems Coverage expansion, influx of chronically ill patients, and impact of not expanding Medicaid Innovations in health care delivery, payment and technology Focus on population and community health Patient activation and engagement Some conclusions
- 3. + First, a story….
- 4. + Once upon a time, there was a ―country‖… With an economy the size of France: $2.8 trillion… With tens of millions of unhealthy people – and life expectancy below that of 28 of the world’s richest countries… Where every day, a group of the natives ―experimented‖ on others by subjecting them to ―medical care,‖ about half of which has no evidence suggesting that it works… Where adverse events that occurred in the course of this ―care‖ were among the top ten causes of death annually… Where tens of millions didn’t get care they needed and tens of thousands died each year as a result… And partly because of the cost of the flawed care it does provide, the country was possibly going broke!
- 5. What would you do with this country? Send in the Marines? Send in the International Monetary Fund? Send in Amnesty International? Other? +
- 6. + We know this country’s identity… The United States of Health Care Ripe for Change!
- 7. What The US Did In 2010… …Enact the Affordable Care Act
- 8. + A Heavy Lift?
- 9. +And about that country… Our $2.8 trillion health system is unequivocally a major economic engine… But the system is propelled by the volume of services, not sufficiently by value The degree to which cost exceeds value is an opportunity cost – i.e., we might better spend the money some other way – for example, on education Expenditures on care not reflected in superior health outcomes For more fundamental reasons, Americans may be at a health disadvantage relative to others How much will more ―health care‖ solve this?
- 10. The Triple Aim Donald Berwick, MD Former Administrator Centers for Medicare and Medicaid Services Better health care Lower cost + Better health Core principle now at heart of major U.S. payment and delivery system reform efforts
- 11. + Better Health
- 12. Fans line up outside Paula Deen’s The Lady and Sons restaurant, Savannah, Georgia, June 2013
- 13. The State Of US Population Health Key Drivers of Health Status Obesity Physical Inactivity 66% adults obese or overweight Contribution to Premature Death Genetic Predisposition Social Circumstances 28% inactive 15% 30% Smoking 23% smokers Environmental 5% Exposure 10% Stress 36% high stress Aging Health Care 22% > 55 years old 40% Behavioral Patterns Source: Schroeder S. N Engl J Med 2007;357:1221-1228
- 14. + Geographic Health Differences: Your zip code matters more than your genetic code
- 15. + Health Factors and Outcomes Health Factors: Low birth weight, tobacco use, adult obesity, physical inactivity, alcohol use, sexually transmitted infections, teen birth rate Rates of uninsured, certain clinical care measures (e.g. preventable hospital stays, screening) Social and economic factors such as high school graduation rates, employment and income, violent crime rate, fast food restaurants Environmental quality (safe drinking water), access to recreational facilities Health Outcomes: premature death; poor or fair health; poor mental health days
- 16. + Missouri: Health Factors by County
- 17. + Missouri: Health Outcomes (Premature death; poor health)
- 18. + Comparison, factors vs. outcomes
- 19. + Institute of Medicine Study, January 2013 ―For many years, Americans have been dying at younger ages than people in almost all other high-income countries.‖ ―Not only are their lives shorter, but Americans also have a longstanding pattern of poorer health that is strikingly consistent and pervasive over the life course – at birth, during childhood and adolescence, for young and middle-aged adults, and for older adults.‖
- 22. + Rising Mortality, Declining Life Expectancy For Many Trends in male and female mortality rates from 1992–96 to 2002–06 in 3,140 US counties. Female mortality rates increased in 42.8 percent of counties, while male mortality rates increased in only 3.4 percent. Factors associated with areas that had lower mortality: higher education levels; low smoking rates Source: DA Kindig, ER Cheng,‖Even As Mortality Fell In Most US Counties, Female Mortality Nonetheless Rose In 42.8 Percent Of Counties From 1992 To 2006.‖ Health Affairs, March 2013
- 23. Change In Male Mortality Rates From 1992–96 To 2002–06 In US Counties. Kindig D A , and Cheng E R Health Aff 2013;32:451-458 ©2013 by Project HOPE - The People-to-People Health Foundation, Inc.
- 24. Change In Female Mortality Rates From 1992–96 To 2002–06 In US Counties. Kindig D A , and Cheng E R Health Aff 2013;32:451-458 ©2013 by Project HOPE - The People-to-People Health Foundation, Inc.
- 25. + What are we doing about these challenges? Good news: some efforts to tackle child obesity, for example, seem to be working Centers for Disease Control and Prevention data show child obesity falling in 19 states, including Missouri
- 26. Source: Centers for Disease Control and Prevention
- 27. Source: Centers for Disease Control and Prevention
- 28. + Hospitals’ New Roles in Population Health New requirements under ACA on tax-exempt hospitals and health systems To retain 501(c)(3) [tax exempt] status, organization must conduct a ―community health needs assessment‖ at least every three years Must adopt implementation strategy to meet the community health needs identified through the assessment Penalty: $50,000 excise tax for each year that a tax-exempt hospital subject to these provisions fails to satisfy requirement
- 29. + Example of Innovation In Population Health Austen BioInnovation Institute, an ―accountable care community‖ in Akron, OH Nonprofit entity that Conducted community-wide combines activities among assessment of health and health care three independent health assets and gaps care systems and two universities Programs launched include costeffective diabetes prevention program; ½ of participants lost Source: Population Health Implications of weight and cost of diabetes care fell the Affordable Care Act: Workshop Summary. Institute of Medicine, 2013. by 10 percent
- 30. + ―Hot-spotting:‖ The Camden Coalition of Healthcare Providers
- 31. + ―Hot-spotting‖ unhealthy communities King County Public Health Director David Fleming ―The solutions to health in this country lie beyond the walls of the clinic and in our communities.‖ Echoing Jeffrey Brenner and the Camden Coalition What if hospitals and health systems ―hot spotted‖ – using similar techniques to identify the nation’s poorest and least healthy communities—and then teamed up with public health and local community development organizations to set them on a path to better health?
- 32. + The fundamental drivers of health ―Improving health outcomes across the United States will require increased public and private investment in the social and environmental determinants of health—beyond an exclusive focus on access to care or individual health behavior.‖ Source: DA Kindig, ER Cheng,‖Even As Mortality Fell In Most US Counties, Female Mortality Nonetheless Rose In 42.8 Percent Of Counties From 1992 To 2006.‖ Health Affairs, March 2013
- 33. Social determinants of health + Income and Income Distribution Education Employment or unemployment; job security; working conditions Early Childhood Development Food Insecurity Housing Social Exclusion; Social Safety Network Access to Health Services; Disability Gender, Race, Aboriginal (Native American/Indian) Status
- 34. + The Social Determinants ―Ten Tips For Better Health‖ 1. Don’t be poor. If you can, stop. If you can’t, try not to be poor for long. 2. Don’t have poor parents. 3. Own a car. 4. Don’t work in a stressful, low-paid manual job. 5. Don’t live in damp, low-quality housing. 6. Be able to afford to go on a vacation and sunbathe. 7. Practice not losing your job and don’t become unemployed. 8. Make sure you have access to benefits, particularly if you are unemployed, retired, or sick or disabled. 9. Don’t live next to a busy major road or near a polluting factory. 10. Learn how to fill in the complex housing benefit/shelter application forms before you become homeless and destitute. Source: Centre for Social Justice, Canada; Social Determinants Across the Lifespan, <http://www.socialjustice.org/subsites/conference/resources.
- 35. + Issues for hospitals and health systems How do you broaden your focus beyond your ―population of patients‖ (panel) to the overall health of the community? Which among these social and economic determinants should you focus on, how, and with whom? How do you engage with the public health system? How do you fund these activities or make the case for more public and private funding of them? Is there a particular role in transforming community health for ―repurposed‖ critical access hospitals?
- 36. + One Model – for critical access hospitals, e.g.? Maryland’s Total Patient Revenue Program – population based rate method 10 rural hospitals in state operating under guaranteed global budget If revenue falls below budget hospitals can increase prices; if exceeds budget they must return surplus Western Maryland Hospital, e.g.: FY 2013 operating profit of $15 million on $370 million in revenues; provides $ for population health focus, care transitions programs, etc. Admissions down 15 percent; 30 day readmission rate now 9 percent
- 38. + Bringing More Americans Under The Health Insurance Security Blanket
- 39. Health Insurance Coverage in the United States, 2010, and Changes Under Affordable Care Act Uninsured 16% EmployerSponsored Insurance 49% Total = 305.2 million Approximately 20-30 million will remain Medicaid uninsured 17% Medicare 12% Private NonGroup 5% This group will also grow and purchase coverage through insurance exchanges * Medicaid also includes other public programs: CHIP, other state programs, military-related coverage. Numbers may not add to 100 due to rounding. SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS.
- 40. + Marketplaces and Medicaid: Across the States
- 41. + Medicaid Expansion – Or Not Republican Gov. bypassed legislature to embrace expansion Premium assistance model; Arkansas approved by CMS; PA considering
- 42. + Who Will Be Left Out Source: New York Times, Oct. 2, 2013
- 43. + Who’s Hurt in States Not Moving Ahead With Expansion? Source: Kaiser Commission On Medicaid And The Uninsured
- 44. The Federal Government Will Pay for the Large Majority of the Medicaid Expansion Federal 95.4% $443.5 Billion Total: $464.7 billion over 2014-2019 Note: Adults less than 133% FPL under standard participation scenario. SOURCE: Analysis for KCMU by The Urban Institute, May 2010 State: 4.5% $21.1 Billion
- 45. + Impact on health: Oregon Medicaid Study After one year of Medicaid coverage, previously uninsured adults in Oregon were 10 percent less likely to report having depression 25 percent more likely to report their health as good, very good, or excellent. Also experienced lower financial strain because of lower out-of-pocket expenditures, lower debt on medical bills, and lower rates of refused medical treatment because of medical debt Source: Sommers BD, Baicker K, Epstein AM,. N Engl J Med 2012;367:1025-34.
- 46. + Quality of Care and Care Coordination Issues
- 47. + Care Coordination/Avoidable hospital use Advanced Illness/End of Life Half of older Americans (51%) visited emergency department in last month of life; 77% of those seen in ED admitted to hospital 68% of admitted died in hospital Americans’ broad preference is to die at home Emergency department use in last month of life rare when enrolled in hospice one month before death Source: Alexander K. Smith et al, ―Half of Older Americans Seen In Emergency Department In Last Month of Life; Most Admitted To Hospital, And Many Die There,‖ Health Affairs, June 2012
- 48. + High-Value Health Care Collaborative Cleveland Clinic, Dartmouth-Hitchcock Medical Center, Denver Health, Intermountain, Mayo, and nearly 20 others Identified nine high volume, high cost, high variation conditions to focus on: total knee replacement diabetes congestive heart failure depression spine surgery labor and delivery asthma hip surgery bariatric surgery
- 49. + Variability, even among ―the best‖ Pooled data to examine differences in primary total knee replacements (total US costs in 2008 = $9 billion) Found substantial variations in such metrics as hospital lengths-of-stay; longer operating times associated with higher complication rates Used findings to alter care, including more coordinated management for complex patients Source: Ivan M. Tomek et al, Health Affairs, June 2012 vol. 31 no. 6 1329 ff
- 50. + Comparison among institutions Metric A B C D E Total Mean LOS 3.6 4.2 3.9 3.3 3.2 3.2 Median LOS 3 4 3 3 3 3 By MD # of procedures (annual) 0-99 3.6 3.8 4.4 3.5 3.3 3.5 200+ -- -- 3.4 3.0 2.8 2.9 Surgery on Mon. 3.6 4.2 3.7 3.2 2.9 3.1 On Fri. 3.6 -- 4.3 3.4 3.0 3.3 31.2% difference, low to high 16% difference
- 51. Care Moving Out of Hospitals: ―Hospital At Home‖ Presbyterian Health Services, New Mexico, in partnership with Johns Hopkins Identified patients who could be ―hospitalized‖ at home and deployed physicians and nurses to care for them All results equal or better than in hospital Variable costs per stay are $1000-$2000 lower = 19% Patient satisfaction mean score = 90.7% Source: Lesley Cryer et al, ―Cost For Hospital At Home PtientsWere 19 Percent Lower, With Equal Johnny Baker, then 49, COPD patient in ―Hospital At Home‖ program
- 52. Telehealth/telemedicine Project ECHO (Extension for Community Healthcare Outcomes) in New Mexico Via technology, specialists at University of New Mexico partner with primary care clinicians in underserved areas Deliver complex specialty care to patients with hepatitis C, asthma, diabetes, pediatric obesity, chronic pain, substance use disorders, rheumatoid arthritis, cardiovascular conditions, and mental illness Source: ―Partnering Urban Academic Medical Centers And Rural Primary Care Clinicians To Provide Complex Chronic Disease Care‖. Sanjeev Arora et al, Health Affairs, June 2011 18 states now have laws mandating payment for covered services using broadband telehealth technology
- 53. + Virtual Visits: Verizon, Cisco, Others
- 54. + Waste in Health Care: The Savings Opportunity Estimated to equal 21% to 34% of all US health spending (estimated $558 billion to $910 billion annually) Source: Donald M. Berwick and Andrew D. Hackbarth, ―Reducing Waste in Health Care Spending,‖ , Journal of the American Medical Association, April 11, 2012.
- 55. + Focus on ―Lean‖ Example in Washington: Virginia Mason
- 56. + Reengineering Primary Care at Virginia Mason via Lean Lean concept of jidoka - having the instructions and knowledge necessary to do one’s job right the first time Result: new ―standard work‖ in appointment scheduling When a patient requests appointment, patient services representative checks the computer to identify preventive tests patient is due for and schedules them right at the point of service Lean concept of having each team member doing the right work for their skill level, also known as level loading or heijunka Some tasks that physicians handled reassigned to others Medical assistants practice to the top of certification, going through the problem list with the patient, reviewing medication lists, verifying allergies, reviewing test results and administering vaccines. Source: http://www.virginiamasoninstitute.org/workfiles/Virginia-Mason-Institute-Case-StudyMistake-Proofing-Primary-Care.pdf
- 57. + Patient Engagement and Activation Engagement = actions that people take for their health or health care Activation = understanding own role in care process and having knowledge, skills and confidence to take it on Increasingly understood as a distinguishable factor in achieving Triple Aim (better health, better care, lower costs)
- 58. + Patient Activation Measure Gauges the knowledge, skills and confidence essential to managing one’s own health and healthcare 13-item questionnaire; patients rate selves on a scale Statements include “When all is said and done, I am the person who is responsible for managing my health condition. “I am confident that I can take actions that will help prevent or minimize some symptoms or problems associated with my health condition. “I know what each of my prescribed medications do.” Measure segments consumers into one of four progressively higher activation levels Source: Judith Hibbard et al, Health Affairs, Feb. 2013
- 59. + Patient Activation Measure Patient activation and the ―3 M’s‖ It can be measured It can be moved – patients’ low scores can be improved via engagement over time It matters – the degree to which patients are activated predicts their factors such as their success in medication adherence, use of emergency department, and their likelihood of having avoidable readmissions
- 60. + Lower Costs
- 61. ―Health care costs are the pounding headache to which all of us in medicine will awaken each day for the rest of our lives.‖ --Thomas Lee, former network president, Partners Healthcare System
- 62. Annual Growth Rates, Gross Domestic Product (GDP) And National Health Expenditures (NHE), Calendar Years 1990–2022. Cost curve still not bent enough Cuckler G A et al. Health Aff doi:10.1377/hlthaff.2013.0721 ©2013 by Project HOPE - The People-to-People Health Foundation, Inc.
- 63. It’s the Prices, Stupid! International Price Variation Service (US$) Cost* (US$; 25 and 95%tile) Canada US (4,001; 45,902) Medical Tourism** (US$) Cost/Hosp. Stay 7,707 14,427 Angioplasty 12,581 New Zealand 29,055 US (18,266 – 60,448) US CA Bypass 67,583 Normal Delivery 1,336 2,997 France US (2,380 – 4,848) India Hip R. 4,308 MRI Imaging 874 1,009 Switzerland US (509-2590) US Hip R. *International Federation Health Plans 2010 Report India CA Bypass 4,525 38,017
- 64. Safeway Reference Pricing For Colonoscopy (Limit = $1,250) Range of Prices Paid by Safeway for Colonoscopy in Three Markets, plus Reference Price Limit Established in 2010 $6,000 $5,984 $5,000 $4,571 $4,000 $3,508 $3,000 MIN MAX $2,000 $848 $1,000 $1,386 $443 $Houston Source: Safeway Health San Francisco Portland, OR Safeway reference price set at $1,250
- 65. + How we (mostly) pay for health care Paying by ―piecework‖ – known as ―fee for service‖ for outcomes Paying for the ―package‖ – known as bundled payment, capitation etc. – and tying payment to quality outcomes
- 66. + Payment Innovation: Improving Value And Affordability Old Model New Model Reward unit cost Reward health outcomes and population health Inadequate focus on care efficiency and patient centeredness Lower cost while improving patient experience Payment for unproven services; limited alignment with quality Improve quality, safety and evidence
- 67. + Performance-based Innovations under CMS Patient Centered Medical homes: e.g., all-payer national pilot; federally qualified health centers; ½ of states in Medicaid Comprehensive Primary Care initiative Accountable Care Organizations State Demonstration Projects for Dual Eligibles State Innovation Model Grants Partnership for Patients/program to reduce avoidable readmissions
- 68. + Throwing It Up Against The Wall To See What Sticks?
- 69. + CMMI Innovations in Missouri
- 70. + Medicare ACO’s
- 71. + ACOs in Private Sector – e.g., Blue Shield of California Launched pilot ACO with Dignity Health (formerly Catholic Health Care West) and Hill Physicians in January 2010 for 41,000 CalPERS employees and dependents Global budget; shared upside and downside risk Tactics included eliminating unnecessary care, such as excessive bariatric surgery; coordinating processes such as discharge planning; reducing variation in practices and resources; reducing pharmacy costs 2010-11 combined results: $37 million in savings to CalPERS; compounded annual growth rate for per member per month costs was ~ 3% vs. ~7% for everyone else
- 72. + Medical homes in Private Sector Alabama Health Improvement Initiative Medical Home Pilot – Blue Cross Blue Shield of Alabama Health plans in Maryland, Pennsylvania, Ohio, elsewhere reporting savings from medical homes E.g., in Maryland, CareFirst reported 2.7% savings in health costs for its 1 million members in 2012 Group Health-University of Washington: TEAMcare program for people with depression and either diabetes, heart disease or both, saved as much as $594 per patient in outpatient costs after expenses of program
- 73. + Performance-based Innovations under CMS Programs to reduce unnecessary readmissions Partnership for Patients, Community-Based Care Transitions program (organizations paid an all-inclusive rate per eligible discharge based on cost of care transition services) Medicare penalties: hospitals above certain ratios for 30-day readmissions in 3 conditions (heart attack, heart failure, pneumonia) begin to be penalized under Medicare in October 2012 Readmissions rates in Medicare dropped 1 percentage from an average of 19 percent during 2008-2011 to 17.8 percent in 2012, according to CMS Declines largest in hospitals participating in Partnership for Patients. Source: Economic Report of the President, 2013
- 74. + Reducing Avoidable 30-Day Readmissions
- 75. + Hospital inpatient utilization down and projected to decline further 40 percent difference Sources: Milliman, Kaiser State Health Facts, American Hospital Association
- 76. + State Innovation Models under Center for Medicare and Medicaid Innovation Examples: • Arkansas: majority of population in patient-centered medical homes • Minnesota: majority of population in ACO’s, including long-term services and supports • Oregon: ―Coordinated Care Organizations‖
- 77. Overall Trends + Care moving out of hospital to ambulatory settings and homes; inpatient utilization falling Primary care fees up; hospital reimbursement down Emphasis on team-based care with ―task-shifting‖ Primary care physician panels becoming larger; 1 physician in a team handling10,000 patients considered goal in many systems Population health approach dramatically increases emphasis on prevention and patient engagement
- 78. Hospital of the Future? + Narayana Hrudayalaya (NH) Narayana Hrudayalaya – ―God’s Compassionate Care‖ – Bangalore, India-based health and hospital system/network 5,000 beds in India now; aims for 30,000 in next five years Average cost of heart surgery is $2,000 and is aiming for $800 ―Our vision: Affordable Quality Healthcare for the Masses Worldwide‖ Partnering with Ascension Health Alliance on $2 billion tertiary care hospital in Cayman Islands Above: Chairman, Dr. Devi Shetty; NH hospital in Bangalore
- 79. Some Conclusions + About Health Reform
- 80. ―I don’t believe there’s any problem in this country, no matter how tough it is, that Americans, when they roll up their sleeves, can’t completely ignore.‖ The Late Comedian George Carlin
- 81. ―The Americans always do the right thing…after they’ve exhausted all the other alternatives.‖ Sir Winston Churchill
- 82. ―There has never been a better time to be an innovator in health care.‖ --Don Berwick, former administrator, CMS Military Health System conference January 2011
- 83. ―Those who say it can’t be done are usually interrupted by others doing it.‖ --the late James Baldwin, American novelist, essayist and playwright
- 84. “We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten.‖ --Bill Gates Jr.
- 85. The Final Verdict on Building an American Health and Health Care System? ―Somebody has to do something, and it’s just incredibly pathetic that it has to be us.‖ --the late Jerry Garcia of the Grateful Dead
- 86. + The End