Transcript New Directions In Systems Innovations

New Directions In
Systems Innovations
Susan Dentzer
Editor-In-Chief
July 7, 2011
National Press Club
Washington, DC
What Other States Can
Learn From Vermont’s
Single-Payer Experiment
William C. Hsiao
Anna Gosline Knight
Steven Kappel
Nicolae Done
Systemic Reform Under Single-Payer Plan
Major Health Problems of USA
• Uninsured and
underinsured
Reform Measures
•
•
• Health Care Cost Inflation
• Uneven Quality of Care
•
Universal coverage: decouple
health insurance from
employment and based it on
residency; financed by payroll
contribution
Lower cost base on admin. cost,
reduce fraud and abuse: one
insurance plan and single pipe
payment
Bend cost curve: independent
board, global budget, capitation,
prioritize prevention & primary
care, integrate delivery
Integrate health care delivery:
Risk-adjusted capitation, Pay for
Value , ACO’s.
Projected Savings
Source of savings
Amount
(percent of total health
spending)
Administrative expenses
7.3%
Fraud and abuse
5.0%
Payment reform and integration of
delivery system
10.0%
Malpractice reform
2.0%
Governance and administration
1.0%
TOTAL
25.3%*
*Note: The savings will accrue gradually over a ten-year period. In 2015, the first year or reform, the
savings are projected to be $580 million, and by 2019 they would reach about $1.1 billion.
Lessons For Other States
• Have a credible, viable, and practical reform
plan ready when a political space opens for
reform
 Design to overcome political, economic,
legal, and institutional hurdles
 Employ credible, impartial, and technically
competent group to design the plan
 Rely on evidence to derive
recommendations
Lessons: Parts That Can Be Adopted If A
Full Single-Payer Plan Is Unfeasible
• Create comprehensive all-payer claim data base to reduce
fraud and abuses—can reduce total health spending by 5%.
• Establish single-pipe payment with uniform payment
methods, rates, and claim adjudication rules & processing:
 Reduce administrative costs to providers and insurer
which can amount to 3.6% of total health spending.
 Eliminate monopolistic pricing and cost shifting
 Enhance the establishment of ACOs to organize integrated
delivery systems
• Reform medical malpractice system, which can reduce
total health spending by 2%
The Accountable Care
Organization (ACO): Whatever
Its Growing Pains, The Concept
Is Too Vitally Important To Fail
Francis J. Crosson, M.D.
Kaiser Permanente
The ACO Concept Is Critical
The U.S. needs to achieve the “Triple
Aim”, and do so soon:
• Improve the health status of the
American population
• Improve each individual’s health
care experience
• Control the inflation of health care
costs, to improve the affordability of
health insurance coverage
The Path Forward
• Delivery system integration and
payment reform (the ACO concept)
is the most direct way to achieve the
Triple Aim
• The ACO concept is broader than
just the Medicare Shared Savings
model
• CMMI and the commercial sector
will lead as well
The ACO Concept Has Critics
• The Medicare Shared Savings draft
regulations has some flaws
• Insurers
• Physicians
• Hospitals
• General skeptics
• Consumers?
But If The ACO Concept Fails?
• Health care cost inflation continues
• The federal budget deficit problems
increase; private insurance becomes
even more unaffordable
• Public and private payers are forced
into indiscriminate cost cutting,
with resultant reductions in quality,
patient experience, and eventually
U.S. population health status
Polling Analysis: Public Support
For Health Reform Broader Than
Reported And Depended On How
Proposals Were Framed
David Grande, MD, MPA*
Sarah E. Gollust, PhD
David A. Asch, MD, MBA
*Perelman
School of Medicine and the Leonard
Davis Institute of Health Economics, University
of Pennsylvania
Reporting On Health Reform Has
Focused On Polarization
• Analyzed polls on the public option and
individual mandate
• Does the public support an expanded role
of government?
Support Fluctuated Considerably
The Public Option
Average Support: 57.6%
Range: 43-72%
Source: Grande et al., Health Affairs 2011
The Individual Mandate
Average Support: 53.0%
Range: 26-73%
Support Depended On How
Frames account
Questions Were Asked
for 60% of
variation
The Public Option
70%
60%
50%
64.6%
62.8%
59.4%
58.9%
55.2%
46.5%
56.2%
47.0%
40%
30%
20%
10%
0%
th
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No O
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Support Depended On How
Frames account
Questions Were Asked
for 56% of
variation
The Individual Mandate
70%
60%
62.5%
58.7%
57.3%
54.5%
50%
52.0%
46.5%
40%
34.7%
35.5%
30%
20%
10%
0%
A id
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Low
Implications
• Majority but varied support
– “Framing effects” show that public opinion is
more consistent than reported
– The public is not opposed to an expanded
government role but is sensitive to how that
role is described (similarity, choice, aid as
opposed to enforcement)
• The focus on “horse race” polls ignores
what polls can tell us
– Why does one poll differ from another?
– The answer is probably not just time
Differences In The Volume Of
Services And In Prices Drive Big
Variations In Medicaid Spending
Among US States And Regions
Todd Gilmer
Richard Kronick
University of California, San Diego
Medicaid Spending Varies
Substantially Across States
• Does interstate variation in
Medicaid spending result primarily
from variation in the volume of
services or in the price of services?
• Is spending related to outcomes?
Spending Is Determined
Primarily By Volume
• Spending in the top 10 states was
$1,650 above average, 72% due to
volume ($14 billion)
• Spending in the bottom 10 states
was $1,161 below average, 58% due
to volume ($9.5 billion)
Importance Of Primary Care
• The supply of primary care physicians,
the average number of primary care
visits, and the price per visit were
associated with reduced admissions
• This suggests that the provisions of the
Affordable Care Act of 2010 that were
aimed at increasing access to primary
care may reduce admissions
Reinventing Medicaid:
State Medicaid Medical
Home Innovation
Mary Takach, MPH, RN
National Academy for State Health Policy
July 7, 2011
Washington, DC
National Academy For State Health Policy
– 24-year-old non-profit, non-partisan
organization
– Offices in Portland, Maine and Washington,
D.C.
– Academy members
• Peer-selected group of state health policy
leaders
• No dues—commitment to identify needs and
guide work
– Working together across states, branches and
agencies to advance, accelerate and implement
workable policy solutions that address major
health issues
Seventeen “Leading” State Programs That Tie
Payment To Objective Medical Home Criteria
AK
WA
VT
MT
MN
OR
NY
WI
ID
SD
MI
WY
PA
IA
NE
OH
NV
IL
UT
ME
ND
CO
CA
KS
MO
IN
WV VA
NH
MA
RI
CT
NJ
DE
MD
KY
NC
TN
AZ
OK
NM
SC
AR
MS
HI
TX
AL
GA
LA
FL
Note: North Carolina data includes only those seven regions participating in the Medicare Advanced Primary Care
Demonstration, not the entire state-wide Community Care of North Carolina (CCNC) Program
Support for this research came from The Commonwealth Fund.
Select Care Coordination Payments In Medical Home
Initiatives
State Initiative
Per member per
month range
Adjusted for
Patient
Complexity or
Demographic
Adjusted for
Medical
Home Level
Lump Sum
Payment
Financial
Incentive
Based on
Quality
▲
▲
▲
▲
Iowa
$1.50 - $3.00
Maine
$3.00 - $7.00
Maryland
$4.68 - $8.66
▲
Massachusetts
$2.10 - $7.50
▲
Michigan
$3.00-$4.50
▲
Minnesota
$10.14 - $79.05
▲
Oklahoma
$2.93 - $8.41
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▲
▲
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Pennsylvania
$3.00 - $8.50
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▲
▲
▲
Rhode Island
$3.00
Vermont
$1.20 - $2.39
Washington
$2.00 - $2.50
▲
▲
▲
▲
▲
▲
What Does “Medical Home” Mean?
Expectations of Practices
Maine
NCQA criteria plus 10 additional
standards, such as:
– Behavioral health integration
– Population risk-stratification and
management
– Same-day access
– Team-based care
– Inclusion of patients & families in
redesign
– Focus on cost containment and
waste reduction in QI activities
– Integration of health IT
– Connection to community
resources
Source: www. mainequalitycounts.org;
http://www.okhca.org/providers.aspx?id=8470&menu=74&p
arts=8482_10165
Oklahoma
Tier One: 8 requirements, such as:
– Provides/coordinates all
primary and preventive care
– Organizes clinical data in
electronic or paper format
– Maintains a system to track
referrals, tests and follow-up
results
Tier Two: additional 9
requirements, such as:
– Open access scheduling
– Limited after-hours coverage
Tier Three: 5 more requirements,
such as:
– Work in teams
– Medication reconciliation
Summary of Key Cost and Quality Outcomes from
Medicaid Medical Home Programs
•
Colorado State Programs for Children
– Median annual costs $215 less for children in medical home practices due
to reductions in emergency department visits and hospitalizations
– Median annual costs $1,129 less for children with chronic diseases in a
medical home practice than those without such care
•
Oklahoma
– Per-capita member costs declined $29 per-patient/per-year from 20082010 with increases in evidence-based primary care including breast and
cervical cancer screening.
– Positive feedback from both providers and patients
•
Vermont Blueprint
– In one Blueprint community, in-patient use and related per month costs
decreased by 21 and 22 percent, respectively
– Emergency department use and related per person per month costs
decreased by 31 and 36 percent, respectively
– Mixed results for another Blueprint community.
For More Information on Medical Homes....
•Please visit:
www.nashp.org
www.pcpcc.net
•Contact:
[email protected]
29
An Early Look At A
Four-State Initiative To
Reduce Hospital
Readmissions
Amy E. Boutwell, MD, MPP
Collaborative Healthcare Strategies
The STAAR Initiative
[State Action on Avoidable Rehospitalizations]
• Grant-funded support from The Commonwealth Fund
• Initiative to reduce rehospitalizations in a state
• Strategy:
– Recruit, mobilize and support quality improvement for providers
– Recruit and mobilize state-level, multi-sector leadership support
and solutions to support systemic change
•
Key partners: 3 initial states (MA, MI, WA); 1 additional
(OH
–
–
Required leadership commitment of hospital associations
State leads capable of convening multi-sector state-level
coalitions
• Designed in 2008; launched 2009
– Specific intention of aligning with all complementary programs
State-Level Priorities
• Leadership Mobilization; Shared Framing of
Approach
– Specifically promote work to reduce rehospitalizations as
a “cross-continuum” team challenge
• Data
– None of the states had access to state-wide data on
rehospitalization
• Financial Impact
– Hospitals had not assessed the current or future impact of
readmissions on hospital finances
• Alignment
– Among provider organizations: promoting “system-ness”
– With complementary programs; finding synergy in
education, recruitment
– With payers; What are they? Can they be aligned?
Results to Date
• Leadership Mobilization/ Shared Framing of
Approach
– Steering committees: essential guide, align, mobilize and sustain
– “Cross continuum” concept took hold: >148 hospitals with >500
community providers and organizations to improve communication,
coordination
• Data
– All 3 original states arrived at local solutions to accessing “best-available”
state-wide rehospitalizations data reports
• Financial Impact
– Financial impact “roadmap” developed; 1,100 attendees on webinar
• Alignment
– Among providers: cross-continuum teams, aggregates & there of at
regional level (e.g. Detroit CARR, Baystate Medical Center)
– With complementary programs: STAAR + INTERACT + AAA/ADRC +
medical home + MOLST (see Figure in paper of Massachusetts “map” of
alignment)
– With payers: WA (Medicaid); MI (BCBS); MA (BCBS, Health
NewEngland)
Recommendations For National Work
To Reduce Hospital Readmissions
• State-level multi-sector steering committees are valuable assets to
efforts such as this which require contributions from many settings and
sectors.
• Work to reduce hospital readmissions is greatly enhanced when
hospitals work with their community partners, as in a “cross-continuum
team.”
• Obtaining state-level data is a challenge but should not discourage
action; technical assistance and resources yielded local solutions.
• Synergy in recruiting participation and establishing shared state-wide
vision was accelerated because the program was designed to align with all
complementary efforts; this flexibility may decrease ability to asses the
unique differential impact of the program, but is valued by participants.
• Implementing required changes in care delivery will likely be
accelerated by incentives to change, such as those provided in the CMS
Community-Based Care Transitions Program.
Thank you
Amy E. Boutwell, MD, MPP
Collaborative Healthcare Strategies
[email protected]
Institute for Healthcare
Improvement:
Michigan Leads:
Massachusetts Leads:
Washington Lead:
Marian Johnson, Pat Rutherford
Sam Watson, Nancy Vecchioni
Pat Noga, Paula Griswold, Bruce Auerbach
Carol Wagner
Grant support provided by The Commonwealth Fund
The New Quality Compass:
Hospital Boards’ Increased
Role Under The Affordable
Care Act
Robin Locke Nagele, JD, Presenter
Quality in Action Task Force
American Health Lawyers Association
1. The Affordable Care Act’s New
Quality Mandate
2. Why Hospital Boards Are
Becoming More Active in Quality
Oversight
3. The Board’s Quality Toolkit
4. Legal and Operational Challenges
5. The Path Forward
Changes In The Racial And
Ethnic Makeup Of The US
Nursing Home Population
Zhanlian Feng
Mary L. Fennell
Denise A. Tyler
Melissa Clark
Vincent Mor
Brown University
Support:
National Institute on
Aging (P01AG027296)
Author Contact:
[email protected]
Phone: 401-863-9356
Forum:
New Directions In
Systems Innovations
National Press Club
Washington, DC
July 7, 2011
Key Findings
• During 1999-2008, the US nursing home
population shrank by 6.1%, as a result of:
–
–
–
–
10.2% decline of white residents
10.8% increase of black residents
54.9% increase of Hispanic residents
54.1% increase of Asian residents
• Beyond demographics, these shifts suggest a
new disparity in long-term care:
– white elders better able to use a variety of care
options in preferred settings
– minority elders facing more barriers in access to
nursing home alternatives
Feng Z, Fennell ML, Tyler DA, Clark M, Mor V. Growth of racial and ethnic minorities in US nursing homes driven by
demographics and possible disparities in care options. Health Affairs (Millwood). July 2011; 30(7):pp.
Minorities Increasing in US Nursing
Homes and White Residents Declining
Sources: National Minimum Data Set.
Increase of Minorities in Nursing Homes
Mirrors Growth of Minority Populations 65+
Sources: National Minimum Data Set (nursing home residents); Census Bureau population estimates (US population 65+).
What’s Behind These Shifts? Implications?
• Not just changing demographics
• Persistent disparities in long-term care
• Is there unequal minority access to home
and community-based services (HCBS)?
• Imperative to create equity by
rebalancing initiatives
THE CARE SPAN:
Medicaid Savings Resulted When
Community Health Workers Searched For
Those With Long-Term Care Needs And
Linked Them To Home And Community
Care
Holly C. Felix
University of Arkansas for Medical Sciences
Fay W. Boozman College of Public Health
Holly C. Felix, Glen P. Mays and M. Kathryn Stewart of the University of Arkansas for
Medical Sciences Fay W. Boozman College of Public Health and Naomi Cottoms and Mary
Olson of the Tri-County Rural Health Network
What Did We Find?
• The Community Connector Program
– Used community health workers
– Link to HCBS
– Reduced NH use
– ROI of $2.92 per $1 invested
Why Use CHWs?
•
•
•
•
Lay members of the community
Use pre-existing relationships
Shared characteristics
Build trust between consumers and
the system
Why Use CHWs For LTC
Outreach?
• Consumers prefer HCBS
• LTC system fragmented
• Limited knowledge of available
services
• Some in nursing homes with mild
limitations
• Racial disparities in unmet need
How Did The Program Work?
Acknowledgements
– Co-authors Glen Mays and Kate Stewart at the University of
Arkansas for Medical Sciences Fay W. Boozman College of
Public Health, and Naomi Cottoms and Mary Olson at the Tri
County Rural Health Network
– Funding support from the Arkansas Department of Human
Services, the Robert Wood Johnson Foundation, Enterprise
Corporation for the Delta, Medicaid
– Special thanks goes also to the Community Connectors,
program participants and staff at the Arkansas Department of
Human Services
Thank You!