Transcript Document

Rough Waters Ahead:
Navigating Health Reform,
the Future of Health Care, and
Telemedicine’s Expanding Role
John F. Duval
Virginia Commonwealth University Health System
March 18, 2013
Agenda
• Quick overview of the Affordable
Care Act
• What’s popular, what’s controversial
• The promise and key disconnects
– Costs
– Workforce adequacy
– The States: Medicaid Expansion and
Insurance Exchanges
• Stay tuned
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What we don’t know
Critical disconnects
What is happening in spite of reform
Telemedicine’s expanding role
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What is good about
the health care
delivery system?
John’s List
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Robust medical community, well represented by specialties
Strong & dedicated allied health workforce
Best education system in the world across all disciplines
Cutting edge technologies & pharmaceuticals
Strong research basis
Social safety net
Modern physical plant
Improving transparency & accountability
Improving quality & safety
Major economic engine, frequently largest employer
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What is not good
about the
health care
delivery system?
John’s List
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Current costs and growth rate are economically not sustainable
≈ 50 million uninsured
Racial / economic / geographic disparities in access to care
Unnecessary variations in amount / quality of care provided and some care
is not evidence based
Quality and safety accountability improving, but still too opaque
Economic incentives between provider and insurer communities not
aligned
Regulatory structure / licensure laws result in inefficient use of workforce
Sickness as opposed to wellness focused
High administrative overhead is wasteful
Education costs of healthcare workforce are borne by providers and
government payors
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Patient Protection and Affordable Care Act (PPACA):
Signed into Law March 23, 2010
• Most comprehensive change in healthcare finance since
1964 Medicare & Medicaid legislation
• Reforms the actuarial financing model for health services
in the United States
• Improves access to care for most citizens and reduces the
number of uninsured
• Reins in unpopular insurance industry practices
• Increases quality and safety of health care
• Improves transparency of health and insurance
information
• Creates Health Insurance Exchanges in each state
• Provides option for Medicaid Expansion in each state
• And much, much more
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PPACA: What is Popular?
• Extends insurance coverage to 32 million people
• Allows parents to cover children up to the age of 26 under their
private insurance plans
• Eliminates lifetime dollar limits on benefits imposed by most
medical plans
• Prevents medical plans from denying insurance and benefits based
on preexisting conditions
• Limits the amount insurers spend on administrative costs versus
medical costs (Medical Loss Ratio)
• Provides more transparency with publically reported metrics
related to quality, safety, and patient outcomes
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PPACA: What is Controversial?
• Mandates individuals have health insurance by 2014 or pay a penalty
• Expands Medicaid coverage to residents with incomes up to 133% of the
federal poverty level (FPL)
– Federal government will cover all costs for this group starting in 2014 and
will phase down to 90% by 2020
• Role of the States
– Health Insurance Exchanges
– Medicaid Expansion
• Requires some employers with 50+ employees who do not offer health
insurance to pay a penalty
• Significantly reduces Medicaid and Medicare Disproportionate Share Hospital
(DSH) allocations
• New taxes on Individuals, health insurance sector, and manufacturers of
pharmaceuticals and medical devices
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PPACA: What the Law Doesn’t Cover
• PPACA does not adequately address important issues facing
the health delivery system including:
– Impending physician and nursing shortages
– Rapidly escalating costs and their cause within our hospitals and
health systems
– Large variations in medical practice observed across the nation
– Financing of graduate medical education / other workforce
issues
– Foreign national population
– Costs of those who opt out
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Program Costs
Murphy’s Law of health care
legislation:
“If it can cost more than the
highest available official
estimate, it probably will.”
Senate Joint Economic Commission
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Will They Be Right?
• Coverage expansions
cost $938 billion over
10 years
• Federal deficit reduced
by $124 billion over 10
years
Source: Kaiser Family Foundation, 2011
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A Lesson from History…
Program (Estimate Year)
Original estimate Actual cost
Medicare Part A (1965)
$9b/1990
$67b/1990
All of Medicare (1967)
$12b/1990
$110b/1990
ESRD program (1972)
$100m/1974 $229m/1974
Medicaid DSH (1987)
Mcare Home Care (1988)
< $1b/1992
$17b/1992
$4b/1993
$10b/1993
Source: Senate Joint Economic Committee, 7/31/09
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Workforce
Health Care Labor Force
• Projected shortages BEFORE health care reform
• Reform makes some efforts to begin addressing
shortages
BUT
• The law covers 32 million new patients nationally and
approximately 1 million in Virginia
• That may not add up…
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Will There Be Enough Doctors?
• Pockets of physician shortages now
• 40% of practicing physicians ≥ age 55
• In Virginia, a recent survey showed one-third
were ≥ age 55 and 10% ≥ age 65
• How many more will we need?
– E.g., currently 6,830 geriatricians nationally
• That is only 1 for every 1,900 seniors ≥ age 75
• IOM indicates 36,000 needed by 2030
Sources: Alliance for Health Reform, 2011; Virginia DHP, 2009; Institute of Medicine, 2008
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What About Other Health Professionals?
• 33% of nursing workforce ≥ age 50
– More than half of these plan to retire within 10
years
• Will an improved economy
reduce supply?
• Nursing shortage projected
to grow to 260,000 RNs by 2025
Source: Alliance for Health Reform, 2011
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What other health professionals may be needed?
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Case Managers/Social Workers
Physical/occupational therapists
Pharmacists
Medical technologists
Clinical psychologists
Dieticians
Rehabilitation counselors
Medical coders
Health information technicians
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The States:
Medicaid Expansion and
Insurance Exchanges
What States are Participating in Medicaid Expansion?
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State Action Toward Creating
Health Insurance Exchanges
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Policy Issues for State Medicaid Expansion
Opt In
• Long-term cost
• Long-term support (Workforce, etc.)
• Long-term benefits of reduced uninsured population
Opt Out
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Cost of larger uninsured population
Federal leverage – What sticks still remain?
Lost dollars to state
Tax exportation
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Stay Tuned
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What we don’t know
Critical disconnects
What is happening in spite of reform
Telemedicine’s expanding role
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What About What We Don’t Know?
The Secretary Shall…
Source: Congressional Quarterly Weekly, 4/5/10
He Wasn’t Discussing Reform, But…
“There are things we
know that we know.
There are known
unknowns. That is to say
there are things that we
now know we don't
know. But there are also
unknown unknowns.
There are things we do
not know we don't
know.” D. Rumsfeld
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Critical Disconnects
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Cost estimates?
Economic impact
Access to providers
Graduate medical / other education
Implementation unknowns
Payment alignment with delivery goals
Tort reform
Medicaid/Medicare requirements /
provider cuts / Disproportionate Share
Hospital payments
• Undocumented foreign nationals
• Personal responsibility
• And more…
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Ongoing efforts, even before
(in spite of) reform
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Quality improvement
Increased safety
Greater efficiency
More transparency
Coordinated care
Healthier populations
Integrated providers
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Where does
telemedicine fit in?
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How can we use telemedicine to
address critical disconnects?
• Combating the rising cost of care
– Reduces emergency transport costs from rural communities to urban areas
– Decreases ED admissions and readmissions through remote telemonitoring
• Providing high-quality care
– Decreases mortality and length of stay with Tele-ICU coverage
– Initiates more timely treatment with ED-ED consults via telemedicine
• Meeting care demands
– Provides rural and underserved communities expanded access to specialists and subspecialists
• Overcoming provider shortages
– Expands reach of providers who prefer to live in larger cities by giving them remote access to
rural patients
– Creates additional capacity for traveling physicians by removing barriers of time and distance
• Achieving patient satisfaction
– Improves patient satisfaction by providing care in a timely fashion
– Keeps care local – only the most serious cases should be packed and shipped to tertiary centers
Source: Telemedicine: An Essential Technology for Reformed Healthcare
(Computer Sciences Corporation, 2011)
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The Potential of Telemedicine
• Emergency Medical Services
– TeleECG on ambulances transmitted to cardiologists via
smartphones or other devices
– Immediate treatment started in transit before patient hits ED
• Telesurgery using robot surgical systems
– MD Anderson received a $1M contribution from AT&T to seed
its venture into remote surgical care for cancer patients
– If successful, surgical cases would occur in rural and
underserved Texas communities rather than Houston
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VCUHS Telemedicine Strategic Plan
Mission Statement & Vision
Mission Statement:
VCUHS Telemedicine supports the mission of the Health System by offering
confidential, timely and cost-effective medical services to patients; removing
distance barriers throughout the Commonwealth of Virginia; providing
superior, compassionate and innovative patient care.
Vision:
Integrate Telemedicine as a part of VCUHS’ strategy to respond to Affordable
Care Act mandates and grow its relationships with community and regional
providers, hospitals and community health centers.
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Goals of VCUHS Telemedicine Program
• Develop and grow relationships with all correctional
facilities in order to provide access and decreases costs
• Utilize telemedicine in under-served and rural areas to
reduce health care disparities
• Leverage the clinical, educational and outreach efforts
of our Centers of Excellence to provide specialty
expertise across the Commonwealth
• Develop innovative models of care using telemedicine
that keep care local and provide care for complex
patients in their homes
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VCUHS Telemedicine
18 years experience
30,000 encounters
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VCUHS Telemedicine: Prior to 2010
Correctional Facilities Served
Updated 7/17/2015
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VCUHS Telemedicine Expands to Meet Needs
of Outlying Communities: Post-2010
Correctional:
Before 2010
Community Based:
Growth since 2010
Pending Contracts/Negotiations
Updated 7/17/2015
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VCUHS Telemedicine provides increased access
to specialists in South Hill, Virginia
• VCUHS utilizes telemedicine to expand access to patients
at Community Memorial Healthcenter:
• Clinical Telepsychiatry Services – Inpatient and Long Term Care
• ICU Intensivist support
• Virginia Tobacco Commission Grant expands Patient Access
• Two new wireless telemedicine units and MCU bridge
• Multidisciplinary tumor conferences, clinical research and
Telemed consults
• Massey Cancer Center case conference review and provider
collaboration – Southern Virginia
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VCUHS is working with several outlying community providers
to launch ED-ED Pediatric Telemedicine
Goal: Improve access and quality by providing telemedicine consults to pediatric patients
admitted to Virginia community hospital Emergency Departments
Objectives:
– Provide physician based pediatric critical care in terms of stabilization and
intervention for children in need of transfer to CHoR
– Provide visual report for nursing hand-off
– Physician based screening for pediatric “puzzlers” (i.e., skin rash, lab finding, etc.)
– Assist with ER disposition plan for subspecialty inpatient/outpatient follow-up
care
– Expand telemedicine collaboration to other specialties and services
– Develop a successful ED to ED model for state-wide roll out at other referring
hospitals
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Independence at Home Demonstration
• In 2012, Virginia Commonwealth University applied for a consortium site to
demonstrate the value of the Independence at Home clinical model
– Partnered with MedStar Washington Hospital Center and the University of
Pennsylvania
– Based on VCU House Calls program that has provided in-home primary care for
more than 5,000 home-bound patients over the past 25 years
• Tests a payment incentive and service delivery model that utilizes physician and
nurse practitioner directed home-based primary care teams
• The Consortium will utilize remote diagnostics and telemonitoring as part of
the IAH program
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Pulse oximetry
I-STAT devices
iCard IPhone EKGs
EKG harnesses for laptops
In-home telemedicine
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Telemedicine’s Expanding Role
• Many challenges are coming our way:
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Health reform implementation
Provider shortages, especially in rural and under-served areas
Aging of the Baby Boomers
Addition of previously uninsured population
• New strategies/models for providing access and quality care are essential
• Telemedicine is a maturing tool that will help stretch our workforce and
ensure all patients have access to needed care
– Offers opportunity to redeploy and reengineer workforce in ways that were
previously not attainable
– Holds promise for dramatically improving access and reducing health inequities in
rural and economically distressed areas
• It’s not a cure-all, but will help us as we figure out how to avoid this….
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