Transcript Vermont Health Care Reform of 2006

Vermont Health Care Reform
Blueprint for Health
NAIC Spring Conference
Orlando, Florida
March 29, 2008
Paulette J. Thabault
Commissioner, Vermont Department of Banking, Insurance,
Securities and Health Care Administration
How is our nation doing?
 The US Census Bureau indicates:
• 43 countries have life expectancies that exceed the
United States
• 40 countries have a lower infant mortality rate
U.S. Census Bureau, International Data Base, http://www.census.gov/ipc/www/idb/
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How is our nation doing?
 When compared to 10 European countries, the
prevalence of many major chronic diseases among
adults age 50+ in the U.S. is higher – heart disease, high
blood pressure, high cholesterol, stroke, diabetes,
chronic lung disease, arthritis and cancer.
 The prevalence of obesity in these European countries is
about half that of the U.S.
Thorpe, KE, Howard, DH and Galactionova, K, “Differences in Disease Prevalence as a Source of the U.S. –
European Health Care Spending Gap”, Health Affairs, October 2, 2007
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The U.S. Compared to England
 Poorer health exists at all income levels in the U.S.
compared to England
 “Individuals in the top (half) of the education and income
strata in the U.S. have comparable rates of diabetes and
heart disease as those in the bottom (half) strata of
income and education in England.”
Banks, J, Marmot, M, Oldfiled, Z and Smith, J.P., Disease and Disadvantage in the United States
and in England, Journal of American Medical Association, Vol. 295, No. 17, pp 2037-45, May 3,
2006
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Why Not the Best?
Results from a National Scorecard on U.S. Health
System Performance:
 Income: Low-income and uninsured rates would need to improve by
about 33% to close the gap with higher incomes and the insured
 Ethnicity: It would take a 20% decrease in Hispanic risk rates to
reach benchmark white rates on key indicators
 Race: Overall, it would require a 24+% improvement in African
American mortality, quality, access and efficiency indicators to
approach benchmark white rates
The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from a
National Scorecard on U.S. Health System Performance, The Commonwealth Fund, September 2006
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U.S. Investments in Health
 The U.S. spends more on health care (16% of GDP) than any
other country in the world, but has worse health outcomes on
most measures of health status
 Actuarial studies show that spending on public health
accounts for only 2-3% of national health spending
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Vermont Context
 Population: 623,000
 19 U.S. cities are larger than Vermont
 Ranked 11th for proportion of population insured 1
1 US Census 2005 revised
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Vermont is relatively healthy
 United Health Foundation
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Vermont is 1st in 20071
Ranked 2nd in 2006
In the top 10 states on 14 of the 20 measures
Vermont ranks higher for health determinants than for
health outcomes, indicating that overall healthiness
should remain high over time
• Challenge: ranks 37th in binge drinking
1 United Health Foundation, 2007
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Vermont Challenges
 An “aging state”: the older population is
growing faster than the younger population
• Vermont has approximately 78,000 (12.6%) residents age 65 or
older
• By the year 2030, it is estimated that 25% of Vermont’s
population will be age 65 and older
 Over 65,000 Vermonters are uninsured
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Vermont Challenges
 Growing cost of health care is unsustainable
• Annual expenditures of $3.9 billion
• 16.3% of Vermont’s gross state product
• Vermont’s per capita costs still less than national average, but spending
growth rates have been higher than national average for last 6 years
Health Care Expenditures(2006)
Vermont
Total (billions)
$3.9
Per capita
$6,321
Annual Change (2005-2006)
8.5%
Average Annual Change (2003 -2006) 7.8%
Share of Gross State/Domestic Product 16.3%
U.S.
$2,122.5
$7,092
6.8%
7.0%
16.0%
 An estimated 50% of Vermonters with chronic
conditions account for 70% of health care spending,
but only 55% get the right care at the right time
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Vermont’s Response
 2003 – Governor’s Initiatives for Health Care
• Launch of the Blueprint for Health
• Fit & Healthy Kids
 2006 Legislation
• Health Care Affordability Acts (Acts 190, 191)
 Established Director of Health Care Reform Implementation
 Established the joint legislative Commission on Health Care Reform
 Multi-payer claims data base
 Catamount Health Insurance
• Common Sense Initiatives (Appropriations Bill)
• Safe Staffing and Quality Patient Care (Act 153)
 2007 Legislation
• Corrections and Clarifications to the Health Care Affordability Acts of
2006 (Act 70)
• An Act relating to Ensuring Success in Health Care Reform (Act 71)
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Vermont Goals
 Promote Wellness
 Quality Improvement
 Chronic Care Management
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FOCUS ON CHRONIC CARE
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Most health care is for chronic
conditions
 Care for people with chronic conditions accounts for:
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78% of health care spending
76% of hospital admissions
72% of all physician visits
88% of all prescriptions filled
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Blueprint for Health
 The Blueprint for Health is Vermont’s statutory plan
for better management and prevention of chronic
illness across all payers and health care providers
 Vision:
Vermont will have a standardized
statewide system of care that improves
the lives of individuals with and at risk
for chronic conditions.
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Blueprint for Health
 To achieve this vision, the Blueprint is:
• Statewide system reform based on the Chronic Care
Model
• A public-private collaborative
• Recognizes the central role of the patient, provider
and community
• Designed around “Core System Competencies” rather
than disease programs
• Will eventually provide mandated standards for
chronic care management across all payers and
providers
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Vermont Blueprint Context
 Relatively good distribution of Primary
Care Providers (PCPs) statewide
• 800 PCPs in 300 practices in 13 Hospital Service
Areas
 Three major health plan carriers + Medicaid
+ Medicare
 Most PCPs participate in all plans
 History of working together
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Blueprint Players
 State Government
• Executive and Legislative branches
 Insurers – publicly and privately funded
 University of Vermont College of Medicine
• Area Health Education Centers
• Vermont Child Health Improvement Program
 Local and national QI organizations
• Vermont Program for Quality in Health Care (VPQHC)
• Institute for Healthcare Improvement (IHI)
• Agency for Healthcare Research and Quality (AHRQ)
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Vermont Information Technology Leaders (VITL)
Providers – Hospitals, MD, DO, NP, PA, nursing and office staff
Patients and families
Over 100 volunteers serving on committees and workgroups
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Blueprint Development
2003—Launch of the Blueprint
2004—Planning
Burlington
2006—Statutory Endorsement
St. Johnsbury
Barre
Springfield
Windsor
Bennington
2007— Medical Home Integrated
Pilots in Statute
2005—Initial two pilot Hospital Service
Areas (Diabetes Focus)
2006—Four new Hospital Service Areas
(Diabetes Focus)
Healthier Living Workshops
Community Physical Activity Grants
April 2007
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The Vermont Blueprint for Health
Chronic Condition
Core System
Risk Factors
Competencies
Diabetes
CAD
Depression
Public Policy
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Community
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Self-Management
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Information
Systems
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Health Care
Practice
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Health Systems
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Tobacco
Obesity
Substance
Abuse
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The Vermont Blueprint for Health
Core System
Chronic Condition
Competencies
Public Policy
Community
Self-Management
Information
Systems
Health Care
Practice
Health Systems
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Public Policy
 Has been successfully used to target tobacco
use: clean indoor air legislation, tobacco price
increases, youth prevention, clinical intervention,
state quit-lines
 Time to focus public policy on other risk factors
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Increase Risk of Obesity Related Diseases
with Higher BMI
BMI of 25
or less
BMI between
25 and 30
BMI between
30 and 35
BMI of 35 or
more
Arthritis
1.00
1.56
1.87
2.39
Heart Disease
1.00
1.39
1.86
1.67
Diabetes (Type 2)
1.00
2.42
3.35
6.16
Gallstones
1.00
1.97
3.30
5.48
Hypertension
1.00
1.92
2.82
3.77
Stroke
1.00
1.53
1.59
1.75
Disease
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Public Policy: Obesity
 Vermont Adults:
• 20% obese
• 36% overweight
 Nationally:
• 30% are obese
• 65% of adults are overweight
 The percentage of overweight children has more than
doubled in the past 20 years
• Overweight adolescents have a 70% chance of becoming
overweight or obese adults
 Obesity is linked to a significant increase in chronic
conditions
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Public Policy: Obesity
 According to the USDA, healthier diets could prevent at least
$71 billion per year in medical costs, lost productivity, and lost
lives
 Nutrition Labeling Works
• Studies show U.S. adults report use of nutrition labels on packaged
foods and such labels have a positive influence their food choices
 States that have introduced menu-labeling legislation: AZ, CA,
CT, HI, IL, ME, MA, MI, NJ, NM, NY, PA, TN, VT, WA
Levy AS, Derby BM, 1996 & Burton S, Creyer EH, Kees J, Huggins K, 2006, C Malone and J BlandCampbell, 2006
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Public Policy – Trans Fats
 Trans fat is the most harmful fat (on a gram-for-gram
basis) in the food supply. Trans fat has been causing
about 50,000 fatal heart attacks annually
 States that have introduced trans fat bans: CA, CT, DC,
FL, HI, IL, MD, MA, MI, MS, NH, NJ, NM, RI, SC, TN, VT,
VA
 The Vermont Legislature is currently considering a study
of banning trans fats from foods without labels
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The Vermont Blueprint for Health
Core System
Chronic Condition
Competencies
Public Policy
Community
Self-Management
Information
Systems
Health Care
Practice
Health Systems
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Community
 State and local governments, private developers, and
community groups can promote physical activity by
increasing access to sidewalks, playgrounds, parks, bike
paths, and safe streets and neighborhoods
 Community groups and local governments can work
together to increase capital improvement projects that
promote physical activity
 The Vermont Department of Health administers grants to
communities to promote wellness (CHAMPPS)
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The Vermont Blueprint for Health
Core System
Chronic Condition
Competencies
Public Policy
Community
Self-Management
Information
Systems
Health Care
Practice
Health Systems
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Self Management
 99.8% of the time individuals make their own health care
decisions in the context of their family and community
 Through the Blueprint, Vermont conducts Healthier
Living Workshops
• Workshops are free
• Held at various convenient locations throughout the state
 Over 40 statewide
 500+ enrolled
• Participants show a 60% reduction in doctor and emergency
department visits after one year
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The Vermont Blueprint for Health
Core System
Chronic Condition
Competencies
Public Policy
Community
Self-Management
Information Systems
Health Care
Practice
Health Systems
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Information Systems
 Vermont Information Technology Leaders established in
2005
• Published a Vermont Health Information Technology Plan in July
2007
 Legislature is presently considering adoption
• Legislature is contemplating a funding mechanism that will allow
VITL to provide IT systems to primary care providers for minimal
costs
 Multi-payer Database
 Vermont’s largest hospital is planning an electronic
health records system that will be available to community
physicians and provide a discount for other adopting
hospitals
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The Vermont Blueprint for Health
Core System
Chronic Condition
Competencies
Public Policy
Community
Self-Management
Information
Systems
Health Care Practice
Health Systems
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Health Care Practice:
Working together to improve health
Public health + Health care
Prevention + Treatment
Physician Practices
 Blueprint Provider Workgroups establishing consensus standards
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Diabetes
COPD – chronic obstructive pulmonary disease
CAD – coronary artery disease
CHF – congestive heart failure
hypertension
asthma
 Clinical systems support for primary care practices to help practices
provide the right care to patients at the right time
• Training
• Coaching
• Peer support
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The Vermont Blueprint for Health
Core System
Chronic Condition
Competencies
Public Policy
Community
Self-Management
Information
Systems
Health Care Practice
Health Systems
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Bringing It All Together:
2007 Legislated Blueprint Integrated Pilot
 Implementation of single approach across primary public
and private carriers in 2 Hospital Service Areas during
CY2008 for:
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Medical Home
Care Coordination
Payment Reform
IT
 3 Private Carriers + Medicaid in conceptual agreement:
• Joint Funding of Care Coordination Teams
• Joint development of one methodology for provider metrics and
incentive payments
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Blueprint Integrated Pilot: Summary
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A comprehensive and integrated approach that:
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An information system that:
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Gives patients easily accessible, familiar, and effective healthcare, as
well as integration with public health and prevention programs.
Gives primary care physicians information, tools, resources and a care
team to change the way they deliver care within their practices
Supports providers’ clinical and office workflow to be more efficient,
effective and patient-oriented
Supports information sharing across physicians, Community Care
Teams, pharmacy, and community-based programs (e.g., self-help
programs) to improve patient outcomes
A financial structure that:
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Transitions away from the current complexities towards shared support
for readily available multidisciplinary services and a common simplified
method of reimbursement for providers.
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Regulatory Alignments
with the Blueprint
 State Medicaid Chronic Care Management Program
 State Employee Health Benefit Program
 Must include Chronic Care Management Program aligned with Blueprint
 State-approved Employer-Sponsored Insurance (ESI) Plans for
Premium Assistance
 State will wrap costs for chronic care if not in ESI Plan
 Chronic care services defined by Blueprint Provider Workgroup
 Catamount Health Plans
 Carriers must include Chronic Care Management Program and align with
Blueprint
 Certificate of Need Program
 Health care facility projects subject to CON review must comply with the
goals of the Blueprint
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Coverage Initiatives
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Catamount Health Plan:
• Waiver for cost-sharing for chronic care management if actively
participating in chronic care management program
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Healthy Lifestyles Insurance Discounts
• Permitted deviations from the community rate for healthy
lifestyle choices
• Nongroup (individual) and small group markets
Vermont HealthyLiving (under consideration)
• Two tiered benefit plan - premiums are the same, but benefit
levels differ based on choices
• Can be offered in all markets, including large group
Blueprint compliance in all approved forms (under
consideration)
• Managed care organizations will be evaluated for compliance
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Special Thanks
 Dr. Paul E. Jarris
• Association of State and Territorial Health Officials
 Susan W. Besio, Ph.D.
• Vermont Director of Health Care Reform Implementation,
Vermont Agency of Administration
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