Transcript National Commission for Quality Long Term Care

National Commission for
Quality Long Term Care
Testimony of
George Taler, MD
Director, Long Term Care
Washington Hospital Center
Washington, DC
Past President, American Academy of Home Care
Physicians
Summary
• Primary Care & Geriatric Medicine
• A different approach to the health care
challenges of an aging population
• Restructuring health care delivery and
health care financing
Median Compensation for Selected Medical Specialties
Woo B. N Engl J Med 2006;355:864-866
Bodenheimer T. N Engl J Med 2006;355:861-864
Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates
Bodenheimer T. N Engl J Med 2006;355:861-864
Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists,
Subspecialists, and Hospitalists
Bodenheimer T. N Engl J Med 2006;355:861-864
National Medical Association
Gallup Poll of Membership, 2003
Maryland Academy of Family Physicians
2005 Practice and Income Survey
• 663 Active Members (private practice: 66%)
• Median annual income: $103,400
– 37% no change since 2001
– 41% decrease since 2001
• In response:
– 16% have increased hours or # of patients/wk
– 44% have decreased hours in clinical practice
– 35% plan to retire, relocate or change careers
Geriatricians Have Greatest
Career Satisfaction
Changes in Medicare Payments to
Physicians 1999-2012
Percent
Concentration of Total Annual Medicare
Expenditures Among Beneficiaries, 2001
Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.
High-Cost Medicare Beneficiary Spending
Medicare Spending
Medicare Spending
% of
Total
Mean
% of
Total
Mean
85%
$24,800
Top 5 %
43.1%
$63,030
Second
Quartile
11%
$3,290
Top 6-10 %
18.4%
$26,900
Top 11-25%
23.5%
$11,430
Bottom
Half
4%
$550
Total
100%
$7,310
Top
Quartile
Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.
Note: Spending reported in 2005 dollars
Yes, but…
Just because you have a bad
year, does your bad luck
persist and for how long?
Expenditure History of the Top 25%
of Medicare Beneficiaries, 1997
Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.
Distribution of High-Cost Months, 1997-2001
Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.
Concentration of Total Cumulative Medicare
Expenditures Among Beneficiaries, 1997-2001
Targeting the High-Cost User
• Diagnostic characteristics
• Functional characteristics
• Resource utilization history
Prevalence of Chronic Conditions
Beneficiary Group
(Spending pattern)
All
Low Cost
High Cost
(Non-persistent)
(Persistent)
Coronary Artery Disease
28.2%
19.1%
50.0%
53.7%
COPD
19.6%
13.9%
28.9%
37.5%
Congestive Heart Failure
18.5%
10.1%
33.0%
44.3%
Diabetes
16.7%
12.6%
23.5%
29.5%
Cognitive Impariment
8.8%
5.7%
13.9%
18.7%
Asthma
3.9%
2.9%
4.5%
7.3%
ESRD
2.3%
0.7%
4.2%
7.9%
1.0
0.7
1.6
2.0
Mean number of conditions
Notes: COPD=Chronic Obstructive Pulmonary Disease, ESRD=End Stage Renal Disease. Data from a 5 percent
random sample of fee-for-service (FFS) beneficiaries between 1989 and 1997. Source: CBO preliminary analysis.
Number of Chronic Conditions Predicts
High-Cost Status
Beneficiary Group
(Spending pattern)
Low Cost
High Cost
0 of the 7 conditions
89.5%
4.4%
6.1%
1 condition
71.5%
11.1%
17.3%
2 conditions
53.3%
15.0%
31.7%
3 conditions
34.5%
16.1%
49.4%
4 conditions
20.2%
13.8%
66.0%
5 conditions
10.8%
9.9%
79.3%
6 conditions
5.4%
6.0%
88.7%
7 conditions
0.0%
0.0%
100.0%
(Non-persistent)
(Persistent)
Notes: The 7 conditions considered were: CHF, CAD, COPD, ESRD, Asthma, Diabetes, and Cognitive impairment.
Source: CBO preliminary analysis.
Avg. Annual Health Care Expenses Per
Person
Spending for People with Chronic
Illnesses and Activity Limitations
$14,000
$13,420
No Activity Limitation
$11,890
$12,000
With Activity Limitation
$10,000
$7,800
$8,000
$5,650
$6,000
$4,000
$2,000
$5,650
$4,060
$3,830
$2,890
$7,560
$2,550
$1,500
$680
$0
0
1
2
3
Number of Chronic Conditions
Sources: Partnership For Solutions, “Chronic Conditions: Making the Case for Ongoing Care,” December 2002; MEPS, 1998.
4
5+
Service Organization
Structure & Process Criteria
• Make the HOME the center of health care
delivery and social supports
• Re-establish the Doctor-Patient relationship
• Continuity of care across all settings and
over the natural history of illness
• Coordinate Medical, Social and Housing
services
• Match patient goals and processes of care
Life Care Coordination Fees
• Layered fee for non-covered services
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–
–
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Comprehensive Geriatric Assessment
Team meetings
Care coordination
Enhanced urgent care services
On-call services
Gap-filling fund
• Renewable contingent on performance
– Adherence to evidence-based guideline targets
– Patient and caregiver satisfaction targets
– Reduced costs
“Whose Ox Gets Gored?”
• Sponsoring Hospitals
– Cover “margin” expectations
– Rate incentives for supporting innovation
• SNF/ICF
– Escalated payments for greater complexity
– Decreased payments for custodial care
– Incentives for community-based referrals
The “Ask”: How You Can Help
• Advocacy for a focused, population-based
health care delivery system transformation
• Development of population target criteria
• Development of new financing mechanisms
• Special interdisciplinary training programs
• Development of a public-private partnership
towards common goals and incentives
“You can judge a civilization
by the care it takes of its old
and sick people. I want
America to pass this test well.”
Rep Claude D. Pepper