Transcript Creating a High Performance Health System

Creating a High Performing Health System
David Blumenthal, MD, MPP
President, The Commonwealth Fund
Mark McKenna Lecture
Arizona State University
Tempe, AZ
April 23, 2014
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Agenda
• Challenges
• Next Steps
–ACA
• The Good and Bad News
• Update on Health IT
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COST
•$Billions in unnecessary and wasteful spending
•Overuse puts patients at risk, drains resources, and
makes healthcare less accessible and less effective
A
BROKEN
SYSTEM
QUALITY
Despite rapid
advances,
thousands of patients
die each year from
medical error
COVERAGE
55 million uninsured;
many more underinsured
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30 Percent of Working-Age Adults Uninsured Now or
During the Past Year
Percent of adults ages 19–64
Insured now, time uninsured in past year
Uninsured now
35
30
26
28
9
9
8
10
17
18
20
19
2003
2005
2010
2012
25
20
30
28
15
10
5
0
Note: Totals may not equal sum of bars because of rounding.
Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, and 2012).
In 2012, Nearly Half of Adults Were Uninsured During
the Year or Were Underinsured
Insured all
year, not
underinsured^
54%
100 million
Uninsured during
the year*
30%
55 million
Insured
all year,
underinsured^
16%
30 million
184 million adults ages 19–64
Note: Numbers may not sum to indicated total because of rounding.
* Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^ Underinsured defined as insured all
year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket
expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of
income.
Source: The Commonwealth Fund Biennial Health Insurance Survey (2012).
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Cumulative Increases in Health Insurance Premiums,
Workers’ Contributions to Premiums, Inflation,
and Workers’ Earnings, 1999-2013
250%
Health Insurance Premiums
Workers' Contribution to Premiums
200%
196%
Workers' Earnings
Overall Inflation
182%
150%
117%
119%
100%
56%
57%
50%
50%
34%
40%
14%
29%
11%
0%
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2013. Bureau of Labor Statistics, Consumer Price
Index, U.S. City Average of Annual Inflation (April to April), 1999-2013; Bureau of Labor Statistics, Seasonally Adjusted Data from
the Current Employment Statistics Survey, 1999-2013 (April to April).
2013
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U.S. Health in International Perspective:
Shorter Lives, Poorer Health
• Americans live shorter lives and are
in poorer health at any age
• Poor outcomes cannot be fully
explained by poverty or lack of
insurance
• White, insured, college-educated,
and upper income Americans are in
poorer health than their
counterparts in other countries
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When it Comes to Health Care,
There are Two Americas
Source: D. Blumenthal, Two Americas, (New York: The Commonwealth Fund, August 2013).
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Overall Health System Performance
for Low Income Populations
Source: Commonwealth Fund Scorecard on State Health System Performance for Low-Income Populations, 2013.
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International Comparison of Spending on
Health, 1980–2012
Average spending on health
per capita ($US PPP)
10000
9000
8000
7000
6000
5000
US
SWIZ
NOR
NETH
GER
CAN
FRA
SWE
AUS
UK
NZ
20
$8,745
18
16
14
12
AUS
NOR
UK
SWE
NZ
CAN
SWIZ
GER
FRA
NETH
US
10
17.6%
8.9%
8
4000
3000
Total expenditures on health
as percent of GDP
$3,182
6
2000
4
1000
2
0
0
80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 10 12
80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 10 12
Note: $US PPP = purchasing power parity.
Source: Organization for Economic Cooperation and Development, OECD Health Data, 2013 (Paris: OECD, November 2013). US
data from National Health Expenditure Accounts, adjusted to match OECD definitions.
$$$$$$$$$$$$$$$
The U.S. sweeps GOLD, SILVER, and BRONZE
in international competition
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Health Policy at a Fork in the Road
Benefit and
Price
Reduction
OR
Fundamental
Delivery
System
Reform
Regardless of how you envision the role of
government, health care and the markets in
which it’s purchased need to be improved
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Improving Performance
Microsystems
Health System
Performance
Macrosystems
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Microsystems
ICU
ED
MD practice
Microsystems
OR
Admitting dept
People, processes and practices
that interact directly with patients or
support patient care at the local
level (the “sharp end”).
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Macrosystems
Organizations and environmental
forces that support and influence
microsystems (the “blunt end”).
Govt programs/
regulations
Health
plans
Hospitals
Macrosystems
Accrediting
organizations
National
boards
Supply Chains:
Micro, Macro or Something in Between?
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Interventions That Work: Microsystem
Microsystems
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Macrosystems
We have failed to create macrosystems
that encourage and support use
of these solutions,
thereby changing the behavior
of large numbers of microsystems
and raising the performance
of the health care system as a whole.
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Fundamental Delivery
System Reform
We need to make it easier to do the
right thing…
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Improving Performance
Microsystems
Health System
Performance
Macrosystems
Affordable Care Act
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The Affordable Care Act
Reduced Payments for
Avoidable Complications
Value Based Purchasing
Accountable
Care Organizations
Medicare Advantage
Plan Bonuses
Bundled Payments
Hospital Inpatient
Quality Reporting
Physician Quality
Reporting System
Medical Homes
Meaningful Use
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Surge of Expert Reports
Shared Approaches to Confronting Costs
• Provider payment reform
– Repeal Medicare sustainable growth rate formula
– Move from paying for volume to paying for value
– Enhance support for primary care
• Delivery system reform
– Encourage development and implementation of innovative
delivery models
• Medicare reform
– Improve financial protection for beneficiaries
– Provide positive incentives for choosing high performing
providers
• Consumer/patient engagement
• Enhancing performance of health care markets
– Increase transparency of quality and cost information
– Eliminate administrative inefficiency
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Some Good News:
Medicare accountable care organizations (ACOs)
• Over 360 Medicare ACOs serving
up to 5.3 million people
• Costs for beneficiaries aligned to
“Pioneer ACOs” increased 0.3
percent in 2012 vs. 0.8 percent for
other beneficiaries.
• Over $380 million in savings have
been generated by Medicare ACOs
and Pioneer ACOs.
• 9 out of 23 Pioneer ACOs produced
gross savings of $147 million in
their first year (though 9 ACOs also
dropped out).
Source: Centers for Medicare & Medicaid Services.
ACO Distribution to Date,
by Hospital Referral Region
Total of 601 accountable care entities in the U.S.
• 366 Medicare ACOs
• 235 Non-Medicare ACOs
Note: Data for Medicare ACOs as of January 2014; data for non-Medicare ACOs and in map as of July 2013.
Source: Petersen M, Muhlestein D, Gardner P, “Growth and Dispersion of Accountable Care Organizations: August
2013 Update,” Leavitt Partners; Centers for Medicare and Medicaid Services.
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Delivery System Reform, Further Effects
Reporting on hospitalacquired conditions
• Rates of serious hospital-acquired
conditions (HACs) now available on
Hospital Compare website
Creation of the Center
for Medicare and
Medicaid Innovation
(CMMI)
• More than 50,000 health care providers
involved in CMMI innovation projects
Source: CMS.
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Healthcare Associated Infections Declining
Standardized Infection Rate
[2008 set to 1.0]
1
20% drop
0.8
44% drop
0.6
2008
2012
0.4
0.2
0
Central Line-associated
Bloodstream Infections
Surgical-site Infections for 10
Common Procedures
Source: “National and State Healthcare Associated Infections: Progress Report,” Centers for Disease Control and
Prevention, March 2014.
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Medicare Hospital Readmissions Declining
20%
19%
Monthly Rate
18%
Trendline
17%
2007
2008
2009
2010
2011
Note: Medicare 30-Day, All-Condition Hospital Readmission Rates January 2007 - May 2013
Source: CMS.
2012
2013
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Rate of Uninsured Falls to Lowest Level
of Obama’s Presidency
Source: Gallup-Healthways Wellbeing Index.
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Spending Growth Rate Has Slowed in Recent Years
NHE per capita spending growth
Percent
7
6
5
4
3
2
1
0
2005
2006
2007
2008
2009
2010
2011
2012
Source: Martin AB, Hartman M, Whittle L, Catlin A; National Health Expenditure Accounts Team. National health
spending in 2012: rate of health spending growth remained low for the fourth consecutive year. Health Aff (Millwood).
2014 Jan;33(1):67-77.
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Is This the Dawn of a New Day?
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…Costs Began Picking Up at the End of 2013
Year-Over-Year Growth Rates in NHE
Source: “Insights from Monthly National Health Expenditures Estimates through February 2014,” Altarum Institute,
April 8, 2014.
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U.S. Health Spending is Larger Than the GDP of
Most Nations
Notes: Data from 2011, adjusted for differences in cost of living
Source: D. Blumenthal and R. Osborn, In Pursuit of Better Care at Lower Costs: The Value of Cross-National
Learning, (New York: The Commonwealth Fund Blog, April 2013).
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Looking Back: What We Could Have Saved if We
Had Matched the Next Highest Country (Switzerland)
Increase
spending on
public health
by 20,000%
Note: Per capita spending amounts adjusted for differences in cost of living, total U.S. savings adjusted for inflation.
Source: D. Squires, The Road Not Taken: The Cost of 30 Years of Unsustainable Health Spending Growth in the
United States, (New York: The Commonwealth Fund Blog, March 2013).
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Update on Health IT
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Meaningful Use Framework in HITECH Act
Rewards the effective (meaningful)
use of EHRs certified by the federal
government.
Key provisions
• Clinicians: $44,000 / $63,750
over 5-10 years
• Hospitals: $2 million bonus
plus per DRG payments
• Penalties after 2015
Estimated expenditures:
• $9-27 billion over 10 years
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MU Registration and Attestation
• More than half of all doctors and
other eligible providers have
received Medicare or Medicaid
incentive payments for adopting or
meaningfully using electronic
health records
• 94 percent of hospitals are
enrolled in the program.
• More than $21.6 billion in
payments as of February 2014
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EHR Adoption Among
Office-Based Physician Practices, 2006-13
90.0%
78.4%
80.0%
71.8%
Any
EMR/EHR
System
70.0%
57.0%
60.0%
48.3%
50.0%
20.0%
48.1%
42.0%
40.0%
30.0%
51.0%
Basic
System
39.6%
34.8%
33.9%
29.2%
27.9%
21.8%
16.9%
10.5% 11.8%
10.0%
0.0%
2006
2007
2008
2009
2010
2011
2012
2013
Source: Hsiao C-J, Hing E. “Use and characteristics of electronic health record systems among office-based
physician practices: United States, 2001–2013.” NCHS data brief, no 143. Hyattsville, MD: National Center for Health
Statistics. 2014.
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EHR Adoption Among
Hospitals, 2008-12
50.0%
44.0%
45.0%
At Least Basic
EHR
40.0%
35.0%
30.0%
26.6%
25.0%
Basic
EHR
27.3%
20.0%
15.1%
15.0%
11.9%
10.0% 8.8%
5.0% 7.2%
0.0% 1.5%
9.2%
2008
2.7%
2009
18.0%
11.5%
16.7%
8.7%
3.6%
2010
2011
2012
Source: DesRoches CM, et al. Adoption Of Electronic Health Records Grows Rapidly, But Fewer Than Half Of US
Hospitals Had At Least A Basic System In 2012. Health Affairs, July 2013.
Comprehensive
EHR
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Future Challenges for HIT: Realizing Value
• Usability.
• Interoperability and exchange.
• Analytics.
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Question and Answer