healthcare reform beacon-may 2013
TRANSCRIPT
HEALTHCARE REFORM 2.0
WHAT IT MEANS FOR CME AND MEDICAL COMMUNICATION PROFESSIONALS
Debra Gordon, MSPresident, GordonSquared, [email protected]
ABOUT ME
• 20+ years writing about medicine and health care
• 8 years as a newspaper reporter
• 13 years as independent medical writer
• Managed care experience (provider relations manager for mid-sized HMO)
• Kaiser Family Foundation media fellowship
• ~50% of business now related in some way to healthcare system/policy
• Certified health policy wonk
QUESTION 1
LEARNING OBJECTIVES
• Describe key components of the Affordable Care Act and other healthcare reform initiatives
• Discuss the potential impact of the ACA and healthcare reform on CME and other medical communication businesses
• Identify potential new clients/funding for CME and medical professionals
HEALTHCARE REFORM 2.0. . . HERE WE GO AGAIN
WHY DO WE NEED HEALTHCARE REFORM?
COST
Kaiser Family Foundation. April 2011. Available at: http://www.kff.org/insurance/snapshot/OECD042111.cfm
Growth in Total Health Expenditure Per Capita, US, and Selected Countries, 1970-2008
OECD=composite of 34 industrialized countries
QUESTION 2
ANSWER
The greatest contributors for the rise in health care spending in the past 20 years:
• The rising prevalence of treated disease accounted for 50.8 percent of growth in overall spending among adults and 77 percent in the case of Medicare spending. Higher spending per treated case accounted for a 39 percent increase and joint effects of the two accounted for the remaining 10.2 percent.
• The doubling of obesity since 1987 contributed to 10.4 percent of the overall rise in spending.
• Increasing treatment intensity accounted for 11.9 percent of the growth spending between 1987-2009.
“Understanding the relative contribution of changes in treatment guidelines, obesity, rates of screening, and disease detection would provide critical information on where best to invest in slowing the rise in treated prevalence.”
Thorpe KE. Health Affairs. 2013;32:851-858.
LACK OF ACCESS
US Census
US Uninsured: 1987 - 2011
LACK OF ACCESS
• Regardless of demographic characteristics, health insurance coverage affects medical service utilization and cost.1
• Uninsured people more often forgo or delay medical services compared with people who have health insurance coverage.1
• Uninsured people cost the health care system more than insured the insured.1
High numbers of uninsured = uncompensated care = higher costs for the insured
This “hidden health tax” costs US families and their employers paid an extra $1,017 in health care premiums in 2008-92
1. US Census. Health Status, Health Insurance, andMedical Services Utilization: 2010. 2. Families USA. Hidden Health Tax: Americans Pay a Premium. May 2009
LACK OF COORDINATION, WASTE
If banking were like health care, transactions would take not seconds but days or longer as a result of unavailable or misplaced records.
If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination.
--- National Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. 2012.
LACK OF COORDINATION
"Nobody is responsible for coordinating care. That’s the dirty little secret about health care." --- Lucian Leape, MD, Harvard health policy analyst and a nationally recognized patient safety leader.
• Confusion about who is managing a patient's care -- and lack of coordination among those caregivers – contributes to the estimated 44,000 to 98,000 deaths from medical errors each year.
• 15,000 Medicare patients every month suffered such serious harm in the hospital that it contributed to their deaths.
• “For families, the sense that no one is on top of their loved one's care can be one of the most harrowing experiences related to a hospital admission.”
Source: Rabin RC. Available at: http://www.kaiserhealthnews.org/Stories/2013/April/30/Coordination-of-care.aspx.
WASTE
More than 130 unnecessary tests and procedures
~20% of medications prescribed to elderly are inappropriate
Test Recommended?
Pelvic exam/Pap OK
Mammogram/Ultrasound OK
Pelvic ultrasound OK
Baseline EKG Nope
LDL-particle Nope
Carotid artery ultrasound Nope
Abdominal ultrasound Nope
Bone density scan Nope
Case Study: 57 yo woman in good health
• Borderline high LDL cholesterol• Not sure if she’s in menopause• Mother died of breast cancer before age
65• Exercises 4-5 times a week• Healthy weight
• Doesn’t smoke• Healthy diet• No family history of osteoporosis or heart
disease• Normal blood pressure• Normal blood sugar• Some carpal tunnel in wrist
Total cost: $2200
WASTE
WASTE
• Current waste [in the healthcare system] diverts resources from productive use, resulting in an estimated $750 billion loss in 2009.1
• 30 percent of all Medicare clinical care spending could be avoided without worsening health outcomes. Extrapolated to total US healthcare spending this equals about $700 billion in savings.1
Total Medicare expenditures in 2011 were $549.1 billion.2
1. Reducing Waste in Health Care. Health Affairs Policy Brief. 2012. 2. 2012 Annual Report Of The Boards Of Trustees Of The Federal Hospital Insurance And Federal Supplementary Medical Insurance Trust Funds
FFS VS MANAGED CARE
LACK OF TRANSPARENCY
If shopping were like health care, product prices would not be posted, and the price charged would vary widely within the same store, depending on the source of payment.
------ National Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. 2012.
LACK OF TRANSPARENCY
New York Times
TRANSPARENCY
“Consumers who received strong and clear information on quality alongside cost data were more likely to choose high-value
providers that offer high-quality care at lower costs.”
--- Hibbard J, et al. An experiment shows that a well-designed report on costs and quality can help consumers choose high-value health care. Health Affairs. 2012;31(3): 560-568.
Hibbard J, et al. Health Affairs. 2012;31(3): 560-568.
QUALITY
If . . .
• Automobile manufacturing were like health care, warranties for cars that require manufacturers to pay for defects would not exist so few factories would monitor and improve production line performance and product quality.
• Airline travel were like health care, each pilot would be free to design his or he own preflight safety check, or not to perform one at all.
--- National Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. 2012.
QUALITY
Compared to Australia, Canada, Germany, Netherlands
Indicator AUS CAN GER NETH NZ UK US
Overall 3 6 4 1 5 2 7
Quality of care 4 7 5 2 1 3 6
Effective careSafe careCoordinated care Patient-centered
2642
7555
6373
3126
5411
1237
4764
Access 6.5 5 3 1 4 2 6.5
Cost-related access problemsTimeliness of care
66
3.57
3.52
21
53
14
75
Efficiency of care 2 6 5 3 4 1 7
Equity of care 4 5 3 1 6 2 7
Long, healthy, productive lives 1 2 3 4 5 6 7
Davis K, et al. Mirror, Mirror on the Wall. 2010 Update. The Commonwealth Fund
2,000 DEATHS A WEEK FROM MEDICAL MISTAKES
Makary M. How to Stop Hospitals From Killing Us. WSJ. September 12, 2012
QUALITY
If the care in every state were of the quality delivered by the highest-performing state, an estimated 75,000 fewer deaths would have occurred across the country in 2005.
--- Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. The Institute of Medicine. 2012
PROVIDER-CENTERED, NOT PATIENT CENTERED
“You’re worried…you’re going to piss the doctor off, …[that] it’s going to change the relationship. …I don’t want to rock the boat.”--- 49-year-old man
Frosch DL, et al. Health Affairs. 2012;31(5):1030-1038
THE PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA) AND HEALTHCARE REFORM
QUESTION 3
MAJOR GOALS OF HEALTHCARE REFORM/ACA
Increase accessImprove quality and
outcomesContain spending
• Increase Medicaid eligibility
• Health insurance exchanges
• No preexisting conditions
• Children up to age 26 covered on parent policy
• Accountable care organizations
• Value-based purchasing
• Health information technology
• Patient-centered/empower patients
• “Free” preventive care
• New reimbursement models (bundling, capitation, shared risk)
• Reduce errors/waste/fraud
• Insurance stop/loss
INCREASE ACCESS
INCREASE ACCESS: INDIVIDUAL MANDATE
Household income >133% of federal poverty level (FPL) must enroll in plan with “minimum essential coverage” or pay penalty
• 2014: 1% of household income over threshold or $95, whichever is greater
• 2015: 2% of household income over threshold or $325, whichever is greater
• 2016 and beyond: 2.5% of household income over threshold or $695, whichever is greater
• Total household penalty cannot exceed 3 times the individual penalty
HEALTH INSURANCE EXCHANGES
EXCHANGES: CLIFF NOTES VERSION
• Individual to each state
• Launch Jan 1, 2014
• Online marketplaces
• By mid 2012, federal government had spent more than $1B in grants to states to establish exchanges
• States fund operations after 2014
• Open to small business employees (for firms with fewer than 50 employees) and individuals
• As many as 80% of those enrolling as individuals could have subsidies
• Up to 400% of federal poverty level ($94,200 for family of four)
33
Sources: HHS, Commonwealth Fund
Kaiser Family Foundation
STATE EXCHANGES: MAY 2013
PICK YOUR PLAN
Bronze: covers 60% of costs
Silver: covers 70% of costs
Gold: covers 80% of costs
Platinum: covers 90% of costs
INCREASE ACCESS: MEDICAID
• Expand Medicaid to all, including childless adults, at 133% or less of federal poverty level
• State-by-state decision
• 100% funding by feds through 2016; then 90%
INCREASE ACCESS: EMPLOYERS
• If you do not offer health insurance to 95% of full-time employees and their children and. . .• Have at least one full-time employee who receives a tax credit or subsidy
on the ExchangeThen you. . . • Face penalties of up to $2,000 per year per full-time employee, minus the
first 30 full-time employees.• If you offer health insurance.
• The coverage must have a minimum value and be “affordable” based on a percentage of the employee’s salary
• If employee still chooses to purchase insurance on the Exchange, the employee generally will not be eligible for any tax credit or subsidy
• If the plan does not meet the definition of “minimum value” or “affordable,” and an employee seeks coverage on the Exchange and is eligible for a tax credit or subsidy, then employer faces a $3,000 annual penalty for each such employee.
ESSENTIAL BENEFITS FOR COMMERCIAL HEALTH INSURANCE
• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care
38Source: HHS
INCREASE ACCESS
• No more pre-existing condition denials/ratings
• No more annual/lifetime caps
• No out-of-pocket cost for preventive services/screenings
• Coverage of children up to age 26
• “Free” preventive care
IMPROVE QUALITY: NATIONAL STRATEGY FOR QUALITY IMPROVEMENT IN HEALTH CARE
Three Aims
1. Better Care: Improve the overall quality of care, by making health care more patient-centered, reliable, accessible, and safe.
2. Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.
3. Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.
Six Priorities
1. Deliver safer care
2. Engage patients and family as partners in their care
3. Promote effective communication and coordination of care.
4. Promote the most effective prevention and treatment practices for the leading causes of mortality
5. Promote wide use of best practices to enable healthy living.
6. Make quality care more affordable for through new health care delivery models.
IMPROVE QUALITY
• Hospital Readmissions Reduction Program
• Readmissions dropped from ~19% in 2011 to 17.8% (70,000 fewer preventable readmissions)
• Accountable care organizations
• Medicare Stars
• New reimbursement models
• Center for Medicare & Medicaid Innovation to test to delivery models
• National strategy for quality improvement
IMPROVE QUALITY: MEDICARE STARS
• Covers all Medicare Advantage (MA) plans, point-of-service plans, local preferred provider organizations (PPOs), regional PPOs, and private fee-for-service plans
• Designed to link the beneficiary experience and quality of care to payments
• Provides bonuses based on performance• First bonuses distributed in 2012 to plans with ≥4 stars• Bonuses will offset payment reductions to MA plans mandated by the
Affordable Care Act (ACA)• Payments expected to be reduced by 12% by 2017
DIABETES QUALITY INDICATORS
Outpatient
• A1c control
• LDL control, including statin adherence
• Blood pressure control, including prescription for and adherence to ACEIs/ARBs
• Dilated eye exam
• Urine screening for microalbumin or medical attention for nephropathy
• Foot exam
Inpatient
• Glycemic control: diabetic ketoacidosis, nonketotic hyperosmolar coma, hypoglycemic coma
• Inpatient diabetes care measures: associated infection-surgical site; health care-related infections
• Blood pressure and LDL control
Meeting initiatives = increased reimbursement
2013 Physician Quality Reporting System (Physician Quality Reporting)); Measures Groups Specifications; CMS. Roadmap for Quality; Centers for Medicare and Medicaid Services. 2012 Measure Data: Medicare Part D Report Card Master Table 2012.
CONTAIN SPENDING/IMPROVE QUALITY
• Health insurance stop/loss ratio
• Require insurance companies to justify premium increases
• Independent Payment Advisory Board: focus on targeting waste, reducing costs, improving outcomes, expanding access.
• Reduce payments to Medicare Advantage plans
• Bundling services
• Shared savings
• Pay-for-performance
• Pay-for-reporting
• Pay-for-use (EMR)
• Prospective payment
• Risk sharing
• Value-based purchasing program in FFS Medicare—financial incentives to hospitals
• Accountable Care Organizations (ACOs)
• Patient-Centered Medical Homes (PCMH)
CONTAIN SPENDING
“Employers are no longer willing to pay whatever premium a health plan charges. Instead, they are questioning whether their employees covered by the plan are healthier and more productive and use less sick time. They are asking providers to prove that their care is making a difference in patients’ lives. In other words, they are demanding value for their healthcare dollars.”
--- O’Malley C. Quality Measurement for Health Systems: Accreditation and Report Cards. Am J Health-Syst Pharm. 1997;54:1528-1535
NEW DELIVERY MODELS = NEW INCENTIVES=IMPROVED QUALITY?
Patient-Centered Care
QUESTION 4
PATIENT-CENTERED CARE
“…providing care that is respectful of and responsive
to individual patient preferences, needs, and values
and ensuring that patient values guide all clinical
decisions…”
“ „Patient-centeredness‟ is a dimension of health care quality in its own
right…its proper incorporation into new health care designs will involve some
radical, unfamiliar, and disruptive shifts in control and power, out of the hands
of those who give care and into the hands of those who receive it.” – Donald
Berwick
“Providers partner with patients to anticipate and satisfy the full
range of patient needs and preferences. Providers support staff in
achieving their professional aspirations and personal goals.”
DEFINING PATIENT-CENTERED CARE
BENEFITS OF EMPOWERED PATIENTS
• Improves quality of delivered health care and reduces costs1
• Creates more motivated patients who:2,3
• Make better day-to-day health decisions
• Are more likely to keep appointments
• Tend to be more satisfied with their care
• Tend to experience fewer complications
• Are more adherent
• Have an improved quality of life
Empowered patients = improved quality
501. Bodenheimer T, et al. JAMA. 2002; 288(19):2469-2475; 2. Lorig K, et al. Diabetes Care. 2010;33:1275–1281; 3. Lorig K, Alvarez S. Diabetes Educator. 2011;37:128.
PATIENT-CENTERED MEDICAL HOME (PCMH) PRINCIPLES
• Personal physician for each patient trained to provide first contact, continuous and comprehensive care
• Physician-directed medical practice headed by personal physician who leads team of individuals that provides ongoing care for patient
• Whole-person orientation. Physician provides care for all stages of life, including acute and chronic care
• Coordinated/integrated care across all elements of the health care system
• Quality and safety
• Enhanced access to care through open scheduling, expanded hours, email, etc.
• Payment that recognizes the added value of a PCMH
Patient-Centered Primary Care Collaborative. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed March 9, 2012.
ACCOUNTABLE CARE ORGANIZATIONS (ACOS)
• Include hospitals, physicians, and other providers that manage care across the entire spectrum of care
• Can be a real (incorporated) or virtual (contractually networked) organization
• Create incentives for providers to work together to treat patients across settings
• Improve care coordination to reduce fragmented care, control costs, and improve outcomes
Key Point: Put patients first
CMS. Improving Quality of Care for Medicare Patients. http://www.cms.gov/sharedsavingsprogram; Longworth DL. Clev Clinic J Med. 2011;78(9):571- 582.
CURRENT MODEL VS ACO MODEL
Current Model ACO ModelSiloed/fragmented care Teamwork, including administrative
staff
Primary care physician = gatekeeper Coordinated care across organizations; primary care physician as “advocate” or “coach”
Paternalistic care Patient-centered care
Little focus on data Information technology critical
Acute-care focused Preventive and chronic-care focused
Little attention to cost Protocols to streamline care, improve quality, reduce redundancies in order to reduce costs
ACO = accountable care organization.
AHRQ. The Roles of Patient-Centered Medical Homes And Accountable Care Organizations in Coordinating Patient Care. 2010; Shortell SM et al. Health Affairs. 2010;29(7):1293-98; Health Affairs. Health Policy Brief. 2010; http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=23
CCM requires integrated systems of care, informed, empowered patient
ACOs provide financial models for PCMH and integrated care for PCMH patients
Chronic Care
Model(CCM)
Accountable Care
Organization
Patient-Centered Medical Home(CMH)
CHRONIC CARE MODEL + ACCOUNTABLE CARE ORGANIZATION = PCMH
“The patient-centered medical home is the foundation for everything that calls itself an ACO.”-- Karen Davis, PhD. President. The Commonwealth Fund
The Commonwealth Fund. Better to Best. March 2011. http://www.pcpcc.net/files/better_best_guide_full_2011.pdf
Chronic conditions requi
re
Patient engagement
PCMH/ACO Quality initiativesImproved
quality/reduced costs
Healthcare systems need to engage patients and provide patient-centered care. Without it, they will not meet
chronic care quality initiatives
PUTTING IT ALL TOGETHER
WHAT IT MEANS FOR YOU
“. . . scholars and policy makers see a role for CME in improving health care outcomes, specifically physician performance and patient health status.”
--- Moore DE, et al. J Cont Educ Health Prof. 2009; 29(1):1–15.
WHERE DOES CME COME IN?
KEY ADULT LEARNING PRINCIPLE
“Adults learn best when convinced of the need for knowing the information”
Implication for CME: The changing healthcare system requires that healthcare providers learn new ways to deliver care, interact with patients, and improve quality and outcomes
• Greater emphasis on evidence-based medicine• Greater emphasis on comparative effectiveness• Greater emphasis on performance improvement/Six Sigma• Greater emphasis on care coordination across settings• Need to empower patients to take a more active role in their
health• Need to integrate technology into medical practice to improve
outcomes (electronic health records, mobile health)
IMPLICATIONS OF QUALITY EMPHASIS FOR CME
• Greater incentives for clinicians to partake of CME
• New options for marketing CME
• New funders:
• Healthcare systems, whose reimbursement is based on quality outcomes
• Payers, who are under pressure to control costs given medical/loss ratios. competitiveness of health exchange products, and mandated (unfunded) benefits
• Large, self-funded employers who are also trying to reign in costs
• Federal government which promised to provide affordable health care for all
FOR HEALTHCARE COMMUNICATORS
1. Transparency around quality will put intense pressure on providers to improve quality in order to retain patients.
Opportunity: What services can you provide to help your clients (or their clients) improve quality and communicate outcomes to consumers?
2. Patient empowerment/patient-centered care is at the heart of successful healthcare reform, meeting quality indicators, and increasing reimbursement.
Opportunity: How can you help your clients (and their clients) empower patients and provide patient-centered care? Think training and education, direct marketing, social media.
3. The shift from fee-based to value-based purchasing means a shift in the way care is delivered and assessed.
Opportunity: How does this shift affect your clients’ business and their clients’ business? How can you help them maximize revenues/reimbursement/sales in the new world?
4. Millions of uninsured and thousands of small businesses will be shopping for insurance on the state health insurance exchanges.
Opportunities: Member education/coaching, website management/design, marketing for insurance companies
5. 220.5 million insured Americans just got access to free preventive care services; 30 million previously uninsured Americans will have access in 2014. This will result in a significant uptick in chronic and acute disease diagnosis and treatments.
Opportunity: Patient education, provider education, companies that sell drugs/products to manage/treat these conditions, health education/prevention/promotion for large employers
LEARNING OBJECTIVES
• Describe key components of the Affordable Care Act and other healthcare reform initiatives
• Discuss the potential impact of the ACA and healthcare reform on CME and other medical communication businesses
• Identify potential new clients/funding for CME and medical professionals
RESOURCES
• Kaiser Family Foundation: www.kff.org
• The Commonwealth Fund: www.commonwealthfund.org
• US government: www.healthcare.gov
• The Robert Wood Johnson Foundation: www.rwjf.org
• The Center for Studying Health System Change: www. hschange.com
• Health Affairs: www.healthaffairs.org
• Office US government site: www.healthreform.gov
