healthcare reform, hitech & the view from 2015meaningful use pressure will “snowball”...

Copyright © 2010 Siemens Medical Solutions USA, Inc. All rights reserved.

Healthcare Reform, HITECH & The View from 2015

John Glaser, PhDCEO, Siemens Health ServicesSeptember 1, 2010


Increasing Growth in Healthcare Costs

Chronic Disease Under Control: Managed Care Plan Distribution, 2006

70 73

49

81

88

68

6056

30

0

25

50

75

100

Private Medicare Medicaid

Mean 90th %ile 10th %ile

Note: Diabetes includes ages 18–75; hypertension includes ages 18–85.Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).

Percent of adults with diagnosed diabetes whose HbA1c level <9.0%

Uneven Care Quality

Source: Commonwealth Fund National Scorecard on U.S . Health System Performance, 2008 3

6057

53

68 67 66

4946

39

0

25

50

75

100

Private Medicare Medicaid

Mean 90th %ile 10th %ile

Percent of adults with hypertension whose blood pressure <140/90 mmHg

Diabetes Hypertension


Factors Contributing to Heightened Pressure on Healthcare – Particularly Costs

� Relentless increases in care costs to individuals and purchasers of care

� Cost increases occurring against an adverse economic backdrop� Federal government deficits

� State government revenue shortages� Lingering economic recession for businesses

� Slow job growth, underwater mortgages and evaporated retirement plans for consumers

� Suspicion that cost increases reflect monopolistic behavior rather than the true costs of care

� Lack of comparable increases in care quality and safety � Problematic data on care quality

� Too much care variation

� Data that distinguishes no one

� Overall poor performance on global measures of health


Techniques for Limiting Growth InHealth Spending and Likely Impact

� Very Limited Impact� Encourage Greater Use of

Preventive Services (Short-term)

� • Limited Impact� Provide Better Price and

Quality Information� Require Patients To Pay

More� Restrict Use of Harmful

Care� Reduce Expense and Waste

of Medical Mal-Practice System

� Reduce Administrative Costs of Insurance

� Develop and Use Government Supported “Comparative Effectiveness Studies”

� Greater Impact� Restructure Payment System -- (Bundled

Payment and Value Based Pricing)� Restructure Delivery System (Integrated

Care)� Restrict Use of Marginally Useful Care� Limit Supply of Expensive Services� Incentives to Use Preventive Services

(Long-Term)� Expand and Restructure Primary Care ---

Create Effective “Medical Homes” for Patients

� Create a Governmental “High Cost Reinsurance System” with Effective Disease Management

� Systems for Chronic Conditions� Greatest Potential Impact

� Gov. Regulation of Payments To Providers� Establish Global Budgets

Source: Discussion at The Cash Catalyst Meeting, Stuart H. Altman, 7/15/10


Health IT as a Critical Enabler for Healthcare Transformation

TIMETIME

Transformational Change in Health Care Delivery and Population Health - ACA

Technology Adoption and Use - HITECH

20042004 2012?2012?


Examples of Meaningful Use

Perform at least one test of capacity to provide su ch data

Capability to provide electronic syndromic surveillance data to public health agencies (M)

Summary provided for at least 50% of all transition s of care or referrals

Provide summary of care record for each transition of care or referral (M)

At least 50% of patients who request an electronic copy are provided it within 3 business days

Provide patients with an electronic copy of their health information

Reminders sent to 20% of all patients seen that are over 65 years old

Send reminders to patients per patient preference for preventive/follow-up care (M)

At least 50% of patients seen or admitted have “smoking status” recorded

Record smoking status for patients 13 and older

At least 80% of patients seen or admitted have at l east one entry

Maintain an up-to-date problem list of current and active diagnoses


CMS Estimates of the Number of Providers who will be Meaningful Users in 2011

73%58%43%High

46%35%30%LowHospitals

44%40%36%High

15%13%10%LowEligible Professionals

201320122011Scenario

Baselines considerations (2008):

29% of hospitals have some level of medication CPOE (AHA)

4% of eligible professionals have a full function electronic health record


32 million now covered

Closes Medicare donut hole

32 million now covered

Closes Medicare donut hole

The Healthcare Reform Legislation Focused on Access but has Significant Payment Reform Provision s


$940 billion over ten years


Changing Perspective

SpecialtyHospitals &

Clinics

Provider-centric �� Person-centric

Implications• Data/information/knowledge focus (not function/UI focus) • EHR focus shifts to coordination and collaboration • Open, standards-based data exchange• Move towards person controlled data access

RetailClinics

GeneralHospitals

Employers

NetworksThat Profit

From Health

FacilitatedPatient

Networks

IndependentPhysicians’Practices

AcademicMedicalCenters

Provider

Provider

Provider

Provider

ProviderProvider

Provider

Provider

Provider


Horizon 1 - Exchange

Horizon 2 - Orchestrate

Horizon 3 - Guide

HIT Market Evolution

2009 2013 2015 2017Low

High

Market Evolution

Exchange•Non-disruptive secure sharing of normalized patient data

•Respects privacy boundaries•Directed push dominatesDrivers•MU stages 2, 3•Physician recruitment•Federal/state grants

Orchestrate•Builds on Exchange•Actionable, supports care coordination across settings

•Driven by care guidelines, care-giver arrangements

Drivers•Payment reform, bundled payments

•ACOs, medical homes

Guide•Builds on Orchestrate•Provides care-givers with contextual knowledge at PoC

•Supports translational researchDrivers•Heightened reimbursement pressures

•Comparative effectiveness implementation

Stakeholder Value


Lower Altitude but Still High Altitude Ramifications

� From now on Medicare/Medicaid payments will be mate rially based on effective use of EHRs� Beginning with meaningful use

� And moving to payment reform� Meaningful use pressure will “snowball”

� Payment reform and increased care accountability assume meaningful use� Commercial health plan incentives may be based on an assumption that

meaningful use has been achieved

� Maintenance of certification may have meaningful use requirements� Will licensure and/or accreditation consider meaningful use status?

� Industry EHR development agenda will be increasingl y dominated by certification, interoperability, meaningful use and ACA requirements� The Federal agenda will define the EHR


Lower Altitude but Still High Altitude Ramifications

� The presence of a broadly adopted EHR will cease to be a competitive differentiator. Differentiation could occur in seve ral areas:

� EHR-leveraged care improvement within the organization and with other providers

� Care analyses and secondary use of data

� Superior utilization of clinical decision support

� Engagement of the patient in their care

� The growth of exchange infrastructure will bring in creased interdependence between the information systems age nda of provider and other stakeholder organizations

� A wide variety of new “species” will enter the healt hcare information technology market

� They will focus on secondary use of data and delivering “intelligence” to the care process extending into the EHR


Health Plans (and others) are Making Moves


Near Term Ramifications for Information Technology

� Electronic health record� Core EHR capabilities, e.g., manage a problem list and eprescribing, remain very

relevant

� Other functions increase in importance� Ability to identify and track a patient across multiple organizations

� Clinical decision support to deliver evidence-based guidelines, reminders, order sets and alerts

� Disease registries to provide analyses of care processes and outcomes for a population

� Care documentation

� Some functions are new� Technologies to support care coordination and care team collaboration, e.g., discussion rooms and event

messaging

� Health Information Exchange� Enable tight interoperability with clinical affiliates

� Enable exchange of “directed push” transactions

� Support messaging of patient events, e.g., missed radiology procedure appointment

� Initial HIE efforts will be focused on a well defined set of clinical relationships


Near Term Ramifications for Information Technology

� Data Management

� Business intelligence tools to support

� Assessment of care quality and costs for cohorts of patients (episodes and bundles)

� Analyses of practice variations

� Examination of care delivery alternatives

� Predictive modeling to identify high risk patients

� Personal Health Records

� Provide patients with access to their EHR data

� Support communication with care team

� Enable direct entry of data

� Provide access to health information and self management tools


Impact on Care Documentation

� Because of the change in reimbursement care documen tation will:� Support a more extensive diversity of needs

� Require greater thoroughness

� Be shared by multiple care providers

� Face increased time pressures

� This will require efforts to:� “Compile” necessary data from multiple sources; claims, processing of text,

other providers and patients

� Enable the provider to focus on context-specific data

� Develop means to ease the documentation challenges of time and thoroughness


Identifying a CMP Patient


Email and Page Alerts –Admissions and Discharges

From: Care Management Program Admit Notification [mailto:[email protected]] Sent: Thu 01/01/2008 12:00 PM To: Neagle, Mary Subject: ABC Patient MRN 123456 Has Been Admitted to the ED at approx 17:26 on 07/10/2008 (AMN)

Neagle, Mary, your patient ABC Patient MRN: 123456 Has Been Admitted to the ED at approx 12:00 on 01/01/2008 (AMN) With a Chief Complaint of: CP/ SOB

*** This alert is generated when a patient is REGISTERED in the ED *** *** Clinical information may not be immediately available ***


Inpatient Census – Real Time


Blurring of Information Technology Boundaries

� There has been a progressive erosion in the boundaries between the organization’s IT infrastructure, staff and applications and the rest of the world� Minicomputers� Personal computers� Remote computing services� Outsourcing

� This erosion is accelerating� Mobile devices� Cloud computing� Web 2.0 collaboration tools

� The mature form of this erosion is unclear. It is clear that the provider IT response will involve a collection of “owned” and “sourced” infrastructure, staff and applications

Consider…� 71% of doctors consider a smart phone

essential to their practice

� More than 500,000 Wi-Fi networks will be implemented in the US healthcare market in 2010, a 50% increase from 2009. Expected to double the 2010 figure to more than 1 million by 2015

� 73% of Siemens software sold this year is hosted or “in the cloud” – up significantly over prior years

� Siemens has nearly 900 customers with over half a million healthcare professionals using its hosted systems on any given day

Source: Manhattan Research, 3/2010, ABI Research, 7/2010 & Siemens Healthcare 8/2010


We are in for a Tumultuous but Exciting Period of Time

� Payment change is THE “disruptive innovation” in care delivery

� The Federal agenda “defines” several aspects of the healthcare information technology industry:

� Conceptual models of healthcare information technology

� Definition of the electronic health record

� Interoperability and exchanges

� Standards

� Adoption and implementation support (RECs)

� A wide range of new entrants with innovative ideas and diverse interests will enter the market

� Along the way we will see major advances in the technology and its delivery

� Cloud computing

� Mobile devices

� Web 2.0 collaboration tools


Early ACO Results

� Community Care of North Carolina

� Formed in 1998; enhanced medical home supported by the state’s Medicaid program

� Results: Saved roughly $3.3 million in the treatment of asthma patients and $2.1 million in the treatment of diabetes patients between 2000 and 2002, while reducing hospitalizations for both patient groups.

� In 2006, the program saved the state roughly $150 to $170 million

� Physician Group Practice (PGP) Demonstration

� Formed in 2005 and developed by Medicare; group of 10 provider organizations and physician networks to test shared savings.

� Performance payments are designed to reward both cost efficiency and performance on 32 quality measures

� Results: Through year three of the program, all ten participating sites achieved success on most quality measures, and five collectively received over $25 million in bonuses as a share of $32 million in Medicare cost reductions

� Pathways to Health, Battle Creek, Michigan

� Formed in 2006, Integrated Health Partners participated in a chronic disease initiative with Blue Cross Blue Shield of Michigan (BCBSM).

� Later restructured into Pathways to Health

� Results: BCBSM reports that hospitalizations for conditions that can be prevented via better ambulatory care have dropped 40 percent over the three-year life of the program

Source: AHA, 6/2010


There are two ways this could go…


Or…


We’re Facing a Serious Horror Show


Comparing US Utilization to Other Countries

10.4%1.23514.12456.1UK

15.2%0.977N/A2018.6Germany

12.4%1.261230.988N/ACanada

13.3%0.842302.61585.7Australia

12.4%1.8114424.81215.6US

% of Total HC Spend on Pharma.

Liver Transplant*

(2002)

Renal Dialysis*

(2005)

Cardiac Catherization*

(2003)

Dis-charge Rate*

(2005)

Avg.

LOS (2005)

* Per 100,000 pop.

Source: OBCD Health Data


A Comparative Look at Costs

$22,092N/A$2,200$300$72USA -

Medicare

$56,472-$116,798

$125-$334$3,181-$12,708

$950-$1,800$59-$151USA

$12,868$40N/A$179N/AUK

$15,761$32$579$161$15Spain

N/A$63$502$258$32Netherlands

N/A$48$550$319$22Germany

$11,916$53$1050$212$31France

$14,111$33$837$41-$530$30Canada

Bypass Surgery

Lipitor (Rx)

Avg. Cost Per Hosp.

Day

Head CT Scan

Phys. Fees Office Visit


Techniques for Limiting Growth InHealth Spending and Likely Impact

� Very Limited Impact� Encourage Greater Use of

Preventive Services (Short-term)

� • Limited Impact� Provide Better Price and

Quality Information� Require Patients To Pay

More� Restrict Use of Harmful

Care� Reduce Expense and Waste

of Medical Mal-Practice System

� Reduce Administrative Costs of Insurance

� Develop and Use Government Supported “Comparative Effectiveness Studies”

� Greater Impact� Restructure Payment System -- (Bundled

Payment and Value Based Pricing)� Restructure Delivery System (Integrated

Care)� Restrict Use of Marginally Useful Care� Limit Supply of Expensive Services� Incentives to Use Preventive Services

(Long-Term)� Expand and Restructure Primary Care ---

Create Effective “Medical Homes” for Patients

� Create a Governmental “High Cost Reinsurance System” with Effective Disease Management

� Systems for Chronic Conditions� Greatest Potential Impact

� Gov. Regulation of Payments To Providers� Establish Global Budgets

Source: Discussion at The Cash Catalyst Meeting, Stuart H. Altman, 7/15/10


The Cost of Healthcare Reform Failure

� The number of uninsured Americans would increase from 49.4 million in 2010 to 59.7 million in 2015 and 67.6 million in 2020.

� A larger share of the uninsured would come from middle- and higher-income families.

� Premiums would become increasingly expensive for employers and their workers.

� Offers of coverage would fall significantly for workers in small and medium firms. Even in the best case, the rate of employer sponsored insurance coverage would fall to 53 percent in 2020.

� Medicaid and Children's Health Insurance Program (CHIP) enrollment and costs would increase substantially.

� Employers would see large increases in premium costs.

� Uncompensated care costs would more than double.

� Health care costs paid directly by families would increase significantly.

Source: Robert Wood Johnson Foundation, 3/2010


Questions

healthcare reform, hitech & the view from 2015meaningful use pressure will “snowball”...

Documents