mainecare redesign task force
DESCRIPTION
MaineCare Redesign Task Force. September, 2012. Elizabeth Mitchell CEO Maine Health Management Coalition. Maine Health Management Coalition www.mhmc.info. Employers. 25 Private Employers 5 Public Purchasers. Providers. 15 Hospitals 15 Physician Groups. Health Plans. 5 Health Plans. - PowerPoint PPT PresentationTRANSCRIPT
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MaineCare Redesign Task Force
September, 2012
Elizabeth MitchellCEO
Maine Health Management Coalition
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Maine Health Management Coalition
www.mhmc.info
The Maine Health Management Coalition Foundation is a public charity whose mission is to bring the purchaser, consumer and provider communities together in a partnership to measure and report to the people of Maine on the value of healthcare services and to educate the public to use information on cost and quality to make informed decisions.
The Maine Health Management Coalition Foundation is a public charity whose mission is to bring the purchaser, consumer and provider communities together in a partnership to measure and report to the people of Maine on the value of healthcare services and to educate the public to use information on cost and quality to make informed decisions.
25 Private Employers5 Public Purchasers
15 Hospitals15 Physician Groups
5 Health Plans
Employers
Health Plans
Providers
Collectively 40% of Comm. Market
The MHMC is a purchaser-led partnership among multiple stakeholders working collaboratively to maximize improvement in the value of healthcare services delivered to MHMC members’ employees and dependents.
The MHMC is a purchaser-led partnership among multiple stakeholders working collaboratively to maximize improvement in the value of healthcare services delivered to MHMC members’ employees and dependents.
MHMC MembersMHMC Members
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quality / outcomes + Value = improved health +
employee satisfactioncost
• Best quality health care• Best outcomes and quality of life• Most satisfaction • For the most affordable cost• For all Maine citizens
MHMC Value Equation
Maine’s Economy Has Moved From Manufacturing to Healthcare
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Maine Jobs in Manufacturing and Health Care, 1990-2010
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Manufacturing
Manufacturing
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Health Care
Maine Has 5th Highest Insurance Premiums in U.S. For Singles
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Average Single Employee Insurance Premiums, 2010Employer Contribution Employee Contribution
Maine
Maine Has 10th Highest Insurance Premiums in U.S. for Families
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Average Family Insurance Premiums, 2010Employer Contribution Employee Contribution
Maine
Premiums ~$650 Above Average:$150-200 Million Excess Costs
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U.S. Avg Single Coverage Premium
Maine Single Coverage Premium
U.S. Avg Family Premium
Maine Family Premium
U.S. Average vs. Maine Insurance Premiums, 2010
Employer Contribution Employee Contribution
$614
$705
More than a Million Preventable Errors & Adverse Events Annually
Medical Error# Errors (2008)
Cost Per Error Total U.S. Cost
Pressure Ulcers 374,964 $10,288 $3,857,629,632
Postoperative Infection 252,695 $14,548 $3,676,000,000
Complications of Implanted Device 60,380 $18,771 $1,133,392,980
Infection Following Injection 8,855 $78,083 $691,424,965
Pneumothorax 25,559 $24,132 $616,789,788
Central Venous Catheter Infection 7,062 $83,365 $588,723,630
Others 773,808 $11,640 $9,007,039,005
TOTAL 1,503,323 $13,019 $19,571,000,000
Source: The Economic Measurement of Medical Errors, Milliman and the Society of Actuaries, 2010
Poor Quality Costs More
On average, the cost of hospital stays for adults who develop health care-associated infections is about $43,000 more expensive2
•Every year 1.7 million people acquire health problems such as bacterial infections and incorrect blood transfusions after arriving at a hospital3—of these, nearly 100,000 die4
•Eighteen types of medical errors account for 2.4 million extra hospital days and $9.3 billion in excess charges each year. 9
2 Agency for Healthcare Research and Quality. Web. 20 Sept. 2011. http://www.ahrq.gov/ news/nn/nn082510.htm.
3 Centers for Disease Control and Prevention. Web. 10 July 2011. http://www.cdc.gov/ncidod/eid/vol7no2/wenzel.htm.
4” United States Department of Health and Human Services. Web. 23 Aug. 2011. http://www.hhs.gov/ash/ohq/.
9"Safe Practices for Better Healthcare". National Quality Forum. Web. 20 Sept. 2011. http:// www.qualityforum.org/News_And_Resources/Press_Kits/Safe_Practices_for_Better_ Healthcare.aspx
Many Procedures Could Be Done for 80-90% Less Than Today
10-Fold Difference
5-Fold Difference
20-25% of Chronic Disease Admits Return Within 30 Days
0% 5% 10% 15% 20% 25% 30%
PARKVIEW ADVENTIST MEDICAL CENTERST MARYS REGIONAL MEDICAL CENTER
HOULTON REGIONAL HOSPITALAROOSTOOK MEDICAL CENTER,THE
ST JOSEPH HOSPITALHENRIETTA D GOODALL HOSPITAL
CENTRAL MAINE MEDICAL CENTEREASTERN MAINE MEDICAL CENTERMILLINOCKET REGIONAL HOSPITAL
PENOBSCOT VALLEY HOSPITALMAINE MEDICAL CENTER
BLUE HILL MEMORIAL HOSPITALSOUTHERN MAINE MEDICAL CENTER
MAYO REGIONAL HOSPITALMERCY HOSPITAL
MID COAST HOSPITALSTEPHENS MEMORIAL HOSPITAL
INLAND HOSPITALNORTHERN MAINE MEDICAL CENTER
FRANKLIN MEMORIAL HOSPITALMAINE GENERAL MEDICAL CENTER
MILES MEMORIAL HOSPITALRUMFORD HOSPITAL
CALAIS REGIONAL HOSPITALYORK HOSPITAL
CARY MEDICAL CENTERST ANDREWS HOSPITAL
DOWN EAST COMMUNITY HOSPITALREDINGTON FAIRVIEW GENERAL HOSPITAL
WALDO COUNTY GENERAL HOSPITALBRIDGTON HOSPITAL
MAINE COAST MEMORIAL HOSPITALSEBASTICOOK VALLEY HOSPITAL
PENOBSCOT BAY MEDICAL CENTERMOUNT DESERT ISLAND HOSPITAL
Hospital 30-Day Readmission Rates from Heart Failure
Maine Has 3rd Highest Rate of Surgeries in U.S.
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Surgeries Per 1,000 Population, 2008
Maine
But Inpatient Utilization Is Low, Meaning Cost/Day is Higher
Source:CommercialCostVariationbyHospitalReferralRegion,MillimanAugust 2010
Portland
Spending on Physicians is Below Average
Source:CommercialCostVariationbyHospitalReferralRegion,MillimanAugust 2010
Portland
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Potentially Avoidable Complications
"Typical" Care
Even With Low Utilization/Costs,Significant Savings Opportunities
40%+ of low cost in
Maine is“Potentially Avoidable”
Source: Health Care Incentives Improvement Institute
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To meaningfully reduce health care costs will require a fundamental restructuring
of the system. The barriers to improvement are significant- lack of
transparency, accountability, and effective incentives to name a few. New
ways of caring for patients, new payment systems and new roles and
responsibilities for all parties are required if we want a different outcome.
Time to stop ‘rearranging deck chairs’
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1) Performance Measurement and Public Reporting
2) Consumer Engagement
3) Value Based Purchasing
4) Reformed Payment/Effective Incentives
4 Steps to Improving Health Care Value
Meaningful system performance measurement and public reporting is necessary for accountability to purchasers, patients and the community.
•Transparency of cost, resource use and appropriateness
•Transparency of utilization rates and patterns
•Transparency of patient outcomes and experience
•Transparency of quality and safety
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PTE SystemsEmployers/Health Plan Sponsors:
•Christine Burke – MEABT
•Joanne Abate – Delhaize America
•Wayne Gregersen – Jackson Lab
•Thomas Hopkins – U Maine System
•Frank Johnson – State Employee Health and Benefits
•Chris McCarthy, Manager – BIW
Consumers:
•David White, MHMC Foundation Board
•SEHC member
Providers:
•Jeff Aalberg, MD – MMC PHO
•Barbara Crowley, MD – MaineGeneral Health
•David Howes, MD – Martins Point Healthcare
•Jim Kane – CWM PHO
•Donald Krause MD – St. Joseph Hospital
•Jim Raczek, MD - EMMC
Health Plans:
•Bob Downs, Vice President - Aetna
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Aims of Value Based Purchasing
• Drive quality and cost transparency
• Motivate performance improvement
• Incent appropriate utilization
• Reward good performance
• Support fully engaged patients acting like consumers and partners
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Employer Use
• State of Maine Tiered Networks– Hospital based on PTE Metrics - 2006
• Added cost of care w/ quality Aug 2011
– PCPs based on PTE Metrics - July 2007
• Other Employers/Plan Sponsors– Jackson Lab and Barber Foods – January 2011– U Maine System – January 2012– MMEHT – January 2012
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Employer Use
• Employer members choose if/how to use performance measures
• Consistency across employers preferred by providers
• Gradual ‘raising of the bar’ on performance
• Transparent, multi-stakeholder process important to employees and providers
• Threshold: Achieving minimum of ‘Good’ in every category (only quality/safety for 5 years)
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Employer Use
• Exceptions made for ACO pilots: ‘Higher value initiatives’– MaineGeneral - PenBay - EMMC
• Drove provider and employer engagement on delivery system and payment reform
• RFP for direct contracts: Jackson Laboratories
• Network Design: MaineSense
Cost Variation
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Publishing Hospital Costs
How purchasers use the data is what matters:
•Without tiering: Low cost hospitals sought higher rates
•With tiering: High cost hospitals renegotiating lower rates to be included in network (4.7%)
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What Role Do Consumers Play?
“There is a growing recognition that our ability to control costs and improve quality will require an effective partnership with informed and engaged consumers.”
-Dr. Judith Hibbard
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•Lack of good information when they need it: price and quality
•Lack of financial stake in selecting wisely or considering alternatives
•Community and System Support: Even if they get to a high quality provider they often do not have proper support for follow through
If food prices had risen at medical inflation rates since the 1930’s
*Source: American Institute for Preventive medicine
2009
1 dozen eggs $85.08
1 pound apples $12.97
1 pound sugar $14.53
1 roll toilet paper $25.67
1 dozen oranges $114.47
1 pound butter $108.29
1 pound bananas $17.02
1 pound bacon $129.94
1 pound beef shoulder $46.22
1 pound coffee $68.08
10 Item Total $622.27
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Adherence to Quality Indicators
10.5%
22.8%
32.7%
40.7%
45.2%
45.4%
48.6%
53.0%
53.5%
53.9%
57.2%
57.7%
63.9%
64.7%
68.0%
68.5%
73.0%
75.7%
0% 20% 40% 60% 80% 100%
Alcohol Dependence
Hip Fracture
Ulcers
Urinary Tract Infection
Headache
Diabetes Mellitus
Hyperlipidemia
Benign Prostatic Hyperplasia
Asthma
Colorectal Cancer
Orthopedic Conditions
Depression
Congestive Heart Failure
Hypertension
Coronary Artery Disease
Low Back Pain
Prenatal Care
Breast Cancer
Percentage of Recommended Care Received
Quality Shortfalls: Getting it Right 50% of the Time
2004: Adults receive about half of
recommended care
54.9% = Overall care 54.9% = Preventive care 53.5% = Acute care56.1% = Chronic care
Not Getting the Right Care at the Right Time
Source: McGlynn EA, et al., “The Quality of Health Care Delivered to Adults in the United States,” New England Journal of Medicine, Vol. 348, No. 26, June 26, 2003, pp. 2635-2645
Employee engagement curriculum to develop optimal incentives and engage patients in their role to improve their health and healthcare:•Module 1: Examining What You Have, Determining What You Want •Module 2: Bright Spotting: Best Practice Locally, Regionally and Nationally•Module 3: Securing High Quality Healthcare Services•Module 4: Preventing Poor Health•Module 5: Monitoring Your Benefits Package to Assure the Best Value for Benefit Dollars
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Benefit Design Changes AreAlso Critical to Success
ProviderPatient
Payment System
Benefit Design
Ability and Incentives to:•Keep patients well•Avoid unneeded services•Deliver services efficiently•Coordinate services with other providers
Ability andIncentives to:•Improve health•Take prescribed medications•Allow a provider to coordinate care•Choose the highest-value providers and services
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Accountable Benefit Design
Option Explanation/Rationale
Incent Selection of PCP provider in ACO
If primary care is to be foundation of ACO, plan must encourage use of selected practices
Incent PCP visits v. ER visits Establish significant differential to obtain care at PCP or network urgent care
Incent compliance with preventive care
100% coverage or preventive services and age-sensitive screenings linked to health credit
Incent participation in practice based care management
Waive all co-pays for participation in practice based care management for members with chronic conditions
‘I am part of labor representing about 360 members. My members can not afford a healthcare plan that does not give them the best possible outcome or quality of care. The classes have taught me the buying power of our group. We should not pay for bad results or poor quality of service. As consumers, we need to be more pro-active in our healthcare.’
- City of Portland Employee
‘Before I learned about the work of the Coalition, I thought the only thing I could do about healthcare was complain.’
- Prof. Arthur Hill, UMaine Employee
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MHMC and the City
National Semi
USMUnumHannaford
City of Portland
University of NE
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Employers Pay For:TestsVisits
ProceduresPrescriptions
Errors & Complications
Employers Want:Informed Employees
Improved Outcomes
Care Coordination
Prevention
Functional Status
Return to Work
You Get What You Pay For
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Current Payment Systems Reward Bad Outcomes, Not
Better Health
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Dr. Steele: The Way YOU Pay is a Major Part of the Problem!
Rests on the head…
of a pin
ERLOSE
??
LOSE
LOSE
LOSE
$$
$$
$$$
• It’s not about “risk” or “incentives,” it’s about giving healthcare providers the ability/flexibility to improve outcomes and reduce costs in a way that is financially feasible
• Desired changes in care should drive payment reforms that support them, not the other way around
• Principal Tools:– Episode-of-Care Payment– Risk-Adjusted Global Payment
Payment Reforms Needed that Support Care Changes
Payers Need to Truly Align to Allow Focus on Better Care
Payer
Provider
Payer Payer
PatientPatientPatient
Better Payment System A
BetterPaymentSystem B
Better PaymentSystem C
Even if every payer’s system is better than it was, if they’re all different, providers will spend too much time
and money on administration rather than care improvement
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Data: The Foundation for Improvement
MHMC Database serving as common database with New data partner (HDMS) to greatly enhance access and utility
Timely Multipayor Claims Data (will expand to include clinical) Central Management and Analytic Support through MHMC Desktop access with role-based authorization Better understand the drivers of variation in quality, utilization,
efficiency and cost Evaluate the profile of your employee population to better target
benefits and wellness programs Benchmarks by region/business types
Many Changes in Care Needed to Achieve Significant Savings
Category of SpendingProjectedSpending
Change in Utilization Savings
Advanced Imaging $971,879 -20% ($194,376)ER Utilization $755,969 -15% ($113,395)ACSC Hospitalizations $2,380,536 -40% ($952,214)Back Surgeries $506,451 -10% ($50,645)CABGs $546,673 -10% ($54,667)Other Hospitalizations & SNF $22,052,815 -3% ($661,584)Other Physician Services $13,320,298 0% $0 Other Outpatient Services $4,527,880 0% $0 Home Health, Hospice, & DME $6,437,500 0% 0
$51,500,000 -3.9% ($2,026,882)
Identifying Opportunities and Strategies for Win-Win Savings
• Questions to Address:– Is this a desirable opportunity to pursue?– Does the opportunity vary among regions or among employers?– What are the barriers and how could they be overcome?– What does each stakeholder need to do differently to support
success?
• Employers/Medicaid• Health Plans• Hospitals• Physicians• Consumers/Patients/Families
– What additional information is needed to develop the business case for a win-win-win approach and implement the changes?
As An Example…Priority 1: Reduce Hospital Admissions for People with Chronic Illnesses
Changes Required:• Providers: Improve care transitions; develop PCMH and CCTs; use data
to analyze admissions• Plans: Change reimbursement to reward primary and community based
care including practice-based care management; enhance Rx coverage for patients with chronic illnesses; reduce cost sharing for preventive care; share data
• Patients: Participate in care management and partner with providers• Purchasers: Benefit incentives for participation in care management;
Education and wellness activities for employees with chronic conditions• Others: Public health initiatives to reduce chronic illness
Implications of Reductions: Fewer hospital admissions will require hospitals to reduce staff/infrastructure with community wide economic impact.
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