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Creating a High Performing Health System
David Blumenthal, MD, MPPPresident, The Commonwealth Fund
Mark McKenna LectureArizona State University
Tempe, AZApril 23, 2014
2
Agenda
• Challenges
• Next Steps–ACA
• The Good and Bad News
• Update on Health IT
3
COST• $Billions in unnecessary and wasteful spending
•Overuse puts patients at risk, drains resources, and makes healthcare less accessible and less effective
QUALITYDespite rapid advances,
thousands of patients die each year from
medical error
COVERAGE55 million uninsured;
many more underinsured
A BROKEN SYSTEM
430 Percent of Working-Age Adults Uninsured Now or
During the Past Year
Note: Totals may not equal sum of bars because of rounding. Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, and 2012).
Percent of adults ages 19–64
2003 2005 2010 20120
5
10
15
20
25
30
35
17 18 20 19
9 9 8 10
Insured now, time uninsured in past year
Uninsured now
26 28 28 30
5In 2012, Nearly Half of Adults Were Uninsured During
the Year or Were Underinsured
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).
Insured all year, not
underinsured^54%
100 million
184 million adults ages 19–64
Insured all year,
underinsured^16%
30 million
Uninsured during the year*
30%55 million
6Cumulative Increases in Health Insurance Premiums,
Workers’ Contributions to Premiums, Inflation, and Workers’ Earnings, 1999-2013
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130%
50%
100%
150%
200%
250%
57%
119%
182%
56%
117%
196%
14%
34%
50%
11%
29%40%
Health Insurance Premiums
Workers' Contribution to Premiums
Workers' Earnings
Overall Inflation
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).
7
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
8
When it Comes to Health Care, There are Two Americas
Source: D. Blumenthal, Two Americas, (New York: The Commonwealth Fund, August 2013).
9
Overall Health System Performance for Low Income Populations
Source: Commonwealth Fund Scorecard on State Health System Performance for Low-Income Populations, 2013.
10
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000 USSWIZNORNETHGERCANFRASWEAUSUKNZ
80 83 86 89 92 95 98
3689
3
3799
1
3909
0 100
2
4
6
8
10
12
14
16
18
20AUSNORUKSWENZCANSWIZGERFRANETHUS
International Comparison of Spending on Health, 1980–2012
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.
Total expenditures on healthas percent of GDP
$8,745
$3,182
17.6%
8.9%
Average spending on health per capita ($US PPP)
The U.S. sweeps GOLD, SILVER, and BRONZE in international competition
$$$$$$$$$$$$$$$
12
Health Policy at a Fork in the Road
Benefit and Price
Reduction
ORFundamental
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
13
Microsystems
Macrosystems
Health SystemPerformance
Improving Performance
13
14
Microsystems
OR
ICU ED
Admitting dept
MD practice
People, processes and practices that interact directly with patients or
support patient care at the local level (the “sharp end”).
Microsystems
15
Macrosystems
Hospitals
Accreditingorganizations
Govt programs/regulations
Healthplans
Nationalboards
Organizations and environmental forces that support and influence microsystems (the “blunt end”).
Macrosystems
16
Supply Chains: Micro, Macro or Something in Between?
17
Interventions That Work: Microsystem
Microsystems
Primary Care
Reminder
Systems
CDS/CPOE
Care
Coordination
ToyotaProductionSystem
Supply Chain
Management?
18
19
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.
Macrosystems
20
We need to make it easier to do the right thing…
Fundamental Delivery System Reform
21
Microsystems
Macrosystems
Health SystemPerformance
Improving Performance
21
Affordable Care Act
22
Reduced Payments for Avoidable Complications
Medicare Advantage Plan Bonuses
Bundled Payments
Physician Quality Reporting System
Meaningful Use
Value Based Purchasing
AccountableCare Organizations
Hospital Inpatient Quality Reporting
Medical Homes
The Affordable Care Act
23
Surge of Expert Reports
24
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
25
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.
26ACO 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.
27
Delivery System Reform, Further Effects
Reporting on hospital-acquired 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.
28
Healthcare Associated Infections Declining
Central Line-associated Bloodstream Infections
Surgical-site Infections for 10 Common Procedures
0
0.2
0.4
0.6
0.8
1
2008
2012
Standardized Infection Rate [2008 set to 1.0]
Source: “National and State Healthcare Associated Infections: Progress Report,” Centers for Disease Control and Prevention, March 2014.
44% drop
20% drop
29
2007 2008 2009 2010 2011 2012 201317%
18%
19%
20%
Monthly Rate
Trendline
Medicare Hospital Readmissions Declining
Note: Medicare 30-Day, All-Condition Hospital Readmission Rates January 2007 - May 2013Source: CMS.
30
Source: Gallup-Healthways Wellbeing Index.
Rate of Uninsured Falls to Lowest Level of Obama’s Presidency
31
Spending Growth Rate Has Slowed in Recent Years
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.
2005 2006 2007 2008 2009 2010 2011 20120
1
2
3
4
5
6
7
NHE per capita spending growthPercent
32
Is This the Dawn of a New Day?
33
…Costs Began Picking Up at the End of 2013
Source: “Insights from Monthly National Health Expenditures Estimates through February 2014,” Altarum Institute, April 8, 2014.
Year-Over-Year Growth Rates in NHE
34
U.S. Health Spending is Larger Than the GDP of Most Nations
Notes: Data from 2011, adjusted for differences in cost of livingSource: 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).
35
Looking Back: What We Could Have Saved if We Had Matched the Next Highest Country (Switzerland)
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).
Increase spending on public health by 20,000%
36
Update on Health IT
37
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
38
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
39
2006 2007 2008 2009 2010 2011 2012 20130.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
10.5% 11.8%16.9%
21.8%27.9%
33.9%39.6%
48.1%
29.2%34.8%
42.0%48.3% 51.0%
57.0%
71.8%78.4%
EHR Adoption AmongOffice-Based Physician Practices, 2006-13
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.
Any EMR/EHR System
Basic System
40
EHR Adoption AmongHospitals, 2008-12
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.
2008 2009 2010 2011 20120.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
8.8%11.9%
15.1%
26.6%
44.0%
7.2% 9.2%11.5%
18.0%
27.3%
1.5% 2.7% 3.6%
8.7%
16.7%
At Least Basic EHR
Basic EHR
Comprehensive EHR
41
Future Challenges for HIT: Realizing Value
• Usability.
• Interoperability and exchange.
• Analytics.
42
Question and Answer