Date post: | 28-Mar-2015 |
Category: |
Documents |
Upload: | lilliana-pinion |
View: | 215 times |
Download: | 1 times |
Transforming HealthcareCollaboration among Payors, Providers and Community LeadersVinod K. Sahney, PhDSenior Vice President and Chief Strategy OfficerPresented at Purdue UniversityNovember 29, 2006
3Blue Cross Blue Shield of Massachusetts
Outline
• Introduction• Performance of U.S. Healthcare System• Collaboration to Improve Access to Healthcare• Collaboration to Improve Healthcare Delivery System• Collaboration to Improve Quality of Care in Massachusetts• Growing Conflicts• Conclusions
4Blue Cross Blue Shield of Massachusetts
Introduction: Key Messages
Healthcare Delivery – Non System Lack of Aims for Improvement System Performance Compares Poorly to Developed Nations Focus on Medical Technology Gives False Sense of Quality Enough Money in System to Cover All Collaboration Initiatives – Improve Care and Health Status Leadership by Community Organizations Needed
5Blue Cross Blue Shield of Massachusetts
y = 1025.3e0.0449x
R2 = 0.9936
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
1965 70 75 80 85 90 95 2000
Per-Capita Health Spending in the United States in Constant 2000 Dollars
MANAGED CARE
6Blue Cross Blue Shield of Massachusetts
Health Insurance Premiums Compared to Other Indicators
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
20.0
1988 1989 1990 1993 1996 1999 2000 2001 2002 2003 2004
Inflation Workers' Earnings HC Premiums
Pe
rce
nt
Incr
ea
se
Source: Employer Health Benefits Survey, KFF, 2004
Premium costs have risen five times faster than inflation and four times faster than wages
7Blue Cross Blue Shield of Massachusetts
International Healthcare Trends
International Health Spending per Capita 2002
Note: Because these data are based on Purchasing-Power Parity values, they will differ slightly from earlier values cited herein.Source: Adapted from Anderson, GF et al. (2005) Health Affairs
In fact, the U.S. spends much more per person on healthcare than other countries, as well as a larger percent of Gross Domestic Product.
0%
3%
6%
9%
12%
15%
$0 $1,000 $2,000 $3,000 $4,000 $5,000
Spending Per Capita
Pe
rce
nt
of
GD
P
Turkey($446, 6.6%)
Mexico($553, 6.1%)
Poland($654, 6.1%)
Japan($2,077, 7.8%)
U.K.($2,160, 7.7%)
Canada($2,931, 9.6%)
U.S.($5,267, 14.6%)
Switzerland($3,446, 11.2%)
8Blue Cross Blue Shield of Massachusetts
Healthcare expenditures are projected to more than double between 2000 and 2010, and healthcare is expected to account for 17% of the Gross Domestic Product by 2010.
*Projected by Centers for Medicare and Medicaid Services.Source: Adapted from Centers for Medicare and Medicaid Services (2005a)
$2,754
$1,937
$1,679
$1,426$1,310
$1,559
$1,805
17.3%15.6%15.4%15.3%
14.9%14.1%13.3%
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
2000 2001 2002 2003 2004* 2005* 2010*
NH
E in
Bill
ion
s
0%
3%
6%
9%
12%
15%
18%
Pe
rce
nt o
f GD
P
National Health Expeditures (NHE) Percent of GDP
National Healthcare Trends
National Health Expenditures (NHE) and Percentage of GDP2000-2010
9Blue Cross Blue Shield of Massachusetts
…and retirees are not faring any better
According to an analysis by the Urban Institute, by 2030 out-of-pocket expenses for retirees will consume:
• 30.3% of income for older unmarried adults, up from 17.3% in 2000, and
•35.1% of income for older married couples, more than double the 16% in 2000
Source: Henry E. Simmons, Pres. National Coalition on Health Care. November 14, 2005 address to International Foundation of Employee Benefit Plans
10Blue Cross Blue Shield of Massachusetts
National Scorecard on U.S. HealthSystem Performance (Commonwealth Fund, September 2006)
Indicator U.S National
Rate
Benchmark
Measure
Benchmark Rate
Score: Ratio of U.S. to Benchmark (%)
Mortality/ 1,000 115 Top 3 Countries
80.0 70
Infant Mortality/ 1,000 7 Top 3 Countries
2.7 39
Healthy Life Expectancy at age 60
16.6 Top 3 Countries
19.0 87
Children missed 11 or more school days
5.2 Top 10% states
3.8 74
Adults received screenings and
preventive care (%)
49.0 Target 80.0 61
11Blue Cross Blue Shield of Massachusetts
National Scorecard on U.S. HealthSystem Performance (Commonwealth Fund, September 2006)
Indicator U.S National
Rate
Benchmark
Measure
Benchmark Rate
Score: Ratio of U.S. to Benchmark (%)
Chronic Disease under control (%)
52.0 90% Medicare
Private Plans
82.0 61
Nursing Home residents with pressure sores (%)
16.0 Top 10% states
11.0 67
Ability to see doctor on same day or next day
when sick (%)
47.0 Top 6 Countries
81.0 58
Easy to get care after hours without going to ER
(%)
38.0 Top 6 Countries
72.0 53
Adults with no access problems due to cost (%)
60.0 Top 5 countries
91.0 66
12Blue Cross Blue Shield of Massachusetts
National Scorecard on U.S. HealthSystem Performance (Commonwealth Fund, September 2006)
Indicator U.S National
Rate
Benchmark
Measure
Benchmark Rate
Score: Ratio of U.S. to Benchmark (%)
Overuse/Waste (%) 22.0 Various 11.0 46
ER visits for conditions could have been treated by PCP
(%)
26.0 Top 6 countries
6.0 23
% of National Health Expenditure on Health
Administration
7.3 Top 3 Countries
2.0 28
Physicians using electronic records (%)
17.0 Top 3 Countries
80.0 21
13Blue Cross Blue Shield of Massachusetts
Why Are We In This Situation?
No national healthcare goals
No organized leadership for improvement
Cottage industry structure
Defined benefit with no planning
No accountability
No one owns enough of the system to enforce change
MassachusettsHealthcare Reform
15Blue Cross Blue Shield of Massachusetts
Health Care Reform: The Genesis
October 31, 2003:
CONSENSUS DECLARED AT THE BCBSMA
CONSENSUS DECLARED AT THE BCBSMA
FOUNDATION: WE NEED A ROADMAP TO
FOUNDATION: WE NEED A ROADMAP TO
HEALTH CARE REFORMHEALTH CARE REFORM
CONSENSUS DECLARED AT THE BCBSMA
CONSENSUS DECLARED AT THE BCBSMA
FOUNDATION: WE NEED A ROADMAP TO
FOUNDATION: WE NEED A ROADMAP TO
HEALTH CARE REFORMHEALTH CARE REFORM
16Blue Cross Blue Shield of Massachusetts
Healthcare Reform Timeline
Health care reform has dominated the political landscape for over one year.
_________________Summer 2004 to early 2005
Legislation drafted
April 2005
Governor, Senate bills released
October 2005
House bill released
November 2005
House, Senate final bills/ conference committee appointed
Legislation finalized
April 4, 2006
Governor signs into law
April 12, 2006
17Blue Cross Blue Shield of Massachusetts
Expanding the Focus
As first proposed, the concept of health care reform was about:
Lowering health care costs for employers
Efforts to enroll those eligible for Medicaid but unenrolled
Increasing access to care
18Blue Cross Blue Shield of Massachusetts
Expanding the Focus
With input from BCBSMA, other issues were added to the mix:
Addressing the Quality of Care
Medicaid Provider Shortfalls
In the end, all the issues came together in one bill.
19Blue Cross Blue Shield of Massachusetts
Massachusetts:The Key Elements of Reform
Medicaid Expansions
Health Insurance Connector
Commonwealth Care – Premium Subsidy Program
Individual Mandate for all MA adult residents
Health Insurance Market Reforms
Employer Responsibilities (for firms > 11 employees)
Medicaid provider rate increases
20Blue Cross Blue Shield of Massachusetts
MA Health Care Reform LawKey Components
$540+ million over next 3 years
Hospitals increases to be tied to quality standards in areas including addressing health disparities
Medicaid provider rate increases for hospitals, physicians and community health centers
21Blue Cross Blue Shield of Massachusetts
MA Health Care Reform Law: Key Components (cont’d)
Commonwealth Health Insurance Connector
New public authority (10-member board)
Administers “Commonwealth Care” low income premium subsidy program
Will offer “affordable” health insurance products to individuals and small businesses (50 or fewer employees)
22Blue Cross Blue Shield of Massachusetts
MA Health Care Reform Law:Key Components (cont’d)
<100% FPL – fully subsidized, comprehensive benefits (including dental)
100-300% FPL - sliding scale subsidies, no annual deductibles
Commonwealth Care Health Insurance Program (C-CHIP) – Premium Subsidy Program
23Blue Cross Blue Shield of Massachusetts
Mass Health Care Reform Law Key Components (cont’d)
Individual Mandate for all MA adult residents
Enforcement mechanisms− Indicate insurance policy number on state tax return− Loss of state personal income tax exemption for tax year 2007− Fine for each month without insurance equal to 50% of affordable
insurance product cost for tax year 2008
24Blue Cross Blue Shield of Massachusetts
Mass Health Care Reform Law Key Components (cont’d)
Health Insurance Market Reforms
Non-group and small-group insurance markets merged
Young Adult plans for 19-26 year olds
Age for eligibility for dependent coverage for health insurance raised to 25 years
25Blue Cross Blue Shield of Massachusetts
MA Health Care Reform LawKey Components (cont’d)
Employer Responsibilities (for firms > 11 employees)
Must offer access to pre-tax purchase of health insurance
“Fair share” assessment of no more than $295 per worker
26Blue Cross Blue Shield of Massachusetts
Stakeholders
Health advocacy organizations Organized labor Business community Hospitals Health plans Faith-based organizations Physicians Community Health Centers Nurses Appointed and elected officials
27Blue Cross Blue Shield of Massachusetts
Health Care Delivery System:Introduction: Key Messages
1. Serious Problems in Quality2. Great Degree of Variability3. Source of Problems – Systems4. Increased Quality and Cost Reduction Possible5. Immediate Benefits by Improving Reliability of Healthcare Delivered
28Blue Cross Blue Shield of Massachusetts
Conformance With Care Agreed byUS Health Experts
CAREPERCENTAGE RECEIVING CURRENT
RECOMMENDED PRACTICE
Preventive Care 50%
Acute Problems(colds, stomach pain)
70%
Chronic Illness(diabetes, hypertension)
60%
Beta blockers after heart attack 21%
Care provided that was not needed – may be harmful - acute care - chronic care
33%20%
29Blue Cross Blue Shield of Massachusetts
And the Latest Large American Study…
McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)
• 439 indicators of clinical quality of care• 30 acute and chronic conditions, plus prevention• Medical records for 6712 patients• Participants had received 54.9% of scientifically indicated care (Acute: 53.5%;
Chronic: 56.1%; Preventive: 54.9%)
Conclusion: The “Defect Rate” in the technical quality of American health care is approximately 45%
30Blue Cross Blue Shield of Massachusetts
Clinical Effectiveness
Focusing on effectiveness and efficiency of clinical processes Great deal of variability within university hospitals:
• Major surgery complications 49%• CHF re-admission rates 49%• Mortality 30%• Total direct costs/OR hour 24%• Total cost/adj. discharge 80%
Collaboration to Improve HealthcareDelivery System
32Blue Cross Blue Shield of Massachusetts
IHI Mission
The Institute for Healthcare Improvement is a not-for-profit organization driving the improvement of health by advancing
the quality and value of health care.
33Blue Cross Blue Shield of Massachusetts
IHI Vision
The Institute for Healthcare Improvement is a premier integrative force, an agent for profound change, dedicated to improving health care for all. Our measures of success
include improved safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
34Blue Cross Blue Shield of Massachusetts
IHI Initiatives
Breakthrough Series• Emergency Rooms• ICU• Surgical Infection• Ventilator Associated Pneumonia
Pursuing Perfection – 13 HospitalsImpact Network – 210 HospitalsCare at the BedsidePatient Safety Officer TrainingExecutive Quality Academy
35Blue Cross Blue Shield of Massachusetts
IHI Breakthrough Series(6 to 13 months time frame)
Select Topic
(develop mission)
Planning Group
Develop Framework & Changes
Participants (10-100 teams)
Prework
LS 1
P
S
A D
P
S
A D
LS 3LS 2
Supports
Email Visits
Phone Assessments
Monthly Team Reports
Congress,
Guides,
Publications
etc.
A D
P
SExpert Meeting
36Blue Cross Blue Shield of Massachusetts
IHI – 100,000 Lives Saved Campaign
Campaign: December 2004 - June 2006
Save 100,000 lives by improving reliability of healthcare within U.S. hospitals
Target 2,300 hospitals
Six proven initiatives
37Blue Cross Blue Shield of Massachusetts
Six Initiatives
Deploy “Rapid Response Teams” at the first sign of patient decline Deliver reliably, evidence-based care for acute myocardial infarction Prevent adverse drug events by implementing medication
reconciliation Prevent central line infections – Implement bundles Prevent surgical site infections – Implement bundles Prevent ventilator associated pneumonia – Implement bundles
38Blue Cross Blue Shield of Massachusetts
Accomplishments
Co-Sponsors:• Agency for Healthcare Research and Quality• American Medical Association• Association of American Medical Colleges• Center for Medicare and Medicaid• Joint Commission on Accreditation of Healthcare Organizations• National Patient Safety Foundation• University Health System Consortium• American College of Cardiology
39Blue Cross Blue Shield of Massachusetts
Accomplishments (continued)
Co-Sponsors (continued):• Centers for Disease Control and Prevention• Society for Healthcare Epidemiology of America• American Nurses Association• Leapfrog• The National Business Group on Health• 20 State Hospital Associations
3,300 Hospitals Voluntarily Signed Up$15M Private Contributions122,000 Lives Saved
Collaboration to Improve Quality of Carein Massachusetts
41Blue Cross Blue Shield of Massachusetts
Seven Levers of Change
I. Governance FocusI. Trustees as champions of New Quality StandardsII. Governance Practices Linked to Hospital Contracts
• Quality and Safety Standards• Adoption of Standardized Quality Measures• Transparent Reporting of Performance Information• Public Recognition Programs to Highlight Extraordinary Achievements in Quality
Improvement
42Blue Cross Blue Shield of Massachusetts
Seven Levers of Change (cont’d)
III. Financing and IncentivesI. Incentives to Achieve New Quality Performance StandardsII. Partnerships with Multiple Quality Improvement Organizations Including IHI,
Dartmouth, RandIII. Funded 100,000 Lives Saved Campaign
I. $35K to each hospitalII. $5M contribution
IV. $400M in Incentives Tied to Quality GoalsV. Redesign Payment Systems to Reduce Overuse and Misuse
43Blue Cross Blue Shield of Massachusetts
Seven Levers of Change (cont’d)
IV. Legislation and RegulationI. Cost and Quality CouncilII. Healthcare Reform
V. Public EngagementI. Segmented Focus GroupsII. Seminar Series – Public ForumsIII. Public EducationIV. Eastern Massachusetts Health Collaborative
44Blue Cross Blue Shield of Massachusetts
Seven Levers of Change (cont’d)
VI. TechnologyI. E-Health CollaborativeII. Three CommunitiesIII. 500 PhysiciansIV. $50M Investment
• Organizational ReadinessI. LEAD OrganizationII. Capability Building
Growing Conflicts
46Blue Cross Blue Shield of Massachusetts
Growing Conflicts
A. Demographics:
Beneficiaries vs. Contributors—Aging of population—Utilization increases exponentially with age:
65 years vs. 45 years 2 times 85 years vs. 45 years 4 times 95 years vs. 45 years 8 times
47Blue Cross Blue Shield of Massachusetts
Growth Trends - Aging Baby Boomers
0
5
10
15
20
25
1990 1995 2000 2005 2010 2020 2030 2040 2050
65 and Over 85 and Over
Elderly Population by Age, 1990 to 2050:Percent 65+ and 85+
• By 2030 one fifth of the population will be over 65 years of age
Growing ConflictsGrowth Trends – Aging Baby Boomers
48Blue Cross Blue Shield of Massachusetts
6%
7%
8%
9%
10%
11%
12%
13%
14%
11% 12% 13% 14% 15% 16% 17% 18% 19%
PERCENT OF POPULATION OVER AGE 65
PE
RC
EN
T O
F G
DP
SP
EN
T O
N
HE
ALT
H C
AR
E
U.S.
Iceland
Canada
AustraliaNetherlands
SwitzerlandGermany
France
U.K.Japan
Sweden
Health Spending and Aging Selected OECD Countries 2000
Source: OECD Data, 2002
Now over 16%
49Blue Cross Blue Shield of Massachusetts
B. Acute Care vs. Chronic Care—Half of seniors have at least one chronic condition:
arthritis: 49% hypertension: 36% hearing impairment: 30% cardiovascular disease: 27%
—Chronic care now accounts for more than 70% of all healthcare expenditures:
acute care system trying to deliver chronic care
Growing Conflicts
50Blue Cross Blue Shield of Massachusetts
C. Severe Workforce Shortages:—Nursing —Pharmacy—Radiology technicians—Physicians - specialties
Growing Conflicts: Current Environment - Crumbling
51Blue Cross Blue Shield of Massachusetts
D. Growing Complexity of Science andTechnology:
— Rapidly expanding knowledge base— Significant investment in R & D— New medical technologies:
transplantation laparoscopic procedures robotic surgery CT/PET scanners gene therapy implants
E. Rising Uninsured and Underinsured
Current Environment – Crumbling Foundation
52Blue Cross Blue Shield of Massachusetts
Healthcare in the USA is at a crossroad:• Managed care rejected• Healthcare benefit cost increasing rapidly
-5
0
5
10
15
20
1990 1992 1994 1996 1998 2000 2002 2004
% of Increase
Growing Conflicts
Conclusions
54Blue Cross Blue Shield of Massachusetts
Conclusions
Large Country with Diverse PopulationTime for LeadershipHealthcare Score CardAims for Regional Healthcare
• Universal healthcare• Primary care and public health• Coordinated care• Transparency
Coalition for Healthcare System Change