Comprehensive Assessment of Reform Efforts:
The COMPARE Initiative
Elizabeth A. McGlynn, Ph.D.Associate Director, RAND Health
November 16, 2009
McGlynn -2- 11/16/09
Outline for Seminar
Background on COMPARE
Review of major bills in Congress
Analysis of HR 3962
Cost containment: the next frontier
McGlynn -3- 11/16/09
Steps Leading to COMPARE We undertook a priority setting process with
RAND Health Board of Advisors Brainstorming session Formal rating of 20 topics Paragraph descriptions written for top 10 Second round of rating 10 topics Subgroup of RHBA & RAND Health staff
assigned to further develop concept
RAND Board of Trustees and RAND Senior management engaged in a similar exercise
Reform of the health care system emerged from both processes as a high priority
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The Status Quo
55% 47M
$2T
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Uncertainty Surrounds Likely Effects of Proposed Changes
??% ?M
$??TMandates
Subsidies
Tax breaks
Expanded eligibility
Transparency
P4P
HIT
Diseasemanagement
Prevention
Tort reform
Medicalhome
CDHP
Nurse staffingratios
Comparativeeffectiveness
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We Considered Two Possible Options
Design a comprehensive plan for health reform
Develop a method for evaluating plans proposed by others
What would you do?
McGlynn -7- 11/16/09
COMPARE Goals
Provide the factual foundation for a national dialogue about health reform options
Facilitate the development of health reform policy options by public and private policy makers
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Health Care Proposals May Recommend One or Multiple Policy Changes
Reform medicalmalpractice law
Examples
Proposal ASingle policy
changes • Employer mandate
• Individual mandate
• Medicaid/SCHIP expansion
• Tax credits
Proposal BMultiple changes
But it can be difficult to compare effects of different proposals
McGlynn -9- 11/16/09
COMPARE Utilizes Multiple Methods to Examine Policy Options
We developed a new microsimulation model Estimates effects of policy changes on spending,
coverage, consumer financial risk and health
We conducted systematic reviews of the literature on prior experiences with and/or theory surrounding policy options
We made COMPARE results available online at www.randcompare.org:
Synthesize status quo Summarize state and federal legislation Analyze likely effects of different policy options
McGlynn -10- 11/16/09
The COMPARE Dashboard Evaluates Policies Across Nine Dimensions
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What Makes COMPARE Unique?
Modular
Multidimensional
Evidence-based
Transparent
Accessible
Adaptable
McGlynn -12- 11/16/09
Outline for Seminar
Background on COMPARE
Review of major bills in Congress
Analysis of HR 3962
Cost containment: the next frontier
McGlynn -13- 11/16/09
Overview – Committees and Floor DebateHOUSE SENATE
COMMITTEEPROCEDINGS
FLOORCONSIDERATION
Debate
Full House vote on Bill(simple majority to pass)
Three Bills combined into One
Rules Committee sets terms for debate; confirmed by full House
House-SenateConference Committee
Energy & Commerce
Ways & Means
Education& Labor
Finance HELP
Full Senate vote on Bill(simple majority to pass)
DebateFilibuster
Cloture
Debate
Debate terms negotiated Limited debate; no filibuster
Regular Order Reconciliation
Two Bills combined into One
Hearings
Legislation
Cost estimate
Mark-Up
Hearings
Legislation
Cost estimate
Mark-Up
McGlynn -14- 11/16/09
Overview – ConferenceHouse-Senate
Conference Committee
Conference Report
Debate
Full House vote on Bill(simple majority to pass)
Rules Committee sets terms for debate; confirmed by full House
Full Senate vote on Bill(simple majority to pass)
DebateFilibuster
Cloture
Debate
Debate terms negotiated Limited debate; no filibuster
Regular Order Reconciliation
HOUSE SENATE
President signs or vetoes the bill
McGlynn -15- 11/16/09
Major Options Under Consideration for Expanding Coverage of Uninsured
Expand eligibility for Medicaid (Medi-Cal)
Require employers to offer insurance (employer mandate)
Improve the functioning of health insurance markets
Require individuals to have coverage (individual mandate)
McGlynn -16- 11/16/09
How Many Americans Lack Insurance?
Insurance status in United States (2007)
Uninsured
45.3million
Insured252 million
McGlynn -17- 11/16/09
What Are the Major Sources of Insurance Coverage?
0 50 100 150 200
Employer-sponsored
Employers are the largest source of insurance
28
38
40
Medicaid/SCHIP
Medicare
Non-group
186
People in millions
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Who Are the Uninsured?
19%
30%
29%10%
12%
A significant portion are low-income
<100% FPL
100-200% FPL
200-300%FPL
300-400% FPL
Over 400% FPL
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Who Are the Uninsured?
Nearly two-thirds are employed or their dependents
Employedand their
dependents62%
McGlynn -20- 11/16/09
Who Are the Uninsured?
More than one in four has access to employer insurance
Has access toemployerinsurance
28%
McGlynn -21- 11/16/09
Who Are the Uninsured?
A similar proportion is eligible for Medicaid or SCHIP
Eligible for
Medicaid/SCHIP28%
Comparison of Major BillsProvision HR 3962 Senate
FinanceSenate HELP
Medicaid expansion
Eligibility to 150% FPL
Eligibility to 133% FPL
No jurisdiction
Employer mandate
Payroll > $500K
Premium share: 72.5% single, 60% family
Penalty for noncompliance: 8% of payroll
No “mandate”
Tax on employers > 100 FTE that do not offer: $400/ employee
Firms > 25
Premium share: 65%
Penalty for noncompli-ance: $400/ employee
Comparison of Major Bills (cont.)Provision HR 3962 Senate
FinanceSenate HELP
Insurance market reforms
Guaranteed issue; 2:1 rate banding*; risk equalization
Guaranteed issue;
4:1 rate banding**; risk equal.
Guaranteed issue; rate banding;
Individual mandate
Yes. Penalty is 2.5% AGI
Subsidies for 150-400% FPL
Yes. Penalty $200/yr to $750 btwn 2013-2016
Subsidies for 133-400% FPL
Yes. Penalty is $750/yr
Subsidies for 150-400% FPL
*age, family size, geography**age, family size, geography, tobacco use
McGlynn -24- 11/16/09
Medicaid Eligibility
200%185%
41%
0%
68%74%
Children PregnantWomen
Elderly andIndividuals
withDisabilities
WorkingParents
Non-WorkingParents
ChildlessAdults
Federal Poverty Line (For a family of four is
$21,200 per year in 2008)
Eligibility for Medicaid Varies by Category of Eligibility
Note: Medicaid income eligibility for most elderly and individuals with disabilities is based on the income threshold of Supplemental Security Income (SSI).SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2009.
Medicaid Eligibility for Working Parents Varies by State
AZAR
MS
LA
WA
MN
ND
WY
ID
UTCO
OR
NV
CA
MT
IA
WIMI
NE
SD
ME
MOKS
OHIN
NY
IL
KY
TNNC
NH
MA
VT
PA
VAWV
CTNJ
DE
MD
RI
HI
DC
AK
SCNM
OK
GA
TX
IL
FL
AL
50- 99% FPL (20 states)
20-49% FPL (14 states)
> 100% FPL (17 states including DC)US Median Eligibility = 68% FPL: $11,968 per year
*The Federal Poverty Line (FPL) for a family of three in 2008 is $17,600 per year.SOURCE: Kaiser Commission on Medicaid and the Uninsured, Where are States Today: Medicaid and State-Funded Coverage Eligibility Levels for Low-Income Adults. October 2009.
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The Effect of Medicaid and SCHIP Expansions on Coverage Depends on Eligibility
4.1
9.4
13.9
17.2
6.1
20
35.2
49.5
0 10 20 30 40 50 60
100% FPL
200% FPL
300% FPL
400% FPL
Elig
ible
if In
com
e B
elo
w:
Number Newly Insured, in Millions
Eligibility Based on Income Relative to the Federal Poverty Level (FPL)
McGlynn -28- 11/16/09
VA
Impact on States Will Depend on Portion of Costs for Newly Eligible Borne by Feds
AZAR
MS
LA
WA
MN
ND
WY
ID
UTCO
OR
NV
CA
MT
IA
WIMI
NE
SD
ME
MOKS
OHIN
NY
IL
KY
TNNC
NH
MA
VT
PA
WV
CTNJ
DE
MD
RI
HI
DC
AK
SCNM
OK
GA
SOURCE: Federal Register, November 28, 2007 (Vol. 72, No. 228), pp 67305-67306, at http://edocket.access.gpo.gov/2007/pdf/07-5847.pdf and correction for North Carolina at Federal Register, Friday, December 7, 2007 (Vol. 72, No. 235), p. 69285, at http://edocket.access.gpo.gov/2007/pdf/C7-5847.pdf.
TX
IL
FL
AL
71+ percent (6 states)
50 percent (14 states)
62 to <71 percent (19 states including DC)
51 to <61 percent (12 states)
VA
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Employer Participation
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On Average, Employers Contribute 83% of Premium Costs for Individuals
779
540
741
806
817
4045
3446
4093
4116
4061
$0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000
ALL
HDHP/SO
POS
PPO
HMO
Employee Employer
Source: Kaiser/HRET Survey, 2009
McGlynn -31- 11/16/09
Most Employees Work for Large Firms that Already Offer Coverage
0% 20% 40% 60% 80% 100%
<25
25-49
50-99
100+
All Firms
<500,000 500-750 >750
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Outline for Seminar
Background on COMPARE
Review of major bills in Congress
Analysis of HR 3962
Cost containment: the next frontier
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What Is Our Contribution?
Transparency around the numbers Assumptions Design choices Analytic methods
Objective source
Insights about unintended consequences
Broader perspective on policy effects
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Key Features of HR 3962
New insurance “Exchange” created National (Health Choices Administration) States may create separate exchanges (or multi-
state exchanges) Private companies and public plan offer policies
meeting minimum benefit standards
Exchange eligibility limited to those without employer offers or Medicaid eligibility
Exchange-eligible individuals with incomes up to 400% Federal Poverty Level can receive subsidies for premiums and out-of-pocket expenses
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Key Features of HR 3962 (cont.)
Medicaid eligibility expanded to all persons with incomes < 150% FPL
States with more generous eligibility must maintain prior levels
Employers required to offer insurance coverage and subsidize premiums
72.5% for individuals, 65% for family
Automatic enrollment of eligible individuals
Exempts firms with payroll < $500K
Penalty for failure to comply: 8% of payroll for firms with payroll > $750K
McGlynn -36- 11/16/09
Key Features of HR 3962 (cont.)
Require everyone to have insurance (individual mandate)
Options include: employer, Medicaid, Medicare, other government, individual
Penalty for failure to comply: 2.5% of adjusted gross income
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We’ve Analyzed the Likely Effects of This Legislation on Three Dimensions
Coverage
Spending
Consumer financial risk
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Effect of Different Subsidy and Penalty Levels on Reducing Uninsured
05
10152025303540
No penalty 30% 50% 80%
% of Exchange Premium
Mill
ion
s o
f u
nin
sure
d
No subsidy Low subsidyModerate subsidy High subsidy
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Newly Insured Obtain Coverage Through Employers, Medicaid, Exchange
0 50 100 150 200
ESI
Medicaid
Non-group
Other
Uninsured
Number of persons (millions)
Status quo HR 3962
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Uninsured in 2019 Are Younger Than Status Quo Projections Without Reform
0% 10% 20% 30% 40%
0-1
2-17
18-34
35-49
50-64
Age(years)
Proportion of uninsured population
Status quo HR 3962
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Uninsured in 2019 Are Relatively Healthier than Status Quo Projections
0% 10% 20% 30% 40% 50% 60% 70% 80%
Excellent orvery good
Good
Fair or poor
Proportion of uninsured population
Status quo HR 3962
Sel
f-re
po
rted
hea
lth
sta
tus
Sel
f-re
po
rted
hea
lth
sta
tus
McGlynn -42- 11/16/09
Uninsured in 2019 Are “Wealthier” than Status Quo Projections
0% 10% 20% 30% 40% 50%
<150% FPL
150-300% FPL
>300% FPL
Proportion of uninsured population
Status quo HR 3962
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We’ve Analyzed the Likely Effects of This Legislation on Three Dimensions
Coverage
Spending
Consumer financial risk
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House Bill Increases National (Personal) Health Spending by 3.6%
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Nationalhealth
spending($B)
Status quo COMPARE
McGlynn -45- 11/16/09
House Bill Would Increase Cumulative Medicaid Spending by 11.2%
$0$50
$100$150$200$250$300$350$400$450
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Calendar year
Medicaidspending
($B)
COMPARE CBO
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Individual Penalty Payments Would Total $42.7B From 2010-2019
$0$50
$100$150$200$250$300$350$400$450
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Calendar year
Penaltypayments
($B)
COMPARE CBO
McGlynn -47- 11/16/09
Employer Penalty Payments Would Total $103B From 2010-2019
$0$1
$2$3
$4$5
$6$7
$8$9
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Calendar year
Penalty payments
($B)
COMPARE CBO
McGlynn -48- 11/16/09
We’ve Analyzed the Likely Effects of This Legislation on Three Dimensions
Coverage
Spending
Consumer financial risk
McGlynn -49- 11/16/09
Outline for Seminar
Background on COMPARE
Review of major bills in Congress
Analysis of HR 3962
Cost containment: the next frontier
McGlynn -50- 11/16/09
U.S. Health Spending Increasing Rapidly
2008
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
5,000,000
1965 1975 1985 1995 2005 2015
Spending($ millions)
Total Expenditures
Total Private
Total Public
Federal
State & Local
Source: Centers for Medicaid Services, Health and Human Services, “National Health Expenditures Accounts, 1965–2017.
Compound Annual Growth in Total Health Spending per Capita in OECD Countries, 1990-2007
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
Kore
a
Ireland
Poland
Portu
gal
Greec
e
Unite
d Ki
ngdo
m
Czec
h Re
publ
ic
Spain
Aust
ralia
Belg
ium
New Z
ealand
Hunga
ry
Norway
Mex
ico
Unite
d St
ates
Nethe
rland
s
Iceland
Aust
ria
Japa
n
Fran
ce
Denm
ark
Cana
da
Swed
en
Finland
Switz
erland
Germ
any
Italy
CA
GR
, To
tal H
ealt
h S
pen
din
g in
Natl
Cu
rren
cy U
nit
s,
2000 G
DP
Pri
ces
U.S. Rate of Growth in Health Spending Is Neither Highest Nor Lowest
McGlynn -52- 11/16/09
Health Care Spending Is Increasing Faster than GDP Growth
12
1990
9
6
3
0
–31995 2000 2005 2010 2015
Percentchange
Sources: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S. Department of Commerce, Bureau of Economic Analysis; and National Bureau of Economic Research.
Growth in national health spending
Growth in GDP
McGlynn -53- 11/16/09
Health Care Spending As A Proportion of GDP Projected to be 20% by 2018
0
5
10
15
20
25
1960 1993 2006 2007 2008 2009 2013 2018
% o
f G
DP
Health Spending
McGlynn -54- 11/16/09
Why Does This Matter?
Money spent on health care can’t be spent on other things
Spending on health care may overtake most other discretionary government spending
But, we’ve been concerned about these increases for a long time without taking any serious action
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Increased Prices Primary Drive of Rising Health Care Spending
PricesVolume/mixPopulation GrowthAging
Source: California HealthCare Foundation. Snapshot, Health Care Costs 101, 2008.
McGlynn -56- 11/16/09
Massachusetts Asked RAND to Evaluate the Effect of Various Cost Containment Options
Project involved several steps
Selected policy options to consider for analysis
Reviewed what was known from prior experience about effects of selected options on reductionsin spending
Modeled the impact of options that showed promise and that had a sufficient evidence base
McGlynn -57- 11/16/09
Options Were Selected for Study in Collaboration with the Client
We interviewed experts and stakeholders in Massachusetts to collect ideas about how to make care less expensive
We identified 75 options based on these sessions, and grouped into five categories
Reform payment systems Redesign health care delivery system Reduce waste Encourage healthy behavior Reform medical malpractice law
With the client, we selected 21 options for analysis, designed to represent each of the five categories
McGlynn -58- 11/16/09
12 Options in 4 Categories Met Criteria for Modeling (1)
(1) Reform payment systems to better align financial incentives with health goals
Implement bundled payment
Institute reference pricing for academic medical centers (AMCs)
Pay AMCs at a community rate
Institute hospital all-payer rate setting
McGlynn -59- 11/16/09
12 Options in 4 Categories Met Criteria for Modeling (2)
(2) Redesign health care delivery to improve efficiency and quality
Encourage greater use of medical homes
Increase use of retail clinics
Encourage greater use of nurse practitioners and physician assistants
Encourage greater use of disease management
McGlynn -60- 11/16/09
12 Options in 4 Categories Met Criteria for Modeling (3)
(3) Reduce waste in the health care system
Eliminate payment for preventable events (e.g., cost of treating hospital acquired infections)
Encourage less intensive use of resources at the end of life
Accelerate adoption of health information technology (HIT)
(4) Encourage consumers to maintain health
Encourage value-based insurance design
McGlynn -61- 11/16/09
Modeling Methodology We developed baseline health care spending
projections in Massachusetts from 2010 to 2020
Adjusted for population change
Allowed for health care cost inflation
Projected $670 billion in cumulative spending
Models estimate a range (upper and lower bound) of potential effects
Vary design and/or impact assumptions
McGlynn -62- 11/16/09
Example: How Bundled Payment Works Fee-for-service payment reimburses providers
separately for each unit of service, which encourages overuse of care
Under bundled payment, the total cost of needed services for a condition is calculated
Bundled payment amount is generally a percentage reduction from average current payment to discourage overuse, encourage coordination
Applies across multiple providers and care settings
Evidence suggests that bundled payment cansave money
McGlynn -63- 11/16/09
What Bundles Did We Include?
Chronic conditions
Diabetes
High blood pressure
Congestive heart failure
Heart disease
Chronic lung disease
Asthma
Procedures or admissions
Heart attack
Bariatric surgery
Hip replacement
Knee replacement
McGlynn -64- 11/16/09
An Example of the Prometheus Bundled Payment Methodology for Diabetes Care
0
1000
2000
3000
4000
5000
6000
7000
Average current payment
$6,076
Typical annual payment for diabetes, current payment system
McGlynn -65- 11/16/09
A Large Share of Health SpendingMay Be Avoidable or Unnecessary
0
1000
2000
3000
4000
5000
6000
7000
Average current payment
$2,357
$3,719
Typical annual payment for diabetes, current payment system
Necessary spending Potentially avoidable spending
61 percent of spending may be avoidable
39 percent of spending for needed care
$6,076
McGlynn -66- 11/16/09
Caps Would Reduce Spending by Limiting Payment for Potentially Avoidable Utilization
0
1000
2000
3000
4000
5000
6000
7000
Average current payment Bundled payment, upper bound
$4,217
$2,357
$1,86050%reduction
Alternative payment rates for diabetes, based on Prometheus
Necessary spending Potentially avoidable spending
$2,357
$3,719
$6,076
McGlynn -67- 11/16/09
Promising, but Many Details Would Need to be Addressed
Evidence is from hospital-based conditions Lower bound includes only hospital conditions But chronic illness is the biggest potential saver
Bundled payment may only work in organized delivery systems Who “holds” the bundle and allocates payments?
Bundles may be difficult to develop and price Prometheus: ten bundles in three years Balance assumptions about relative overuse and
underuse in current use patterns
Unknown effects on quality of care Prometheus & others recommend quality monitoring
McGlynn -68- 11/16/09
Results: Predicted Change in Spending, 2010-2020
-10 -8 -6 -4 -2 0 2Percentage change in spending
Bundled payment -5.7% -0.1%
-7.7%
McGlynn -69- 11/16/09
Payment Reform Options Among the Most Promising
-10 -8 -6 -4 -2 0 2Percentage change in spending
Bundled payment
Hospital rate regulation
Pay AMCs at community rate
Eliminate payment for preventable events
-5.7%
-4.0% 0.0%
-2.7% -0.2%
-1.8% -1.1%
-7.7%
-0.1%
McGlynn -70- 11/16/09
Predicted Changes in Health Spending: 2010-2020
-10 -8 -6 -4 -2 0 2Percentage change in spending
Bundled payment
Hospital rate regulation
Pay AMCs at community rate
Eliminate payment for preventable events
Increase adoption of HIT
Encourage use of NPs/PAs
Promote growth of retail clinics
-5.7%
-4.0% 0.0%
-2.7% -0.2%
-1.8% -1.1%
-1.8% 0.6%
-1.3% -0.6%
-0.9% 0.0%
-7.7%
-0.1%
McGlynn -71- 11/16/09
Results: Predicted Change in Spending, 2010-2020
-10 -8 -6 -4 -2 0 2Percentage change in spending
Bundled payment
Hospital rate regulation
Pay AMCs at community rate
Eliminate payment for preventable events
Increase adoption of HIT
Encourage use of NPs/PAs
Promote growth of retail clinics
Create medical homes
Use value-based insurance design
Encourage disease management
-5.7%
-4.0% 0.0%
-2.7% -0.2%
-1.8% -1.1%
-1.8% 0.6%
-1.3% -0.6%
-0.9% 0.0%
-0.9% 0.4%
0.2%-0.2%
-0.1% 1.0%
-7.7%
-0.1%
McGlynn -72- 11/16/09
We Recently Estimated Effect of Selected Options on U.S. Spending Current legislation in Congress does not include
significant cost containment options
Among options modeled for Massachusetts, selected those that were:
Promising Relevant to the national dialogue
Projected spending on personal health services in the absence of policy change
Estimated likely percentage savings compared to trend from individual options
McGlynn -73- 11/16/09
Cumulative Reduction of 6.2% Needed to Hold Spending to GDP Growth
SQ ProjectionSQ Projection
Hold to growth Hold to growth in GDPin GDP
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019Year
$ Trillions
McGlynn -74- 11/16/09
What Options Did We Model?
Changes in payment Bundled payment Hospital rate
regulation
Delivery system changes
Disease management
Retail clinics
Benefit design (“value-based purchasing”)
Infrastructure investments
Health information technology
Primary care capacity Medical homes Scope of practice
Nurse practitioners
Physician assistants
McGlynn -75- 11/16/09
Payment Reform Tops the List ofPromising Alternatives
Bundled PaymentBundled Payment
Hospital Rate RegulationHospital Rate Regulation
Health ITHealth IT
Disease ManagementDisease Management
Medical HomesMedical Homes
Retail ClinicsRetail Clinics
NP/PA Scope of PracticeNP/PA Scope of Practice
Benefit DesignBenefit Design
6.06.0
5.4%5.4%
4.04.0 3.03.0 2.02.0 1.01.0 00 6.06.0
Percentage change in national health spendingPercentage change in national health spending
5.05.0
0.1%0.1%
2.0%2.0% 0.0%0.0%
1.5%1.5% 0.8%0.8%
1.3%1.3% 1.0%1.0%
1.2%1.2% 0.4%0.4%
0.6%0.6% 0.0%0.0%
0.5%0.5% 0.3%0.3%
0.3%0.3% 0.2%0.2%
Hussey et al NEJM 2009