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Creating a High Performing Health System

Creating a High Performing Health System. David Blumenthal, MD, MPP President, The Commonwealth Fund Mark McKenna Lecture Arizona State University Tempe, AZ April 23, 2014. Agenda. Challenges Next Steps ACA The Good and Bad News Update on Health IT. COST

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Creating a High Performing Health System

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  1. Creating a High Performing Health System David Blumenthal, MD, MPP President, The Commonwealth Fund Mark McKenna Lecture Arizona State University Tempe, AZ April 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 A BROKEN SYSTEM QUALITY Despite rapid advances, thousands of patients die each year from medical error COVERAGE 55 million uninsured; many more underinsured

  4. 30 Percent of Working-Age Adults Uninsured Now or During the Past Year Percent of adults ages 19–64 Insured now, time uninsured in past year Uninsured now 30 28 28 26 Note: Totals may not equal sum of bars because of rounding. Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, and 2012).

  5. In 2012, Nearly Half of Adults Were Uninsured During the Year or Were Underinsured Uninsured during the year* 30% 55 million Insured all year, not underinsured^ 54% 100 million Insured all year, underinsured^ 16% 30 million 184 million adults ages 19–64 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).

  6. Cumulative Increases in Health Insurance Premiums, Workers’ Contributions to Premiums, Inflation, and Workers’ Earnings, 1999-2013 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. International Comparison of Spending on Health, 1980–2012 Average spending on health per capita ($US PPP) Total expenditures on healthas percent of GDP 17.6% $8,745 8.9% $3,182 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.

  11. $$$$$$$$$$$$$$$ The U.S. sweeps GOLD, SILVER, and BRONZE in international competition

  12. Health Policy at a Fork in the Road Fundamental Delivery System Reform Benefit and Price Reduction OR Regardless of how you envision the role of government, health care and the markets in which it’s purchased need to be improved

  13. Improving Performance Microsystems Health System Performance Macrosystems

  14. Microsystems People, processes and practices that interact directly with patients or support patient care at the local level (the “sharp end”). ED ICU MD practice OR Admitting dept

  15. Macrosystems Organizations and environmental forces that support and influence microsystems (the “blunt end”). Health plans Govt programs/ regulations Hospitals Accrediting organizations National boards

  16. Supply Chains: Micro, Macro or Something in Between?

  17. Interventions That Work: Microsystem Supply Chain Management? Primary Care Toyota Production System Reminder Systems Care Coordination CDS/ CPOE

  18. 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

  19. We need to make it easier to do the right thing… Fundamental Delivery System Reform

  20. Improving Performance Microsystems Health System Performance Macrosystems Affordable Care Act

  21. The Affordable Care Act Reduced Payments for Avoidable Complications Value Based Purchasing Accountable Care Organizations Medicare Advantage Plan Bonuses Bundled Payments Hospital Inpatient Quality Reporting Physician Quality Reporting System Medical Homes Meaningful Use

  22. Surge of Expert Reports

  23. 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

  24. 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.

  25. ACO 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.

  26. Delivery System Reform, Further Effects Source: CMS.

  27. Healthcare Associated Infections Declining Standardized Infection Rate [2008 set to 1.0] 20% drop 44% drop Source: “National and State Healthcare Associated Infections: Progress Report,” Centers for Disease Control and Prevention, March 2014.

  28. Medicare Hospital Readmissions Declining Note: Medicare 30-Day, All-Condition Hospital Readmission Rates January 2007 - May 2013 Source: CMS.

  29. Rate of Uninsured Falls to Lowest Level of Obama’s Presidency Source: Gallup-Healthways Wellbeing Index.

  30. Spending Growth Rate Has Slowed in Recent Years Percent 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.

  31. Is This the Dawn of a New Day?

  32. …Costs Began Picking Up at the End of 2013 Year-Over-Year Growth Rates in NHE Source: “Insights from Monthly National Health Expenditures Estimates through February 2014,” Altarum Institute, April 8, 2014.

  33. U.S. Health Spending is Larger Than the GDP of Most Nations Notes: Data from 2011, adjusted for differences in cost of living Source: 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).

  34. Looking Back: What We Could Have Saved if We Had Matched the Next Highest Country (Switzerland) Increase spending on public health by 20,000% 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).

  35. Update on Health IT

  36. 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

  37. 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

  38. EHR Adoption AmongOffice-BasedPhysician Practices, 2006-13 Any EMR/EHR System Basic System 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.

  39. EHR Adoption Among Hospitals, 2008-12 At Least Basic EHR Basic EHR Comprehensive EHR 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.

  40. Future Challenges for HIT: Realizing Value • Usability. • Interoperability and exchange. • Analytics.

  41. Question and Answer

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