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  • 1. Health Care Challenges andOpportunities for Primary Care in West Virginia James Becker, MD Medical Director WV DHHR, Bureau for Medical Services
  • 2. “We are all faced with a series of great opportunities – brilliantlydisguised as insoluble problems.” -- John W. Gardner
  • 3. The evolution of systems Plateau Decline GrowthInvestment Excerpt from “The Age of Paradox,” Charles Handy, 1994
  • 4. National Health Expenditures per Capita, 1960- 2009Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at (see Historical; NHE summary including share of GDP, CY 1960-2009;
  • 5. National Health Expenditures and Their Share of Gross Domestic Product, 1960-2009 Dollars in Billions: 5.2% 7.2% 9.2% 12.5% 13.8% 14.5% 15.4% 15.9% 16.0% 16.0% 16.1% 16.2% 16.6% 17.6%Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at (see Historical; NHE summary including share of GDP, CY 1960-2009; file
  • 6. Projected National Health Expenditures: In Billions and as Percent of GDP $4,500 $4.48 Trillion 19.5% 19.3% GDP $4,000 19.0% $3,500 18.5% $3,000 $2.57 Trillion $2,500 17.3% GDP 18.0% % GDPBillions $2,000 17.5% $1,500 17.0% $1,000 16.5% $500 $0 16.0% 2010 2011 2012 2013 2014 2015 2016 2017 2018 20192008 version of the National Health Expenditures (NHE) released in January 2010
  • 7. Average Annual Health Insurance Premiums and Worker Contributions for Family Coverage, 2001–2011
  • 8. Market Shifts to GreaterGovernment SubsidizationMedicare, Medicaid, individual and small group markets% of % ofTotal 306M Total 296M 127 126 41% Large Group Risk & ASO58% Small Group Segments impacted Individual by Exchange/Other 26 32 Uninsured Government 26 Medicaid Subsidies by 2015 15 20 Medicare 41 59% 5842% 39 43 49 Source: Booz & Co. research (Total Population, Commercial & Individual); Cowen & Goldman 2010 Population 2015 Population Sachs estimates (Government splits)
  • 9. U.S. vs. OECD: U.S. Higher Drug Costs*Manufacturer price; ** Assumes 15% rebates from manufacturers to payors and PBMs; *** Average of U.K., Germany, Italy, France, and SpainSource: IMS Health; McKinsey Global Institute analysis
  • 10. US vs. OECD: Hospital Stays / CostsFewer and shorter hospital stays are offset by higher unit cost Source: OECD, McKinsey Global Institute Analysis
  • 11. AGING OF THE BABY BOOM GENERATION78 million people30 percent of U.S. populationUnfunded liability in Medicare = $70 Trillion
  • 12. System Objectives The Triple Aim (Institute for Healthcare Improvement)1. Improve population health2. Reduce per capita cost3. Improve patient experience  Outcome  Safety  Satisfaction
  • 13. Chronic Disease*People with chronic diseases → 70% HC spending Diabetes Coronary Artery Disease Congestive Heart Failure Asthma Mental health / chemical dependency * George Halvorson Health Care Reform Now
  • 14. Distribution of Health Care Expenditures*1% of population → 35% of HC spending5% of population → 60% of HC spending10% of population → 70% of HC spending * George Halvorson Health Care Reform Now
  • 15. Health Field ModelInfluence Factors on Health Status Social 15% Environmental 5% Human Biology 30%Lifestyle & Behavior 40% Medical Care 10% Source: McGinnis J.M., Williams-Russo, P., Knickman, J.R. (2002). Health Affairs, 21(2), 83
  • 16. BThe Second CurveScenario B
  • 17. WHERE THE RUBBER MEETS THE ROADCost continues to escalate  Acute care system lacks capacity to absorb  2011 Baby Boomers Eligible for Medicare  Increase national debt  Increasing access problem for the elderly  Public dissatisfaction with care quality and coordination
  • 18. Where are the solutions?• Development of a model that creates a Health Community.• Improved data collection systems that allow analysis of outcomes rather than just collecting process measures• Prevention, wellness and medical care that are integrated to create a true health system.• A reimbursement model that rewards healthy outcomes• Integration of behavioral and physical health
  • 19. Profile of WV Medicaid 400,000 Medicaid member We will expand by 170,000 new members Medical costs in 2010 were $2.5 billion We have had several years of surplus We face a short fall in 2013 Reimbursement for most services is at 72- 75% of Medicare 50% of members are in managed care
  • 20. Major Challenges Expanded population Higher cost for services New therapies Requirement to cover more conditions  Mental health parity Risky lifestyle issues (substance abuse) Readmissions, HCACs, Never events
  • 21. Facts about our duals.. There are just under 50,000 West Virginia dual eligible members. That’s 12% of Medicaid eligibles. Ofthe $2.5 billion in SFY 2010 medical expenditures $420 million Medicaid dollars are attached to the care of duals. 71% of that amount is spent caring for those over 65 years of age.
  • 22. Facts about duals.. 40% of the duals had a hospital admission in 2010. 28% had more than one admission. 32,000 dual eligible members (66%) had care from a specialist in 2010 but no care claim by a PCP. 20% of the dual population had at least one nursing home stay in 2010.
  • 23. West Virginia’s foster care children…. Medicaid covers 8,500 children in foster care. 600 of those children have asthma. Many have behavioral, developmental or psychiatric diagnoses. 60% are labeled as “oppositional defiant disorder” Medication profile: stimulants, AAPs, mood meds
  • 24. What are we doing in WV? Data to guide decisions  Data warehouse, APCD, benchmarks Many care coordination efforts  Health homes, PCMH, care integration Usingevidence to guide decisions Working with stakeholders  FQHCs, comprehensives, private payers
  • 25. The importance of coordinated effort!
  • 26. What else? Major pharmacy efforts on opiates, psych meds, high dollar oncology products EHR, incentives, ePrescribing, meaningfull use, Health Information Technology WV is creating a Health Insurance Exchange
  • 27. This is clearly a time of challengeand opportunity for primary carephysicians as we move forwardimproving health and the healthcare system. Primary care needsto lead the way.