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Health Care Challenges andOpportunities for Primary Care in West Virginia James Becker, MD Medical Director WV DHHR, Bureau for Medical Services
“We are all faced with a series of great opportunities – brilliantlydisguised as insoluble problems.” -- John W. Gardner
The evolution of systems Plateau Decline GrowthInvestment Excerpt from “The Age of Paradox,” Charles Handy, 1994
National Health Expenditures per Capita, 1960- 2009Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, athttp://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; filenhegdp09.zip).
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, athttp://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; file nhegdp09.zip).
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
Average Annual Health Insurance Premiums and Worker Contributions for Family Coverage, 2001–2011
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)
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
US vs. OECD: Hospital Stays / CostsFewer and shorter hospital stays are offset by higher unit cost Source: OECD, McKinsey Global Institute Analysis
AGING OF THE BABY BOOM GENERATION78 million people30 percent of U.S. populationUnfunded liability in Medicare = $70 Trillion
System Objectives The Triple Aim (Institute for Healthcare Improvement)1. Improve population health2. Reduce per capita cost3. Improve patient experience Outcome Safety Satisfaction
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
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
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
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
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
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
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
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.
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.
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
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
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
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.