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Health Care Challenges andOpportunities for Primary Care       in West Virginia       James Becker, MD        Medical Dire...
“We are all faced with a series of  great opportunities – brilliantlydisguised as insoluble problems.”       -- John W. Ga...
The evolution of systems                                                            Plateau                               ...
National Health Expenditures per Capita, 1960-                        2009Source: Centers for Medicare and Medicaid Servic...
National Health Expenditures and Their Share of            Gross Domestic Product, 1960-2009     Dollars in Billions:     ...
Projected National Health Expenditures:                                                In Billions and as Percent of GDP  ...
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                ...
U.S. vs. OECD: U.S. Higher                       Drug Costs*Manufacturer price; ** Assumes 15% rebates from manufacturers ...
US vs. OECD:      Hospital Stays / CostsFewer and shorter hospital stays are offset by higher unit cost                   ...
AGING OF THE BABY BOOM      GENERATION78 million people30 percent of U.S. populationUnfunded liability in Medicare = $70 T...
System Objectives                 The Triple Aim    (Institute for Healthcare Improvement)1. Improve population health2. R...
Chronic Disease*People with chronic diseases   →   70% HC spending   Diabetes   Coronary Artery Disease   Congestive He...
Distribution of Health Care Expenditures*1% of population    →   35% of HC spending5% of population    →   60% of HC spend...
Health Field ModelInfluence Factors on Health Status     Social 15%                          Environmental 5%             ...
BThe Second CurveScenario B
WHERE THE RUBBER           MEETS THE ROADCost continues to escalate    Acute care system lacks capacity to absorb    201...
Where are the solutions?•   Development of a model that creates a Health Community.•   Improved data collection systems th...
Profile of WV Medicaid 400,000  Medicaid member We will expand by 170,000 new members Medical costs in 2010 were $2.5 b...
Major Challenges Expanded  population Higher cost for services New therapies Requirement to cover more conditions    ...
Facts about our duals.. There are just under 50,000 West Virginia dual eligible members. That’s 12% of Medicaid eligibles...
Facts about duals.. 40%  of the duals had a hospital admission in  2010. 28% had more than one admission. 32,000 dual e...
West Virginia’s foster care             children…. Medicaid   covers 8,500 children in foster  care. 600 of those childr...
What are we doing in WV? Data   to guide decisions     Data warehouse, APCD, benchmarks Many    care coordination effor...
The importance of coordinated           effort!
What else? Major pharmacy efforts on opiates, psych  meds, high dollar oncology products EHR, incentives, ePrescribing, ...
This is clearly a time of challengeand opportunity for primary carephysicians as we move forwardimproving health and the h...
Becker_Options WV
Becker_Options WV
Becker_Options WV
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Transcript of "Becker_Options WV"

  1. 1. Health Care Challenges andOpportunities for Primary Care in West Virginia James Becker, MD Medical Director WV DHHR, Bureau for Medical Services
  2. 2. “We are all faced with a series of great opportunities – brilliantlydisguised as insoluble problems.” -- John W. Gardner
  3. 3. The evolution of systems Plateau Decline GrowthInvestment Excerpt from “The Age of Paradox,” Charles Handy, 1994
  4. 4. 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).
  5. 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, athttp://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; file nhegdp09.zip).
  6. 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. 7. Average Annual Health Insurance Premiums and Worker Contributions for Family Coverage, 2001–2011
  8. 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. 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. 10. US vs. OECD: Hospital Stays / CostsFewer and shorter hospital stays are offset by higher unit cost Source: OECD, McKinsey Global Institute Analysis
  11. 11. AGING OF THE BABY BOOM GENERATION78 million people30 percent of U.S. populationUnfunded liability in Medicare = $70 Trillion
  12. 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. 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. 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. 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. 16. BThe Second CurveScenario B
  17. 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. 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. 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. 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. 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. 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. 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. 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. 25. The importance of coordinated effort!
  26. 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. 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.
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