South Carolina Self-Insured Conference 2013

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Dr. Teresa Bartlett

Dr. Teresa Bartlett

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  • Was a first for BlueCross in SC
  • Often requires 6 to 9 legal documents
  • supply of a specific resource has a major influence on utilization rates. The frequency of use of supply-sensitive care is not determined by well-articulated medical theory, much less by scientific evidence; rather, it is largely due to differences in local capacity, and a payment system that ensures that existing capacity remains fully deployedPatient Preference Sensitive Care-- options involving significant tradeoffs among different possible outcomes of each treatment (some people will prefer to accept a small risk of death to improve their function; others won’t). Decisions about these interventions -- whether to have them or not, and which ones to have -- should thus reflect patients’ personal values and preferences, and should be made only after patients have enough information to make an informed choice, in partnership with the physician. There are two principal causes of variations in rates of preference-sensitive care.Comprises treatments for conditions where legitimate treatment options exist -- options involving significant tradeoffs among different possible outcomes of each treatment (some people will prefer to accept a small risk of death to improve their function; others won’t). Decisions about these interventions -- whether to have them or not, and which ones to have -- should thus reflect patients’ personal values and preferences, and should be made only after patients have enough information to make an informed choice, in partnership with the physician. There are two principal causes of variations in rates of preference-sensitive care. First, there is the often poor state of clinical science; for many conditions for which major surgery is an option, the alternative treatments have not been adequately evaluated through rigorous scientific studies. Thus, when surgeons recommend surgery, they often do so on the basis of subjective opinion, personal experience, anecdote, or an untested clinical theory that might or might not prove true were it subjected to some actual science.The second problem lies in how many medical decisions are made. Even when evidence exists as to outcomes, surgery rates can vary dramatically from place to place. This is the case in early stage breast cancer. Studies show that mastectomy and lumpectomy achieve similar long-term survival, but women generally differ sharply in their attitudes toward these treatments. Yet in an early Dartmouth Atlas study, we found regions in which virtually no Medicare women underwent lumpectomy, while in another, nearly half did. We see dramatic variations in rates of surgical treatment for other conditions where multiple treatment options are possible, such as chronic angina (coronary bypass or angioplasty), low back pain (disc surgery or spinal fusion), arthritis of the knee or hip (joint replacement), and early stage cancer of the prostate (prostatectomy). Such extreme variation arises because patients commonly delegate decision-making to physicians, under the assumption that doctors can accurately understand patients’ values and recommend the correct treatment for them. Yet studies show that when patients are fully informed about their options, they often choose very differently from their physicians
  • Effective care refers to services that are of proven value and have no significant tradeoffs -- that is, the benefits of the services so far outweigh the risks that all patients with specific medical conditions should receive them. These treatments, such as providing beta-blockers for heart attack patients, are backed by strong scientific evidence of efficacy.Despite all the resources expended on health care in the United States, sometimes treatments that are known to be effective are not used. As the Dartmouth Atlas Project has documented, the underuse of effective care is widespread and occurs even at some hospitals considered among the best in the country. A 2003 study by the Rand Corporation published in the New England Journal of Medicine found that Americans receive only about 55% percent of recommended care for a variety of common conditions.The failure to provide effective care can have dire consequences for patients. It is well established that beta-blockers can reduce the risk of heart attack in patients who have already had one heart attack. Yet many heart attack patients are never prescribed beta-blockers. For patients with diabetes, annual eye exams can help avoid the possibility of blindness; yet many diabetic patients do not receive annual eye exams.Given that providers agree on the importance of providing these types of treatments, why do so many patients go without them? The answer is not a lack of money. The Dartmouth Atlas Project has found that there is no correlation between higher spending and more widespread use of effective care. The causes of underuse include fragmented care (which tends to grow worse when more physicians are involved in the patient’s care) and the lack of systems to ensure that all eligible patients receive these treatments.The remedies for underuse of effective treatments lie in fostering the development of organized and integrated physician practices that can implement reliable processes and changes to the payment system to reward better care, not simply more care
  • Understanding about your diagnosis and disease process may help with self care and lifestyle choices
  • Medical Tourism domestic and abroadRetail markets have treatment available in stores WalMart, Walgreens, CVSMedical concierge Help patients navigate the system usually at a yearly fee over and above premiums your doctor is avialable via phone and internet 24 x 7E health electronic or phone visit DOD uses

Transcript

  • 1. Sedgwick © 2013 Confidential – Do not disclose or distribute.Teresa Bartlett, MD
  • 2. Sedgwick © 2013 Confidential– Do not disclose or distribute. 2Objective• Consumerism• Setting the stage• Discuss Affordable Care Act• Explain Basic Premises of ACA• Evidence Based Medicine• Explore Potential Impact on Workers Comp System
  • 3. • Politicalcomponent• Media• Direct toconsumeradvertising• Technology• Providermarketing• PayercommunicationConsumerism Impacting the HealthDelivery ModelAccesstoinformationKnowledgemanagement• Perceptions• Health risks• Treatmentimpact• Carecoordination• Outcome data• Generationalconsiderations• Nurse navigators• Medical literacy• Physicianschedulingservices• Sound technologysolutions• Key stakeholderawareness• Consumer drivenplansModelconsiderations
  • 4. Sedgwick © 2013 Confidential– Do not disclose or distribute. 4Disease Burden: the perfect storm• Patients with 1 chronic condition– 3 times higher health care spend• Patient with 5 or more chronic conditions– 17 times higher health care spend• 4 out of 5 Medicare beneficiaries are affected by at least one chronic condition• Medicare population incident rates of:– Obesity 38%– Diabetes 27%• Americans are living longer (78.2 years)– Number of Medicare recipients expected to double in next 40 yearswww.aha.org/research/policy/2012.shtml
  • 5. Sedgwick © 2013 Confidential– Do not disclose or distribute. 5Aberrant Economic Model• Employers and Government pay for services• Individuals consume the care• Providers set prices• Archaic administrative system
  • 6. Sedgwick © 2013 Confidential– Do not disclose or distribute. 6Drawback of Fee for Service model• Limited physician patient time• Rewards volume not value• Coordinated care takes too much time and is not rewarded• Quality care not rewarded
  • 7. Sedgwick © 2013 Confidential– Do not disclose or distribute. 7Affordable Care Act• Signed into law 2010• Challenged constitutionality upheld June 2012• Major Focus– Create value based networks– Create integrated health systems
  • 8. Sedgwick © 2013 Confidential– Do not disclose or distribute. 8Legality• Federal Trade Commission/Department of Justice February 13, 2013letter of guidance (CIN)– Antitrust law– Usually joint contracting by physicians constitutes price fixing– Rule of reason– Measurement– Time and Financial Commitment– Initial Capital investment– Financial riskNorman Physician Hospital Organization
  • 9. Sedgwick © 2013 Confidential– Do not disclose or distribute. 9Health Care Change Impact in South Carolina• Increased access to the Medicaid program– 726,847 or 18% of South Carolina’s non-elderly residents are uninsured• 50,000 young adults gained insurance coverage in South Carolina as of December2011 (3.1 million nationwide)• Medicare recipients saved over $84.3 million on prescription drugs since enactmentof Medicare Part D (drug coverage)– In 2012: 52,686 individuals in South Carolina saved over $35.6 million, or anaverage of $677 per beneficiary.• Preventive Health Coverage at no cost share: colonoscopy, Papsmears, mammograms, well-child visits, and flu shots for all children and adults– In 2011 and 2012, 71 million Americans with private health insurance gainedpreventive service coverage with no cost-sharing– 980,000 in South Carolina.Healthcare.gov
  • 10. Sedgwick © 2013 Confidential– Do not disclose or distribute. 10Examples of Affordable Care Act Grants to South Carolina• $4,300,000 for health professions workforce demonstration projectsAssistance for low income families to fund training to enter health care professionsin high demand• $2,811,027 for school based centers to help clinics expand their capacity to providemore health care services and modernize their facilities• $7,283,151 for maternal, infant, early childhood home visiting programs for at riskfamilies– health care– early education– parenting skills– child abuse prevention– nutritionHealthcare.gov
  • 11. Sedgwick © 2013 Confidential– Do not disclose or distribute. 11Primary Care Physicians’ Collaboration (Columbia, SC)• 800 diabetic patients• Sponsored by BlueCross BlueShield of South Carolina, BlueChoice®, HealthPlan, and PalmettoPrimary Care Physicians• 2-year study• Patient-centered medical home• Results– 14.7 percent fewer inpatient hospital days– 25.9 percent fewer emergency room visits.– better control of their blood pressure, cholesterol and glucose levels.– healthier body mass index (BMI) rates, and– more of them received eye exams.• Patient-centered medical home– Primary care based– Leads medical team including care coordinators– Coordinates health needs including prevention, acute and chronic care– Providers were paid a per member per month fee plus a bonus for improved health inadditional to fee for service• Led to initiation of other projects (heart failure and hypertension)
  • 12. Sedgwick © 2013 Confidential– Do not disclose or distribute. 12Clinically Integrated Organization (CIO)• Legal entity• Structured to hold contracts for• Commercial• Government based products• Challenge for hospital systems to create arrangements thatallow for shared savings• Develop partnerships with physicians outside of thecontractual arrangements in place today
  • 13. Sedgwick © 2013 Confidential– Do not disclose or distribute. 13CIO• Physician will be paid for care management and evidenced based care• Patient centric medicine• Health plans are likely to– Employ physicians– Purchase physician practices
  • 14. Sedgwick © 2013 Confidential– Do not disclose or distribute. 14Accountable Care Organization (ACO)• State based entity• Qualifies to participate in Medicare shared savings program• Must have 5000 Medicare beneficiaries• Comply with 33 Quality MetricsPRIMARY MODEL• Medicare shared savings program• Launched 1-1-12• Maximum shared savings for hospitals and physicians is10% of aggregate cost of patient careTHE BASIC PREMISEMoves from fee for service to a value based reimbursement
  • 15. Sedgwick © 2013 Confidential– Do not disclose or distribute. 15Measurements for ACOValue• Better care• Preventative care• Patient safety• Care coordination between specialties• Focus on AT RISK populationsMeasurement and Reporting• Year one: must report on all 33 measures• Year two: must fall within the 30th percentile of National Medicarequality performance measures for 70% of required measures• Year three: must meet the standards established in the second year
  • 16. Sedgwick © 2013 Confidential– Do not disclose or distribute. 16Other Models• Pioneer ACOs– Health organizations selected by the federal government prior to the ACA toparticipate in a shared savings model– Had prior managed care experience– Can achieve greater savings and assume greater risk– Can move to a capitated model in the 3rd year• Bundled payments• Patient centered medical homes (PCMH)www.innovation.cms.gov
  • 17. Sedgwick © 2013 Confidential– Do not disclose or distribute. 17Models• Advanced payment– Developed by CMS innovation to provide up front monthly payments toencourage the development of ACOs in rural areas– Limited capital– Loans are deducted from any future savings• Shared savingsHealth organizations can opt for one or two risk models– Bonus only- no risk• Only available for the first 3 years– Complex formula• Higher savings• Quality benchmarks
  • 18. Sedgwick © 2013 Confidential– Do not disclose or distribute. 18Health Exchanges• Federal• State• Private
  • 19. Sedgwick © 2013 Confidential– Do not disclose or distribute. 19Health Insurance Exchanges• 12 million Americans expected to begin purchasing health insurance• October 2013 for coverage beginning 2014• Federal subsidies will entice many to market– Public– Private• Insurers need to be careful to balance healthy and sick members• State requirement to educate consumers on financial assistance options– 100% to 400% of poverty level qualify for subsidy or reduced costsharing• 40% of the volume will come from 5 states: NY, CA, TX, FL, IL• State Insurance Exchanges are projecting $205 Billion opportunity for thehealth sector within the first seven years of operation
  • 20. Sedgwick © 2013 Confidential– Do not disclose or distribute. 20• Insurer-run (plan choices)• Retailer-run (companies outside health industry that sell theirown insurance products and will have bundles or buy upproducts such as wellness• Third-party-run (an administrator that links consumers to avariety of plan choices across multiple insurers. (large brokersand insurance firms)Private Exchanges
  • 21. Sedgwick © 2013 Confidential– Do not disclose or distribute. 21Industry Implications of Health Insurance Exchanges• Providers– Increased number of patients pent up need for care– New expectations of patients (increased focus on customer experience)– Uncertain payment landscape• Insurers– Pricing– Risk selection– Which markets should they enter• EmployersRole of exchanges in the futurePenalty $2000/full time employeeDropping coverage may lead to pressure to increase wagesTax benefits of offering coverageEmployees view health care as a valuable benefitSource:Health Research Institute analysis
  • 22. Sedgwick © 2013 Confidential– Do not disclose or distribute. 22Only 20% of a physicians practice is based on hard scienceAccording to the Federal GovernmentEvidenced based medicine leads to healthier patients andreduced costs
  • 23. Sedgwick © 2013 Confidential– Do not disclose or distribute. 23Dartmouth Atlas of HealthcareUS and UK data show that much of the variation in use ofhealthcare is accounted for by the willingness and ability of doctorsto offer treatment rather than differences in illness or patientpreference. Identifying and reducing such variation should be apriority for health providers “John Wennberg”EXAMPLEThe rates of coronary stents are three times higher inElyria, Ohio, compared with nearby Cleveland, homeof the famous Cleveland Clinic
  • 24. Sedgwick © 2013 Confidential– Do not disclose or distribute. 24Why Such Variation in Care?• Supply-sensitive care– due to differences in local capacity, and a payment system that ensures thatexisting capacity remains fully deployed• Patient Preference-sensitive care comprises treatments for conditions wherelegitimate treatment options exist– Options involve significant trade offs and different possible outcomes– Informed and educated decision– Medical outcomes can vary greatly from place to place
  • 25. Sedgwick © 2013 Confidential– Do not disclose or distribute. 25Effective CareProvenValueNo tradeoffsEvidencedBasedCaused By:UnderuseFragmentedCareLack ofsystemProcessTheSolution:ClinicallyIntegratedQualityCareFinancialIncentives
  • 26. Sedgwick © 2013 Confidential– Do not disclose or distribute. 26EBM Tools for Practicing Physicians• Electronic Medical Records• Prevents duplication of services• Eliminates medication errors• Office Notes appear as template (drop down/canned text)• Links to latest evidenced based information• Health alerts– Pertinent items only to avoid “alert fatigue”• Software tools to grade quality of evidence• Transparency of performance• Practice management• Measurement• Improvement plan
  • 27. Sedgwick © 2013 Confidential– Do not disclose or distribute. 27Challenges of Today’s World• Learning versus dependency on technology• Students and Residents use of smart technology• Ensuring reference material is readily available• Ensuring smart technology does not replace “Real Learning”
  • 28. Sedgwick © 2013 Confidential– Do not disclose or distribute. 29Post Graduate Education• Communication is key• It is not enough to prove you know what to do• COMMUNCICATION SKILLS ASSESSMENT
  • 29. Sedgwick © 2013 Confidential– Do not disclose or distribute. 30Importance of Communication Skills• Medical Literacy• Self Care• Lifestyle choicesPatientEducation• Better Results• Transfer of specificknowledgeConsultingPhysicianEducationBetterOutcomes
  • 30. Sedgwick © 2013 Confidential– Do not disclose or distribute. 31Impact of Evidence Based Medicine• Already seeing changes• Physician/practices are spending up to 25% more time tojustify tests• Health plans are offering incentives and disincentives tophysicians– High cost imaging services– Hospitals seeing dramatic reductions• Physicians want positive position shared savings• Hospitals want shared savings– Following the lead of health plans
  • 31. Sedgwick © 2013 Confidential– Do not disclose or distribute. 32South CarolinaWorkers’ Compensation Medical Spend TrendAverage Medical SpendMedical Category 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012Chiro $695 $952 $304 $493 $415 $286 $366 $73 $485 $450Diagnostic $249 $377 $362 $454 $343 $326 $393 $223 $232 $272DME $335 $785 $949 $1,227 $1,265 $927 $1,180 $836 $835 $1,506In Patient Hosp $10,675 $9,988 $19,977 $11,763 $6,659 $57,365 $8,567 $10,087 $6,942 $11,189Misc Medical $697 $317 $988 $706 $726 $864 $154 $259 $757 $276Occ Therapy $729 $1,165 $1,002 $890 $892 $886 $1,386 $808 $726 $791Out Patient Clinic $158 $101 $98 $191 $205 $160 $307 $423 $330 $485Out Patient Surgery $2,059 $1,148 $1,536 $2,012 $1,090 $1,431 $1,425 $1,862 $1,657 $1,775Pharmacy $575 $554 $603 $844 $650 $851 $838 $687 $659 $815Practioner $915 $547 $500 $719 $548 $589 $746 $678 $644 $739PT $1,060 $1,577 $1,295 $1,662 $1,533 $1,255 $1,431 $1,438 $1,651 $1,656Medical Exam-Independent(IME)/Agreed $775 $431 $399 $591 $419 $253 $1,144 $1,247 $540 $557Field Case Management Fee $988 $1,117 $2,926 $1,503 $3,780 $1,494 $680 $1,594 $1,823 $1,965All Other Medical $533 $460 $506 $1,192 $850 $808 $1,036 $1,360 $710 $836Grand Total $892 $706 $789 $985 $755 $1,071 $939 $844 $744 $890
  • 32. Sedgwick © 2013 Confidential– Do not disclose or distribute. 33Likely impact on Workers’ CompensationBenefits– Use evidence based care and best practices– High quality– Single claim and note format– Enhanced coordination of care– Reduced duplication of services– Enhanced communication– Higher adoption of EHRPotential Challenges– Person centric ( focus on all medical problems not just WC)– Networks• Primary Care Single CIO• Specialists multiple CIO
  • 33. Sedgwick © 2013 Confidential– Do not disclose or distribute. 34New Models of Care
  • 34. Sedgwick © 2013 Confidential– Do not disclose or distribute. 35Trends to watch for• Hospital costs will continue to grow• Physician alignment will be a moving target• Health plans will evolve and try to grow in new lines of business• New models of care• Increased Transparency• Volume will still be a focus• Information technology is key• Consolidations• Creative branding
  • 35. Sedgwick © 2012 Confidential – Do not disclose or distribute. 36Questions and Discussion