Benefits and beyond c. 8 health care reform

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  • http://onlinelibrary.wiley.com/doi/10.1002/hrm.3930340407/abstract
  • http://www.mayoclinic.org/healthpolicycenter/recommendations.html
  • Benefits and beyond c. 8 health care reform

    1. 1. Benefits and Beyond C. 8<br />Improving access to health care.<br />Thomas E. Murphy<br />
    2. 2. 10/09/09<br />Thomas E. Murphy<br />2<br />March 23, 2010 – Patient Protection and Affordable Care Act<br />
    3. 3. 10/09/09<br />Thomas E. Murphy<br />3<br />What led up to this?<br />
    4. 4. U.S. offers excellent health care. <br />It is designed to cover all Americans.<br />Most coverage is employment based and 98% of employers with over 200 employees provide health insurance.<br />But – the cost is too high.<br />Result: cost sharing increased, some small employers abandoning coverage, and too many uninsured. And, since health care is largely tied to employment . . . <br />4<br />What’s wrong?<br />10/09/09<br />Thomas E. Murphy<br />
    5. 5. Fear that “you are a pink slip away from losing health care.”<br />Fear of dropped coverage when sick and exclusion of pre-existing condition. <br />5<br />And, Unemployment is 9.6%. <br />10/09/09<br />Thomas E. Murphy<br />
    6. 6. Continuing coverage under COBRA has been expensive.<br />Stimulus Law – a temporary gov’t subsidy to buy COBRA. Ended May 31, 2010. <br />10/09/09<br />Thomas E. Murphy<br />6<br />Coverage after layoff? (photo: www.medicine.net)<br />
    7. 7. Problems?<br />Issues?<br />Alternatives?<br />Health Policy?<br />Health Care Reform?<br />Let’s look a little deeper!<br />10/09/09<br />Thomas E. Murphy<br />7<br />What does the data show<br />
    8. 8. 8<br />Employer Coverage is down!<br />10/09/09<br />Thomas E. Murphy<br />
    9. 9. 47% of firms with 3-9 employees<br />72% of firms with 10-24 employees<br />93% of firms with over 50 employees<br />98% of firms with over 200 employees<br />10/09/09<br />Thomas E. Murphy<br />9<br />Employer sponsored overall coverage - 59% (+180,000,000)<br />
    10. 10. 10/09/09<br />Thomas E. Murphy<br />10<br />What’s Wrong? <br />
    11. 11. 11<br />Our health care system**There is some overlap – for example, 27 million buy individual health policies.<br />10/09/09<br />Thomas E. Murphy<br />
    12. 12. 10/09/09<br />Thomas E. Murphy<br />12<br />U.S. Residents-No health insurance (in millions – U.S. Census)<br />
    13. 13. 13<br />High Costs Impede Access<br />“My friend ends her own business and gets a job with Starbucks” to get health care. <br />Annual H.C. cost in the U.S. depends on what? (where, who, deductible)<br />Employee total cost sharing is around +30%.<br />U.S. pays more for health care:16.2% of GDP vs. 12% average for other OECD countries.<br />10/09/09<br />Thomas E. Murphy<br />
    14. 14. From 2000-2010, health care premiums have increased 130% and other out-of-pocket cost sharing features have increased 115%.<br />10/09/09<br />Thomas E. Murphy<br />14<br />The increasing cost shift<br />
    15. 15. Current System is too expensive because of:<br />Inappropriate care (35%).<br />Medical errors: 100,000 deaths per year.<br />Third party payer – lack of market dynamics.<br />No value based competition<br />Poor health culture (high obesity and resulting chronic diseases), poor health education, and lack of patient compliance. <br />Tax treatment, and other reasons . . . <br />15<br />Why do we cost more?<br />10/09/09<br />Thomas E. Murphy<br />
    16. 16. Our multi-layered administrative systems cost $35 billion annually more than other OECD countries.<br />Our prices and salaries of health care goods and services are much higher than European countries. <br />We have more and quicker access to technology –such as imaging, robotic surgery, R/x.<br />No government subsidies or price leverage except Medicare and Medicaid. <br />16<br />Why do we cost more?<br />10/09/09<br />Thomas E. Murphy<br />
    17. 17. Why do we cost more?<br />How to control?<br />Cutting is not the answer<br />Aging Population<br />High expenditures in last 3 months of life<br />3d party long term care system<br />Highest compensation for providers.<br />High R/X marketing and R&D costs..<br />10/09/09<br />Thomas E. Murphy<br />17<br />
    18. 18. Malpractice and defensive medicine<br />Third party payer system removes the consumer from “engagement” and making informed decisions.<br />(Photos: www.medicine.net)<br />10/09/09<br />Thomas E. Murphy<br />18<br />More cost drivers . . .<br />
    19. 19. U.S. life expectancy, infant mortality, access to health care is below OECD leaders. <br />U.S. ranks last in “patient safety” among 5 top OECD countries<br />Research says, however, this is not result of health care system but rather culture and education. Adult obesity is over 30% and the cause of a number of chronic diseases.<br />10/09/09<br />Thomas E. Murphy<br />19<br />But are we better? <br />
    20. 20. 10/09/09<br />Thomas E. Murphy<br />20<br />The David, growing up in America!<br />
    21. 21. U.S. is best place to be for serious health problems.<br />Survival rates per 100,000 for major and acute health problems is highest.<br />U.S. leads world in research, innovation, and new drug therapies. (70% of innovation comes from U.S.)<br />U.S. has shortest wait lists by a large margin for elective procedures, and in many cases for medically necessary treatments. <br />21<br />But. . . The reality is . . . . <br />10/09/09<br />Thomas E. Murphy<br />
    22. 22. Cost is the chief reason nearly 50 million are uninsured.<br />And why employers and government are struggling to continue health insurance.<br />10/09/09<br />Thomas E. Murphy<br />22<br />What is the Problem?<br />
    23. 23. High Cost makes access difficult!<br />How do we reduce costs?<br />Need more data . . . <br />Could we enhance access with lower costs?<br />Would a quality-driven market system reduce costs?<br />What are the other choices?<br />Let’s look at more data<br />10/09/09<br />Thomas E. Murphy<br />23<br />
    24. 24. If cost is the problem how do we best deal with it?<br />Can we reduce our costs and still assure high quality and efficacy?<br />What if we conducted a “SURGE” against costs?<br />10/09/09<br />Thomas E. Murphy<br />24<br />The solutions?<br />What data do we need to make a policy decision?<br />
    25. 25. 10/09/09<br />Thomas E. Murphy<br />25<br />Cost Allocation in the U.S. Kaiser foundation, 2009<br />
    26. 26. 10/09/09<br />Thomas E. Murphy<br />26<br />Cost Averages* Depend On:*For state pricing see: www.healthcare.org<br />
    27. 27. 27<br />The health care reform baton is being passed – 2010-2014!<br />Affordable Care Act of 2010 is “access reform” – it is not health care reform that in large part was driven by high numbers of uninsured and the high costs of our health care. <br />10/09/09<br />Thomas E. Murphy<br />
    28. 28. Just less than 50% do not meet Medicaid standards, and cannot afford health care.<br />Some, 24.5%, however, qualify for Medicaid but choose not to enroll. <br />20% can afford private coverage but choose not to buy it. <br />Most work.<br />8% are business owners<br />28<br />Who are the 50 million uninsured?<br />10/09/09<br />Thomas E. Murphy<br />
    29. 29. Most are uninsured for less than one year.<br />55% are between the ages of 18 and 35; many decide they are healthy and don’t need insurance.<br />7% have household incomes in excess of $75,000; 22% made over $50,000 in 2007.<br />Disproportionate number of black and Hispanic are uninsured.<br />10/09/09<br />Thomas E. Murphy<br />29<br />Who are the Uninsured?<br />
    30. 30. 10/09/09<br />Thomas E. Murphy<br />30<br />Problems – Insurance Underwriting<br />
    31. 31. Cost shifting<br />Unreimbursed care<br />Community rating<br />Need old and young, healthy and sick to pool risk.<br />Pre-existing condition. (HIPAA)<br />No guaranteed issue<br />Right to cancel<br />Individual coverage premiums based upon health status<br />Not much portability except for COBRA<br />Adverse selection<br />State control over insured plans<br />10/09/09<br />Thomas E. Murphy<br />31<br />Health Insurance Underwriting<br />
    32. 32. When sick people are without insurance, they don’t need insurance, they need health care.<br />10/09/09<br />Thomas E. Murphy<br />32<br />But remember . . . (Photo: www.medicine.net)<br />
    33. 33. The most powerful instrument in our system that generates the utilization of health care resources and higher costs – is – the physician’s ordering pen. <br />10/09/09<br />Thomas E. Murphy<br />33<br />And really remember . . . <br />
    34. 34. Insurance companies do not write prescriptions or order MRIs.<br />While they add costs to our system, high utilization and prices are major cost drivers in U.S.<br />10/09/09<br />Thomas E. Murphy<br />34<br />And . . .<br />
    35. 35. 10/09/09<br />Thomas E. Murphy<br />35<br />Range of Reform Solutions<br />
    36. 36. 10/09/09<br />Thomas E. Murphy<br />36<br />A “Surge” against costs!<br />
    37. 37. Tax law change<br />Creating quality and value-based markets for health care (-25%)<br />New types of integrated care models<br />Improved pre-natal care education and access<br />Mitigate chronic disease risk factors<br />Electronic medical records – reduce errors<br />HSAs, Wellness, increase engagement<br />Tort Reform – reduce unnecessary care (-10-20%)<br />Interstate insurance competition - <br />Reduce administrative costs.<br />And more. . .<br />10/09/09<br />Thomas E. Murphy<br />37<br />Surge on Costs – What might work?<br />
    38. 38. Convert Medicaid to Defined Contribution Plan.<br />Merge insurance markets – individual and small employer.<br />Pay for results not separate services<br />Capitation of fees (DRGs)<br />Change Supply Side Services<br />Encourage integrated care organizations.<br />Simplify claims processing<br />Assure access to Primary Care <br />10/09/09<br />Thomas E. Murphy<br />38<br />Surge on Costs<br />
    39. 39. 39<br />The 80/20 rule: Preventive Care <br />Put your <br />resources <br />here: <br />Preventive and <br />Chronic<br />care <br />10/09/09<br />Thomas E. Murphy<br />
    40. 40. Change reimbursement system – reward success and pay for non-traditional services that enhance efficiency and effectiveness<br />Is the office visit the only way medicine can be dispensed?<br />Is capitation a reasonable approach vs. fee for service? <br />Encourage integrated health providers.<br />40<br />What’s this “Supply-Side” focus?<br />10/09/09<br />Thomas E. Murphy<br />
    41. 41. What happens when providers compete on basis of quality and price? Look at what has happened to the outcomes and prices for Lasik surgery. <br />Wal-Mart - $4.00 for many drugs. See also, www.rx.com/<br />Walk in clinics in retail stores.<br />Urgent care centers vs. hospital emergency rooms. <br />41<br />Supply side emphasis?<br />10/09/09<br />Thomas E. Murphy<br />
    42. 42. Employer paid health insurance is not taxed as ordinary income to the employee.<br />This is unfair to those who buy insurance on their own; the premiums are paid after tax.<br />If we tax employer paid premiums, employees will search for ways to find their own health plans. The plan will suit their needs and will be portable. No longer dependent upon employment.<br />Forgone tax revenue runs between $90-$130 billion.<br />42<br />What about tax change and reform?<br />10/09/09<br />Thomas E. Murphy<br />
    43. 43. One approach is to limit the exemption from income to $5000 per year. Any higher value would be subject to income tax.<br />In addition, all out of pocket costs for health care would be deductible, thus encouraging purchase of more cost efficient plans.<br />This would not necessarily cause employers to drop sponsored care – there are competitive and productivity reasons to continue. And, employers can deduct expense. <br />43<br />Tax changes and health care<br />10/09/09<br />Thomas E. Murphy<br />
    44. 44. Full deductibility of self-purchased high deductible health care plan and contributions to HSAs.<br />Could be offset by a refundable tax rebate? Should this be available to all or only those who purchase a plan (HDHCP) on their own? <br />Tax preference is based upon convenience and efficiency of employer sponsorship and lack of employee leverage and knowledge to make purchasing decisions themselves.<br />44<br />Tax changes and health care<br />10/09/09<br />Thomas E. Murphy<br />
    45. 45. The view is that this change would engender fairness between those who currently participate in an employer sponsored plan and those who pay for their own insurance. <br />It also will provide a portable health care plan not dependent upon employment. <br />It should have the effect of making health care more affordable and decrease number of uninsured. <br />45<br />Tax changes and health care<br />10/09/09<br />Thomas E. Murphy<br />
    46. 46. Principle of compensating differentials – more health care costs reduces other elements of compensation.<br />Good health care is never “free!” Someone is paying for it. <br />10/09/09<br />Thomas E. Murphy<br />46<br />Tax changes – a few principles<br />
    47. 47. What do we do first?<br />Reduce costs?<br />Increase access?<br />Our health care bridge is burdened with high costs; why would we put more people on the bridge?<br />10/09/09<br />Thomas E. Murphy<br />47<br />How to prioritize – access or costs? <br />
    48. 48. Consequences of + Access?<br />Mandated or Public<br />Mandated or Public<br />Public or mandated system must be financed- it is not free. <br />Underwriting savings not sufficient to finance.<br />Financed by taxes, fines, rationing, artificial reduction of reimbursements. <br />Must have a standard policy with limits on cost sharing and minimum requirements on coverage.<br />Providers must comply with medical protocols<br />Public or State option may swallow the private sector.<br />10/09/09<br />Thomas E. Murphy<br />48<br />
    49. 49. Consequences?<br />Costs will increase! <br />Increased Gov’t. Employment (HHS HQ) <br />Must rely on community ratings<br />Limited underwriting and premium differentiation.<br />Impact on quality and consumer satisfaction?<br />Will a dual system arise as it has in some EU contries?<br />Non-profit insurance system<br />10/09/09<br />Thomas E. Murphy<br />49<br />
    50. 50. Free medical education?<br />Give subsidies to purchase – how much and for what?<br />Arbitrarily imposed price controls on medicine and insurance providers.<br />10/09/09<br />Thomas E. Murphy<br />50<br />Consequences . . . <br />
    51. 51. 10/09/09<br />Thomas E. Murphy<br />51<br />New quality based market?<br />
    52. 52. 52<br />It’s a leap, but we can do this! <br />10/09/09<br />Thomas E. Murphy<br />
    53. 53. A quality and value based competition model would be a sound basis for reforming health care in the U.S. It could be a dynamic choice to make health care affordable!<br />10/09/09<br />Thomas E. Murphy<br />53<br />Murphy says:<br />
    54. 54. 10/09/09<br />Thomas E. Murphy<br />54<br />A Measured Approach to Reform<br />
    55. 55. Allow competition to drive quality improvements and make service more affordable– as it has done in other industries. <br />Centerpiece: clinical outcomes data!<br />10/12/10<br />Thomas E. Murphy<br />55<br />Data is the key!<br />
    56. 56. Reducing the costs of health care and making it more affordable through market changes are aimed at the core cause of the health care crisis in the U.S. <br />10/09/09<br />Thomas E. Murphy<br />56<br />A Focused Approach<br />
    57. 57. Quality, value, and cost are not rewarded.<br />Competition should be structured so that it is quality and value based; this will lead to lower costs.<br />This would be REAL health care reform!(See: “My View” at this link)<br />See also the Mayo Clinic Health Policy Center’s Recommendations: <br />Create Value<br />Coordinate Care<br />Reform payment system<br />Health Insurance for all. <br />10/12/10<br />Thomas E. Murphy<br />57<br />More specifically. . . <br />
    58. 58. Competition drives improvements in quality and cost.<br />Rapid innovation is diffused through the industry.<br />Excellent competitors grow, weaker rivals exit the market.<br />Quality improves, prices fall, value increases, and the market accommodates more consumers<br />10/12/10<br />Thomas E. Murphy<br />58<br />Traditional Competitive Model<br />
    59. 59. Health care must be a patient centered system<br />Currently, it serves others – TPAs, Providers, Sponsors, Patients, Unions, Government. <br />10/12/10<br />Thomas E. Murphy<br />59<br />Competition in health care?<br />
    60. 60. Also, the scope of health care is too narrow: it focuses on a disease, illness, or injury.<br />It should focus on the full cycle of care for a medical condition.<br />There is very little integration of care relating to this condition.<br />The system is structured around medical specialties –who are like “free agents” – performing their function and billing accordingly. <br />10/12/10<br />Thomas E. Murphy<br />60<br />Condition vs. Disease<br />
    61. 61. Would reward value<br />No government or sponsor imposed “solutions.”<br />Providers would arrive at solutions to successfully compete in this new market<br />10/09/09<br />Thomas E. Murphy<br />61<br />A value-based market model:<br />
    62. 62. How many cardiac bypass surgeries?<br />What results?<br />How many post surgical infections?<br />What were length of stay and charges?<br />Complications<br />Re-admissions<br />10/09/09<br />Thomas E. Murphy<br />62<br />The centerpiece – outcomes data!<br />
    63. 63. Published patient outcomes per unit of cost at the medical condition level. <br />We currently pay for services rendered – appropriate or not and in some few cases for the provider’s adherence to certain medical protocols.<br />Outcomes should be but are not considered.<br />We have the ability to review clinical outcomes data NOW! – but we don’t <br />10/12/10<br />Thomas E. Murphy<br />63<br />How should we measure? <br />
    64. 64. 10/09/09<br />Thomas E. Murphy<br />64<br />Who is doing the best job – give them our business!<br />
    65. 65. We have no real quality records of providers.<br />We have no access to charges or prices.<br />A third party selects providers and pays them.<br />We don’t compare.<br />10/09/09<br />Thomas E. Murphy<br />65<br />Health consumers-is this a market?<br />
    66. 66. It is a “zero sum” approach. The gain of one party comes at the expense of the other.<br />Provider costs are simply shifted from one party to another.<br />There is no market system to reward “value” – cost and quality. <br />10/12/10<br />Thomas E. Murphy<br />66<br />Distorted “Competition” Models<br />
    67. 67. 10/12/10<br />Thomas E. Murphy<br />67<br />Current vs. Future Model<br />
    68. 68. Provider consolidations have occurred everywhere – hospitals, physicians, suppliers.<br />This has enabled them to increase reimbursements. Prices are up.<br />But, there are very little net efficiency gains and few efforts to integrate care.<br />No “value” created. <br />Participants and sponsors pay more. <br />10/12/10<br />Thomas E. Murphy<br />68<br />Mergers- increase bargaining leverage<br />
    69. 69. An “artificial” grouping of providers<br />In network practices lead to limited choices.<br />The network is not chosen because of quality outcomes. <br />The network is not focused on medical conditions, improving quality, and reducing costs. <br />10/12/10<br />Thomas E. Murphy<br />69<br />Competition to corral patients and limit choice<br />
    70. 70. Utilization review adds administrative costs to the system without sufficient returns.<br />Capitation can lead to rationing to mitigate financial risk.<br />Malpractice litigation leads to “defensive” and inappropriate care.<br />The more procedures that are ordered the higher reimbursement level for the providers.<br />The only risk free instrument is the stethoscope – other procedures carry risk<br />10/12/10<br />Thomas E. Murphy<br />70<br />Limit or unnecessarily add services<br />
    71. 71. It should occur at medical condition level – where we measure and evaluate the full cycle of care – diagnosing, prevention, monitoring, treatment, and ongoing management of the condition. <br />Value can be created by directing our employees and participants to those providers with the best clinical outcomes. <br />10/12/10<br />Thomas E. Murphy<br />71<br />Competition is at wrong level<br />
    72. 72. Some physicians do a far better job than others. <br />The same for hospitals<br />Typically the best provide services at lower costs – “they get it right the first time!”<br />10/12/10<br />Thomas E. Murphy<br />72<br />Health Care is not a commodity!<br />
    73. 73. Cost reduction should be viewed over the full cycle of care – not just a particular episode of care.<br />Competition should be viewed over a broader geographic scheme – not just local referrals. <br />True integration of care should occur with the objective of offering superior health value.<br />10/12/10<br />Thomas E. Murphy<br />73<br />Challenge the assumptions<br />
    74. 74. Absolutely necessary for patients and sponsors – but not available. <br />Often can lead to important process improvements. <br />Is critical to create informed and engaged consumers and payers of health care.<br />See the Cincinnati and other experiences where payers used clinical outcomes data to direct their participants to the “best providers.” Costs went down! <br />10/12/10<br />Thomas E. Murphy<br />74<br />The importance of outcomes datahttp://onlinelibrary.wiley.com/doi/10.1002/hrm.3930340407/abstract<br />
    75. 75. Should be assisting members in finding the best value care and improving their overall health. They do not.<br />The “annual enrollment” undermines an objective to look at long term health approaches.<br />Billing is incomprehensible and providers are encouraged to under treat.<br />Out of network restrictions lead to poor provider choices.<br />10/12/10<br />Thomas E. Murphy<br />75<br />New incentives for TPAs<br />
    76. 76. Fee for service – creates outcome problems<br />Capitation leads to implicit rationing. <br />Supply driven demand leads to providers “filling up” their capacity. <br />No competition on results means there are no incentives for “quality outcomes.”<br />Create a quality outcomes-based market and the Providers – not government or insurance companies – will find the best way to deliver health care<br />10/12/10<br />Thomas E. Murphy<br />76<br />Incentives for providers<br />
    77. 77. Often believe health care is a commodity<br />They deal with inflation by simply shifting costs to employees.<br />Encourage HSAs but ignore the importance of informed consumers who must make a number of important choices without the requisite data.<br />Employers do not realize the financial VALUE of health care as a benefit. It is often, just a cost to bear. <br />10/12/10<br />Thomas E. Murphy<br />77<br />Employer Perspectives<br />
    78. 78. Competition among providers based upon results and relating to a medical condition over a cycle of care should be the focus.<br />The competition should not be based upon compliance with protocols, but real results.<br />Results based competition will lead to provider learning and sharing of medical information. <br />10/12/10<br />Thomas E. Murphy<br />78<br />Let’s Review Some Principles<br />
    79. 79. Value based competition should lower costs because the best providers will “get it right the first time.”<br />Results are the feedback for providers and the criteria for selection by the participants.<br />The pursuit of quality does not end. It is “continuous.”<br />10/12/10<br />Thomas E. Murphy<br />79<br />Some Principles<br />
    80. 80. An endless pursuit of quality by providers incented by a new health reform system – will lead to: <br />Fewer medical errors and more “appropriate care.” <br />Disease management and real integrated care<br />A migration from diagnosis and treatment to addressing causes. <br />Cost reductions and improved affordability.<br />10/12/10<br />Thomas E. Murphy<br />80<br />Some Principles<br />
    81. 81. 10/12/10<br />Thomas E. Murphy<br />81<br />Needed Data<br />
    82. 82. Some outcomes data shows that patients treated at certain cystic fibrosis centers have a 14 year additional life expectancy than those treated at “average centers.” <br />After New York city hospitals started collecting and disseminating severity adjusted mortality data for cardiac bypass surgery, deaths declined by 41%. In a 4 year period.<br />Data can be used to educate providers!<br />10/12/10<br />Thomas E. Murphy<br />82<br />Outcomes vary by provider . . .<br />
    83. 83. It has been slow in coming.<br />Who should have access?<br />What should the data system measure?<br />How doe one acuity adjust?<br />How can change happen?<br />10/12/10<br />Thomas E. Murphy<br />83<br />Where’s the data?<br />Electronic Medical Records?<br />
    84. 84. 10/12/10<br />Thomas E. Murphy<br />84<br />What are barriers?<br />
    85. 85. TPAs focus on discounts versus patient value.<br />Medicare and other government systems have the wrong incentives and do not encourage patient value. <br />Governments so far have equated “process compliance” with “quality.”<br />Systems do not encourage integration of care.<br />Artificial and arbitrary suppression of provider fees will not create value<br />10/12/10<br />Thomas E. Murphy<br />85<br />What are barriers? <br />
    86. 86. Mindsets against being held accountable for results. <br />Lack of management expertise in the medical provider industry. <br />Medical education does not focus on value driven health care.<br />Health care delivery is too local depriving access to best providers. <br />10/12/10<br />Thomas E. Murphy<br />86<br />What are barriers?<br />
    87. 87. Physicians are often “free agents.”<br />Hospitals take on too many services.<br />The payers of health care have not insisted on accessing quality outcomes data and using it to develop their networks. <br />10/12/10<br />Thomas E. Murphy<br />87<br />What are barriers?<br />
    88. 88. 10/12/10<br />Thomas E. Murphy<br />88<br />Providers are “pushing” back fees<br />
    89. 89. 10/12/10<br />Thomas E. Murphy<br />89<br />TPAs! Orchestrate the best care!<br />
    90. 90. Enable patients to make informed choices of providers. (Not restrict choice with networks)<br />Measure and reward providers based upon results. (Not micromanage provider activities.)<br />Maximize the value of care over the full cycle of a medical condition. (Not minimize costs.)<br />Minimize administrative tasks and costs. (Not overwhelm providers and patients with paperwork)<br />10/12/10<br />Thomas E. Murphy<br />90<br />New Roles for TPAs<br />
    91. 91. Compete based upon their subscribers’ health results (not cost)<br />New focus: <br />10/12/10<br />Thomas E. Murphy<br />91<br />New Roles for TPAs<br />Long term health- Improved life expectancy and quality of life<br />
    92. 92. United Health Group and United Resource Networks. <br />Cigna and Quality Networks<br />Blue Cross and Blue Shield of Minnesota (Disease Management)<br />Blue Cross and Blue Shield of Mass. (Rewards Provider Excellence: reward excellence, higher margins, gains sharing, reward accurate diagnosis)<br />10/12/10<br />Thomas E. Murphy<br />92<br />Some examples<br />
    93. 93. 10/12/10<br />Thomas E. Murphy<br />93<br />And, very importantly . . . <br />To create and manage a single, comprehensive medical record for its patients<br />
    94. 94. Active participation in managing personal health: healthy life style, embrace preventive care, comply with provider recommendations, make informed choices about providers and treatments.<br />Choose TPAs and plans based upon these values.<br />10/12/10<br />Thomas E. Murphy<br />94<br />New Roles for Patients<br />
    95. 95. New Roles for Employers<br />New Perspective on Value<br />Stop the mindless cost shifting<br />Evaluate TPAs based upon “value” not cost.<br />Insist on value based choices of providers<br />Support healthy life styles among employees<br />Establish long term relationship with TPAs and providers. <br />Hold internal benefit staff accountable for long term health and good financial returns on health care benefits<br />10/12/10<br />Thomas E. Murphy<br />95<br />
    96. 96. First and foremost . . . No law required.<br />10/12/10<br />Thomas E. Murphy<br />96<br />Public Policy . . . Priority:<br />Move to Value Based Competition!<br />
    97. 97. Enable More Access<br />Lead to real health reform<br />10/12/10<br />Thomas E. Murphy<br />97<br />This will . . .<br />Enhance quality, reduce costs, and make health care more affordable.<br />
    98. 98. Employer and individual mandates.<br />Guarantee affordable health insurance for all. <br />Single payer, universal health care system<br />Move to individual choice and ownership of health insurance by making it more affordable, tax deductible or, if low income, subject to tax credits.<br />10/12/10<br />Thomas E. Murphy<br />98<br />Then, If needed a New Delivery System? <br />
    99. 99. 10/12/10<br />Thomas E. Murphy<br />99<br />Everyone should have access to quality health care!<br />
    100. 100. Preserve what we already do well<br />Sustain our innovation and research.<br />Focus on quality, cost effectiveness, and value.<br />What about choice? Is this important?<br />We should retain employment as primary locus for health care delivery. <br />Portability – Yes!<br />Should consumers share in some of the costs of health care?<br />10/09/09<br />Thomas E. Murphy<br />100<br />Values to maintain:<br />
    101. 101. People who paid nothing for health care used 30% of health care resources.<br />Cost sharing can enhance informed utilization and positively affect quality.<br />10/09/09<br />Thomas E. Murphy<br />101<br />We need patient engagement. . <br />The market, by exposing clinical outcomes data will drive health care providers to improve quality and deliver value.<br />Failure to do so will leave them . . .<br />
    102. 102. 10/09/09<br />Thomas E. Murphy<br />102<br />Without any “customers”<br />
    103. 103. Should the sponsors tell providers how to practice medicine?<br />Or, should they say let me see how you are doing and we will give you our business?<br />10/09/09<br />Thomas E. Murphy<br />103<br />A market that drives quality and value – See: Mayo Clinic proposal<br />
    104. 104. Without comprehensive legislation and without burdensome costs! <br />Can implement before January 2014!<br />The Market will drive providers, TPAs, and others to find the optimal utilization of health care resources!<br />This will lead to quality based and AFFORDABLE health care.<br />10/09/09<br />Thomas E. Murphy<br />104<br />The Value Based Market<br />. <br />
    105. 105. 10/09/09<br />Thomas E. Murphy<br />105<br />The Path to a healthy America<br />
    106. 106. 10/12/10<br />Thomas E. Murphy<br />106<br />They are depending on us . . . <br />

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