Class XVIII Health Care Day - Charles Buck

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  • We have 40 minutes to get an overview of a $2.2 trillion dollar industry that comprises 18% of our economy…so we’d better get going.
    Let me just say that I have been on all sides of the industry….provider, regulator, and purchaser….what you will hear come across most clearly is the purchaser perspective…at GE my job was to spend our $1 billion dollars in health benefit costs to keep our employees and their families as healthy as possible at an affordable cost…..that’s the perspective you will hear most in this discussion
    …and I recognize that there are many additional “experts” in the room…..including an old friend from CT…Joe Zaccagnino
    We are each looking at a complex elephant from differing perspectives…..it is messy….with many viewpoints
  • Courageous leadership..on all sides…is going to be key to solving this problem
  • Pooled risk makes sense..
    Multiple payers with a mandate was a Heritage Foundation idea…
    26% of non elderly adults are paying off medical bills over time
    These patients are among the 1 percent whose ranks no one wants to join: the costly cohort battling multiple chronic illnesses who consumed 21 percent of the nearly $1.3 trillion Americans spent on health care in 2010, at a cost of nearly $88,000 per person. Five percent of patients accounted for 50 percent of all health-care expenditures. By contrast, the bottom 50 percent of patients accounted for just 2.8 percent of spending that year, according to a recent report by the federal Agency for Healthcare Research and Quality.
  • I would argue that compared to many other countries there is value in having multiple sources of funds….multiple purchasers trying different things to drive change in the delivery system……
    for the last couple of decades large employers drove much of the change….transparency..managed care…….
    now in the last several years Medicare has switched from being only a payer to acting like a purchaser…requiring reporting of performance …and more recently rewarding the best performers….this is good…they are the largest purchaser…
    Individuals/Employers
    for 50+ employers…must offer or pay a penalty
    Individuals must buy (often with subsidies) or pay penalties
  • Originally a Heritage Foundation idea…originally brought forth by Republicans….
    25 states have signed up for expanded Medicaid! Since supreme court made it optional
    Commonwealth Fund survey
    24% of Americans potentially eligible for coverage had visited the ACA web site
    41% ages 19-34
    77% said there were in “good health”
    59%--who had not applied said they were likley to do so …or to explore options
    40% of those sow go the the site do sign up
    20 of those with individual coverage received cancellation letters
    CBO Projections…for end of 2014
    14 million uninsured covered
    9 million through Medicaid
    7 million through exchanges…mostly subsidized (2 million through Jan 1)
    -2 million…leaving employers to exchanges or Medicaid
    Admin delayed until 2015 requirement that ER over 50 EE provide coverage or pay penalty
    As a result of the law, most people are receiving expanded benefits, among them, preventive services without co-pays, including mammograms and other cancer screenings, some vaccinations, contraception services, including birth control pills, and periodic wellness exams.
  • Medicare Projected to almost double between now and 10 years from now
    Berwick…need to bend the cost curve by 1-2% a year….NOT REDUCE costs……
    “The implication for budgeteers is clear: If we can somehow
    solve the health care cost problem, we will also solve the
    long‐run deficit problem. But if we can’t control health care
    costs, the long‐run deficit problem is insoluble.”
    Alan S. Blinder
  • Jack Welch..there goes Motors….serious problem for corporate America
    Health care costs are a part of compensation….robs employees of pay increases…
    Part of the reason for outsourcing
    Average family premiums by employee equals $4565…not including cost sharing
    Health care as a percent of GDP is twice other countries that we compete with
  • Don’t hurt me….safety
    Note about airline quality
    1990’s..13.9 deaths per million flights
    2000-2019 1.7 deaths per million flights an 8 fold drop in an industry that is already the safest on the planet…..characteristic of high reliability is always chasing zero defect.
    Death rate due to errors in hospitals is about 3,800 per million admissions…..
    Airline industry operates at less than 1 death per million flights….health care produces the equivalent of an airplane crash every other day
    Limo driver—hard to imagine—hope to give you enough data to convince you….
    EBM—next slide
    There are no villains
  • Describe the chart
    Wennberg…sources of variation….local medical culture…
    We are a surgical town..Erie cardiac surgeon
    Let’s talk about evidence based medicine—make me well
    10,000 peer reviewed articles a year
    say there are 2000 patient conditions…..over the years there must be a dozen things we know that are best practices for each condition….
    but there is no way for individual physicians to keep track of all of this
    so we do them 55% of the time
    mayo, VM etc have organized processes for reviewing the literature and deciding which insights they are going to apply to their patients.
    Think there is some opportunity in there??
  • Chronic disease is 75% of cost……
    Some of this relates to EBM
    GE 40% low back pain costs outside guidelines
    Per Wennberg another opportunity is to get the patient more involved in the decisions
    when full informed…patients most often make a conservative choice….in this case they’d rather spend the last few months saying goodbye than hooked up to machines trying to delay death
    There is a 50% opportunity between $80k and $40K
  • These estimates don’t include redesign
    Some of the savings need to go to the providers who take the risk to go down this path….most to payers and their beneficiaries….employees..
  • “wouldn’t you rather go to a surgeon who makes 500,000 a year than one who makes 300,000 dollars a year…
    lesson from industry….high quality….means taking excess steps out of the process…and thus reduces costs
    I hope I have convinced you that by chasing excellent qualtiy…that cost will go down!
  • Over a decade ago when I was immersed in GE’s Six Sigma quality effort, when I was privileged to be a part of a two year study health care quality NAS/IOM by nations leading health care quality leaders
    …we produced many of the statistics that I have shared with you
    Equally important we studied what corporate America was doing to advance quality and wrote about what was required to do the health care version
    We know what needs to be done….and some courageous health care leaders are taking their organizations in this direction
    The fundamental lesson is that quality is a property of organizations…it takes infrastructure…it is not the result of individual super stars….obviously, we want excellent surgeons, and perhaps for certain cases or rare diseases we should fly to Hopkins or the Cleveland Clinic…but most of care is not like that….
  • Patient focused—corner stone of needed change….
    current system when passed around from physician to physician you are moving among different economic interests….little accountability for the patient's total experience…or outcome… we need delivery systems economic interests are tied together
    When doctors suggest that their hip and knee replacement candidate patients view decision tools before they undergo surgery…38% fewer patients went ahead with knee procedure and 26 % fewer agreed to undergo hip replacement (Group Health Cooperative in Seattle)
    Evidence based medicine---cook book medicine?—remember all that variation
    Surgical check lists…reduce complications by 35%...and death rates by 47%
    Mayo….fire high admitter who wouldn’t go along with standardized guidelines
    Quality Culture
    Safe to speak up-----Hand washing at 50%.....
    Team based medicine
    Group Health achieved a dramatically lower rate of cardiology referrals, which is at 214 versus a national benchmark of 1,059 cardiology visits per 1000 patients over 65.
    IT investment
    VM builds guidelines into IT system…with documented exception
    Process improvement tools
    Redesign…patient focused.
    Use of email cuts physician visits as much as 30%
    VM re engineered their outpatient clinics with patient is minde…70-90 % of patients’ ..no added value..medical assistant controls flow including location of clinicians….results….nurses now spend 90% of their time with patients instead of 35%....no waiting rooms
    …savings like this are not included in the 30% IOM estimate….
  • Some results from Virginia mason….as example
  • Charter schools…..start with the willing……younger generation….
    Think what competition from Toyota changed the US auto companies…
    Note..not competition among health plans…but among delivery systems
  • How do we enable providers in the cottage industry to transform themselves….take away the FFS barrier?
    493 ACO contract by CMS..expect more icovering about 20 million people
    ACA projects $1B in savings over 4 years if get if 270 orgs sign up….CMS not OMB
    Medical home….PCP
    Chronic disease….. …..75% of costs…..many with multiple conditions….
    Diabetes is the leading cause of kidney failure, nontraumatic lower extremity amputations, and new cases of blindness each year among U.S. adults aged 20–74 years.
    as much as 50% of costs are due to preventable complications
    but think about the economic straight jacket that we put PCP doctors in with FFS They refer patients to specialists when their training would allow them to take care of patients.
    They get no reward if they deal with lifestyle changes that might save future hospitalizations and ER visits
    They can’t save as many as 30% of their visits by using emails….because emails are paid for…
    Medical home….is the start of a way around these finical handcuffs….for the willing…

  • Health care leaders get it…..they know that current cost levels are unsustainable…of course there are lots of problems with the details
    Walmart, Lowe's enter bundled pay deal with four health systems
    New network will offer no-cost implant care for more than 1.5 million workers
    Topics: Bundled Payments, Market Trends, Strategy, Health Care Reform, ACO,Payer and Regulatory Policy, Population Health
    October 09, 2013
    A first-of-its-kind coalition of large U.S. employers—including Walmart and Lowe's—will offer no-cost coverage for hip and knee implant procedures at four U.S. health systems starting on Jan. 1, 2014.
    What are bundled payments? We explain the payment model—and why it matters in this three-minute video.
    The companies joined the Pacific Business Group on Health (PBGH) Negotiating Alliance to create the Employers Centers for Excellence Network, which will offer no-cost knee- and hip-replacement surgeries for more than 1.5 million employees and their dependents at:
    Johns Hopkins Bayview Medical Center in Baltimore;
    Kaiser Permanente Orange County Irvine Medical Center in Irvine, Calif.;
    Mercy Hospital in Springfield, Mo.; and
    Virginia Mason Medical Center in Seattle.
    Employees will receive consultations and treatment without deductibles or co-insurance, as well as travel, lodging, and living expenses for the patient and a caregiver. Participating employers will receive discounted rates for care, as well as "transparent and predictable costs," according to PBGH President and CEO David Lansky.
    "These companies are working to help make sure that their employees get higher quality care and incur lower costs," says Lansky, adding, "The Employers Centers of Excellence Network is designed to serve as a model for delivering high quality health care with transparent and predictable costs."
    The new network is not the first foray into bundled payment initiatives for Lowe's or Walmart. Lowe's entered into a bundled-payment agreement with Cleveland Clinicfor cardiac surgery, and Walmart and six hospitals—including Cleveland Clinic andMayo Clinic—launched bundled payments last year for workers' cardiac and spinal surgeries (Walmart release, 10/8; Rauber, "BizTalk," San Francisco Business Times, 10/8; Lee, Modern Healthcare, 10/8 [subscription required]).
    It's time to reimagine health plan benefit designs - The by-product of health benefit plans that have high deductibles and co-insurance is the current transparency revolution that is sweeping the country. The outcome of that revolution has yet to fully play out, but we can see the outline of a true market for health care services emerge. Take the legislation enacted in NC in mid 2013. It creates complete public transparency on the price of a large basket of episodes of care - "products" that consumers understand and can now price-compare. Providers, as a result, are scrambling to put together new quality measurement programs so that they aren't simply selected based on their price. Some medical specialty societies are assembling teams to develop and promote quality measures, in some instances making the mistake of picking measures that will make all their members look good (it's a mistake because if quality is undifferentiated, then price will remain the sole differentiator). But in many other instances, they're taking the hard road to measure quality rigorously. The upshot is that we're moving very fast from an opaque and paternalistic system to a transparent one driven by consumer action.
  • Progress is slow
  • Recent aricle in NDN on 1% hold back and incentives for best performing hospitsls
    VM redude liability costs by 60%
    Malpracitce paid claims equials 3.2 B…or less than .2% of total costs…..and in OSC’s no incentive for over use….and institution protects you
  • Medicare is 32% of costs…or about 525 B of the total personal health costs of $2.2 trillion
  • Note that 5 of these aim at the enrollees…..a couple like malpractice and drug costs aim at parts of the delivery system…..
  • Class XVIII Health Care Day - Charles Buck

    1. 1. GREATER NAPLES LEADERSHIP Masters Class XVIII Healthcare Day, February 5, 2014 Charles Buck Presentation
    2. 2. Greater Naples Leadership Charles R. Buck, Jr., Sc.D. February 5, 2014
    3. 3. Overview of Federal Health Care Policy Agenda/Objectives • What are the big issues…and (potential) solutions? • How does the Affordable Care Act (Obamacare) deal with (or not) the big issues? • As community leaders…to educate you about the challenges and opportunities…and where things could go off the track
    4. 4. U.S. Health Care System Issues we talk about • Should everyone have health insurance? − If so, how do we do that? • How can we bend the cost curve? − Is this only a Medicare/Medicaid (entitlement) problem? An issue we don’t talk about--Quality • Is Quality an Issue? − How does it relate to cost?
    5. 5. Should Everyone Have Health Insurance? “Values” Reasons • • • Is healthcare a right? International comparisons People without coverage do forego care … become sicker … and more expensive $$ Reasons • “Insurance” makes sense for most people − Lowest 50% cost 2.9% ($851/per person) − Top 1% cost 21% ($88,000/per person) • • • Free rider & downward spiral Cost shift to employers who provide coverage Facilitates comparative shopping for “value” • 2 Basic Approaches -- Single Payer or Multiple Sources of Coverage -- Coupled with a Mandate • “Settled” -- by ACA
    6. 6. Universal Coverage How? Current Coverage FL • Employer 49% (149M) 42% • Individual 5% (15M) 5% • Medicaid 16% (51M) 14% • Medicare 13% (40M) 17% • Other Public 1% (4M) 2% • Uninsured 16% (49M) 20% 100% (308M) • Pluralistic financing drives complexity • 62% have FT job in family − Employers >50 EE – 96% <50 EE – 36% • 38% poverty or below
    7. 7. Coverage: A Few Obamacare Details Medicaid categories to cover all who meet financial criteria • Expand • • National floor - - - 133% of FPL Funding (current: 57% federal, 43% state) • New enrollees − Thru 2016: 100% federal − After 2016: 90% federal Individuals (Mandate -- If Not Covered) • • Incentives − Tax credits up to 400% FPL − Health insurance exchanges Penalties: Phased in Thru 2016 − Greater of: 2.5% of income or $695 − CBO est: 3.9M will pay penalty Employers • • Small employers: tax credits & exchanges Large employers: penalized if EEs use tax credits Keep Your Fingers Crossed! Now to the Cost Curve!
    8. 8. Do We Need to Bend the Cost Curve? Medicare—YES! Medicare insolvent in 2026 Need to Bend The Cost Curve by 1-2% Per Year -- Ongoing
    9. 9. Do We Need to Bend the Cost Curve? Employers—YES, too! • Over the last 13 years healthcare premiums have outpaced inflation by X5 • Family coverage now costs $16,351 • Healthcare = 17.6% of GDP - double other countries The Fundamental Challenge Facing All Payers is the Efficiency and Effectiveness (Quality) of Our Healthcare Delivery System
    10. 10. System Performance: Quality • We have the best trained providers & technology in the world . . . but performance (quality) is way short of where it could be: • “Don’t hurt me” (Safety) − 44,000 to 98,000 patients die each year from preventable medical errors − 1/3 of hospitalized patients are harmed or experience an adverse event “Make me well” (clinically effective medicine) − Americans receive about half of the specific care recommended by current research • It’s Hard to Imagine . . . But The List is Long and Well Established • This Level of Quality Would Not Be Acceptable in Other Industries • There Are No Villains…
    11. 11. CABG Variation: Evidence based care?? Coronary artery bypass grafting (CABG) per 1,000 Medicare beneficiaries (2010) (Wennberg, et al) CABG per 1,000 Medicare beneficiaries 7.5 6.5 5.5 4.5 3.5 2.5 1.5 0.5 Ocala Sarasota Bradenton Panama City Tampa Jacksonville Pensacola Orlando Fort Myers Ormond Beach Fort Lauderdale Tallahassee Hudson Clearwater Lakeland St. Petersburg Gainesville Miami 4.3 4.0 3.8 3.7 3.6 3.6 3.6 3.5 3.3 3.3 3.3 3.1 3.1 3.0 3.0 2.7 2.6 2.0
    12. 12. Variation: Spending on Chronic Care Medicare spending per chronically ill beneficiary during the last two years of life (2007) 110,000 Medicare spending per decedent 100,000 90,000 80,000 70,000 60,000 50,000 40,000 30,000 Miami Fort Lauderdale St. Petersburg Tampa Orlando Clearwater Jacksonville Hudson Bradenton Panama City Sarasota Fort Myers Ormond Beach Gainesville Lakeland Ocala Pensacola Tallahassee $94,408 $72,798 $68,699 $62,627 $62,460 $62,321 $61,941 $60,995 $59,644 $59,409 $59,263 $59,087 $57,990 $56,782 $54,721 $53,513 $52,080 $47,762
    13. 13. What About Costs? Estimated Sources of Excess Costs in Health Care (2009) Category Sources Estimate of Excess Costs Unnecessary Services • Overuse - - beyond evidence-established levels • Discretionary use beyond benchmarks • Unnecessary choice of higher-cost services $210 billion Inefficiently Delivered Services • • • • Mistakes - - errors, preventable complications Care fragmentation Unnecessary use of higher-cost providers Operational inefficiencies at care delivery sites $130 billion Excess Administrative Costs • Insurance paperwork costs beyond benchmarks • Insurers’ administrative inefficiencies • Inefficiencies due to care documentation requirements $190 billion Prices That Are Too High • Service prices beyond competitive benchmarks • Product prices beyond competitive benchmarks $105 billion Missed Prevention Opportunities • Primary prevention • Secondary prevention • Tertiary prevention $55 billion Fraud • All sources - - payers, clinicians, patients $75 billion SOURCE: Adapted from IOM, 2010. $765B in Excess Costs . . . 30% of The Total . . . Mostly Related to Quality and/or Poor Financial Incentives
    14. 14. Doesn’t High Quality Cost More? • Inverse Relationship Between Cost & Quality -- Often • Let’s Consider Chasing Defect Free Quality as The Way to Bend the Cost Curve. 30% Opportunity. 11/2 Points Off of Trend for 20 Years
    15. 15. So…how do we move toward nearly defect free quality (as a way to bend the cost curve)? Institute of Medicine Committee on Quality of Health Care in America “People Working in Health Care Are Among The Most Educated And Dedicated Workforce In Any Industry. The Problem Is Not Bad People; The Problem Is That The Systems Need To Be Made Safer” Quality is a Property of Systems (Organizations) − Organized Systems of Care (OSC’s) − Lessons drawn from health care and corporate America
    16. 16. We do know what they look like: OSC’s have The Required Scope, Leadership, Commitment & Resources to…. • Patient focused − Accountability spans patient conditions • Seek nearly defect free performance • Quality Culture − Involve the patient • Evidence based medicine − Clinical guidelines (baked in) • − Safe to speak up Performance Transparency − Team based care • IT investment • Process improvement tools/training - Redesign—Patient centered We do have examples…: Kaiser-Permanente; Virginia Mason; Mayo; Geisinger; Cleveland Clinic; Lahey Clinic; Thedacare; Group Health…..And others But, OSC’s Are a Small % of Care (Early Adopters) - - Why?
    17. 17. OSC’s: 2 Huge Barriers to Overcome 1. Cottage Industry -- Few “Organizations” to Start With “Our current health care system is essentially a cottage industry of nonintegrated, dedicated artisans who eschew standardization.” (NEJM: Jan. 2010) 2. Fee-For-Service Payment •Drives excess utilization •Barriers to improvement − Savings go elsewhere − Good ideas aren’t reimbursed Plus..major culture change and vested interests.. It’s Not Going To Be Easy To Change An Industry That Represents 17% of Our GDP . . . But Chasing Quality To Bend The Cost Curve is Far Better Than The Alternatives
    18. 18. Employers Rate VM: Leapfrog Doing the Right Thing and Doing It Right Source: The Leapfrog Group, 2009. We Have to Move Beyond The Early Adapters
    19. 19. How Are We Going To Do This? The Vision 1. Use purchaser leverage (Medicare & large employers) to encourage OSC development in many markets. 2. Structure competition on quality and cost (value) to drive continual improvement and spread of OSC’s…and competition between the OSC model and current system Vision is Shared by Public & Private Purchasers . . . And Left & Right Health Care Leaders
    20. 20. ACA Has Provisions to Enable Change … For Those Willing And Ready New payment methods coupled with quality performance requirements -•ACO (Accountable Care Organization) − Population based •Medical Home − Primary Care based •Bundled Payment − Episodic/procedure based --3 Alternatives for Enabling Providers to Consolidate Around Sets of Patient Needs . . . To Share in Savings . . . To Meet (And Report Publicly) Quality Performance --long term payoff
    21. 21. In the meantime a lot is going on • Medicare is driving shift to value purchasing o Not paying for readmissions within 30 days (20% readmissions….target +/_ 10%) o Hospital acquired infections penalties o Value based purchasing…public reporting • Employers…beginning to reward clinical centers of excellence with patient incentives • Venture money is active • Results……survey of 74 C-suite executives from (mostly) teaching hospitals….projections to 2020 --65% believe the healthcare system will be better --93% predict that their quality of care will be better --Average expected per patient cost reduction of 11.7%
    22. 22. What Can We Do As Community Leaders…And Patients? • Ask questions – a few examples…..support healthcare providers who want to lead − Does your organization accept responsibility for the full range of services for the patients it treats? − How safe are your patients? Show me. − Do you have a systematic mechanism to educate your physicians about what is the latest science for my condition? And, to help them practice this way? − Do you track your patients’ outcomes and publicly report your performance? − Are you a national best practice for any specific patient conditions? Which ones? Push For -- And Use -- Performance Transparency -- At The Level of Patients’ Conditions
    23. 23. Greater Naples Leadership • We have the opportunity to shape a uniquely American solution to sustainable health care • If we don’t structure a market to reward excellence…and thereby bend the cost curve…we will, like other countries be forced to drive the cost curve down by “regulation” of the current system • “We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten.” • --Bill Gates
    24. 24. STOP • The end…..previous page • The following slides are extra….not to be used or shown……..
    25. 25. Why Isn’t Anyone (The Administration) Talking About This? • It would seem that both sides would favor using market forces to improve quality…and bend the cost curve • But… − Leaders are afraid to say that our quality could be better − It is too complicated for a sound bite − CBO won’t score it • And…to be fair…it hasn’t been done before
    26. 26. Lessons From Other Industries  Auto − Need the availability of higher quality (Japanese autos) to drive industry-wide change  Education (Charter Schools) − Need different rules to allow innovation − Start with the “willing” As The Largest Purchaser Medicare Must Take The Lead . . . Providers Will Need Clear & Consistent Signals to Make Difficult Changes
    27. 27. Where Are We Now? • Lots of provider attention and action around new CMS models − Many critical details still unknown − Many providers watching from the sidelines…or consolidating to hedge their bets • CMS driving public safety reporting…current model − Starts even unwilling providers down the early stages of the path “TRADITIONAL” Approaches to Medicare still on the table-- Raise Eligibility Age Raise Eligibility Age Raise Premiums—High Income Raise Premiums—High Income Beneficiaries Beneficiaries Premium Support (Vouchers) Premium Support (Vouchers) Use Leverage to Reduce Drug Costs Use Leverage to Reduce Drug Costs Competition Among Plans Competition Among Plans Malpractice Reform Malpractice Reform More Cost Sharing More Cost Sharing Etc. Etc.
    28. 28. Challenge: Provider Consolidation . . . OSC’s or Cartel’s? Provider Consolidation OSC Cartel •• Investment in quality Investment in quality infrastructure & infrastructure & culture culture •• Improved outcomes Improved outcomes •• Market leverage Market leverage •• Higher prices Higher prices •• No change in No change in delivery delivery •• Lower costs Lower costs ?Or? • Requires Constant Vigilance Over The Next Decade To Ensure We Head Down The Right Path • Transparency--Continually Raising the Quality Bar – Patient Focused • We Played This Movie Once Before…”Managed Care”
    29. 29. Universal Coverage How? Current Coverage FL • Employer 49% (149M) 42% • Individual 5% (15M) 5% • Medicaid 16% (51M) 14% • Medicare 13% (40M) 17% • Other Public 1% (4M) 2% • Uninsured 16% (49M) 20% 100% (308M) • 62% have FT job in family − Employers >50 EE – 96% <50 EE – 36% • 38% poverty or below How Do We Cover The 49M?
    30. 30. Medicare: Bending the Cost Curve Raise Eligibility Age Raise Eligibility Age Premium Support (Vouchers) Premium Support (Vouchers) Various Proposals (Medicare Specific) Competition Among Health Plans Competition Among Health Plans More Cost Sharing More Cost Sharing Raise Premiums-High Income Beneficiaries Raise Premiums-High Income Beneficiaries Use leverage to reduce drug costs Use leverage to reduce drug costs Malpractice Reform Malpractice Reform Etc Etc • All of Them May/Should Be Considered—none addresses the fundamental problem • Let’s take a broad look at the cost issue

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