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“The Perfect Storm
           The         Storm”

          Health Care Trends

      Impact on Patient Care:
    How t N i t th S t
    H   to Navigate the System

David M. Schreck, MD, FACEP, FACP, FHM
   Chairman, Department of Emergency Medicine
              Summit Medical Group
              S    it M di l G
Introductions
David M. Schreck, MD, MS, FACP, FACEP, FHM

   Chairman – Department of
    Emergency Medicine, SMG
   Private practice - IM
   Specialist - Hospital Medicine
   Clinical Asst Prof Med - RWJ
   Adj Professor - Stevens Tech
   MS Biomedical engineering
   Past-Vice Chairman, Medicine
    Overlook
Agenda
• How did we get here?
  – You will get angry!!!
• The “Perferct Storm
       Perferct Storm”
  – You will get angrier!!!
• N i ti th system
  Navigating the t
  – You will try to hurt me!!!
• Questions and Answers

  So … Don’t Shoot the Messenger!
Beware Data Analysis
• 3 f i d d i t Fl id
    friends drive to Florida
• They stop at a motel
• Motel l k h
  M l clerk charges $30 per night
                                i h
• Each of the friends pay $10 for the motel fee
• Manager found that they were overcharged $5
  per night (should have been $25 per night)
• C
  Clerk instructed to refund $
                        f    $5…
Data Analysis

• …However, the clerk decided to pocket $   $2
  figuring the friends would never find out.
• So the clerk refunded $3 to the friends…
• How much did each of the friends pay ???
• How much did the clerk pocket ???


   WHERE S
   WHERE’S THE EXTRA DOLLAR ???
Viewpoint

• There are no “bad guys”
• Physicians p their p
     y        put      pants on “one leg at a
                                       g
  time”
• Patients have a need (and a right) to know
• Is healthcare a right?
• Wh t i quality…who d id ?
  What is      lit    h decides?
• This is a very complex situation….
Patients are at the center…

             Employers



                           Hospitals
                           H   i l
  Doctors



                                            Media
                            Patients
  Insurers

                                       Pharmacy
             Govt:         Bio-
             President     industry
             Legislators
Bias
• But there are biases out there….
• Physicians have experience based
   preferences …
  “preferences”…
• Insurance companies have shareholders
• Th
  There are “ambulance chasers”…
            “ b l         h       ”
• Patients want they think is best…
  – (ie, antibiotics for a “cold”)
• Media sensationalism…
Sensationalism

• “Merck's Vioxx scandal widens: Drug
  maker knew Vioxx was deadly for years
  before risk was made public (opinion)”
• January 26, 2011, 11:13 pm “Breast
  Implants Linked to Rare Cancer”
• The Vaccine Victim
Real Issues Do Exist
• Who is “passing the buck”
• We cannot legislate morality
    – 10% of us give us 90% of the headaches
•   …but where does the buck stop?
•   Quality…who pays for it?
•   Technology advances…who pays for it?
•   Access to care who pays for it?
              care…who
•   Convenience…who pays for it?
•   Unscheduled urgencies who pays for it?
                 urgencies…who
ED Marketplace
USA ED Visits 1984 2008
              1984-2008
 “America’s safety net: ~ $100 Billion”
National Health Expenditures
                                p                    National Health Expenditures


       2020                                                                                                               $4,638.40
                                                                                                                   $4,346.50
       2018                                                                                                  $4,080.00
                                                                                                        $3,849.50
       2016                                                                                        $3,632.00
                                                                                              $3,417.90
       2014                                                                              $3,227.40
                                                                                   $2,980.40
                                                                                                      Projected
       2012                                                                    $2,823.90
                                                                            $2,708.40
                                                                            $2 708 40
       2010                                                              $2,584.20
                                                                      $2,486.30
Year




       2008                                                         $2,391.40
                                                                 $2,283.50
       2006                                                   $2,152.10                                     $2.7 TRILLION
                                                           $2,021.00
       2004                                            $1,877.60
                                                    $1,740.60
       2002                                     $1,607.90
                                          $1,358.50
       1999                             $1,270.30
                                        $1 270 30
                                     $1,129.70          Reported
       1993                     $916.50
                            $717.30
       1980      $254.90

         $0.00
         $0 00    $500.00
                  $500 00    $1,000.00
                             $1 000 00   $1,500.00
                                         $1 500 00   $2,000.00
                                                     $2 000 00   $2,500.00
                                                                 $2 500 00   $3,000.00
                                                                             $3 000 00   $3,500.00
                                                                                         $3 500 00   $4,000.00
                                                                                                     $4 000 00   $4,500.00
                                                                                                                 $4 500 00   $5,000.00
                                                                                                                             $5 000 00
                                                                  Billions


Source: www.cms.gov
National Health Expenditures
                        and Their Share of (GDP) 1980-2020
                                           (   )
      $5,000.00                                                                                                                                                                               25%

                                National health spending is projected to continue to increase as a
      $4,500.00
                                               share of GDP over the next decade.               20%
      $4,000.00                                                                                                                       Projected                                               20%
                                                                 Actual
      $3,500.00

                                                                                                                               17.7%
      $3,000.00                                                                                                                                                                               15%


      $2,500.00


      $2,000.00
      $2 000 00                                                                                                                                                                               10%


      $1,500.00


      $1,000.00
        ,                                                                                                                                                                                     5%


        $500.00


          $0.00                                                                                                                                                                               0%
                 80

                        90

                               93

                                      97

                                             99

                                                    00

                                                           02

                                                                  03

                                                                         04

                                                                                05

                                                                                       06

                                                                                              07

                                                                                                     08

                                                                                                            09

                                                                                                                   10

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                                                                                                                                                                                         20
               19

                      19

                             19

                                    19

                                           19

                                                  20

                                                         20

                                                                20

                                                                       20

                                                                              20

                                                                                     20

                                                                                            20

                                                                                                   20

                                                                                                          20

                                                                                                                 20

                                                                                                                        20

                                                                                                                               20

                                                                                                                                      20

                                                                                                                                             20

                                                                                                                                                    20

                                                                                                                                                           20

                                                                                                                                                                  20

                                                                                                                                                                         20

                                                                                                                                                                                20

                                                                                                                                                                                       20
                                                                               National Health Expenditures                                  % GDP

Source: CMS, Office of the Actuary, National Health Statistics Group.
National Health Expenditures and Their Share of
            Gross Domestic Product 1960 2009
                            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, at
http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; file nhegdp09.zip).
Health Care Economics
CPI 1970-2010




US Census Bureau
Total Health Expenditure as a Share of GDP,
                                    U.S. and Selected Countries, 2008
                       18%

                       16%

                       14%

                       12%
As Percentage of GDP




                       10%

                       8%                                                                                                                                              16.0%


                       6%                                                                                                                                    11.2%
                                                                                                                                                             11 2%
                                                                                                                      0 %
                                                                                                                     10.5%     10.5%
                                                                                                                                0 %      10.7%
                                                                                                                                         10 7%     11.1%
                                                                                                                                                   11 1%
                                                                                                  9.9%     10.4%
                                                                    9.0%      9.1%      9.4%
                                      8.5%      8.5%      8.7%
                       4%    8.1%


                       2%

                       0%




              Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-
              en (Accessed on 14 February 2011).
              Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are
              PPP adjusted.
Total Health Expenditure per Capita,
                                                            Per Capita Health Spending, 2002
                                                         U.S. and Selected Countries, 2008
                                    $8,000                     Each year, the US spends roughly 2x the amount on                                               $7,538
                                                               health care as the next most spending country
                                    $7,000


                                    $6,000
Per Capita Spending - PP Adjusted




                                                                                                                                                      $5,003
                                    $5,000                                                                                                   $4,627
                       PP




                                                                                                                      $3,970 $4,063 $4,079
                                    $4,000                                                     $3,677 $3,696 $3,737
                                                                               $3,353 $3,470
                                                                      $3,129
                                                      $2,870 $2,902
                                    $3,000   $2,729


                                    $2,000


                                    $1,000


                                       $0




                                             Anderson GF, Hussey PS, Frogner BK, Waters HR. Health spending in the United States and the rest
                                             of the industrialized world. Health Aff (Millwood ). 2005;24:903-914.
Total Expenditure on Health as a Share of GDP,
                                                    U.S. and Selected Countries, 1970, 1980, 1990, 2000,
                                                                           2008
                                    18%


                                    16%


                                    14%
Health Spending as Percent of GDP




                                    12%


                                    10%


                                      8%
                                                                                                                                                                                             1970
                                      6%                                                                                                                                                     1980
                                                                                                                                                                                             1990
                                      4%                                                                                                                                                     2000
                                                                                                                                                                                             2008
                                      2%


                                      0%




                                    Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-
                                    en (Accessed on 14 February 2011).
                                    Notes: Data from Australia and Japan are 2007 data. 2008 figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. 200
                                    figures for Belgium are OECD estimates. Break in Series AUS (1998); AUSTRIA(1990); BEL(2003, 2005); CAN(1995); FRA(1995); GER(1992); JAP(1995);
                                    NET(1998, 2003); NOR(1999); SPA(1999, 2003); SWE(1993, 2001); SWI(1995); UK (1997). Starting in 1993 Belgium used a different methodology.
Total Health Expenditure Per Capita,
                                             U.S. and Selected Countries, 1970, 1980, 1990,
                                                                2000,
                                                                2000 2008
                                     $8,000

                                     $7,000
     apita Spending - PPP Adjusted




                                     $6,000

                                     $5,000
                                                                                                                                                                                            1970
                                                                                                                                                                                            1980
                                     $4,000
                                                                                                                                                                                            1990
                                                                                                                                                                                            2000
                                     $3,000
                                                                                                                                                                                            2008
Per Ca




                                     $2,000

                                     $1,000

                                        $-
                                        $




                                 Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en
                                 (Accessed on 14 February 2011).
                                 Notes: Data from Australia and Japan are 2007 data. 2008 figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. 2000
                                 figured for Belgium are OECD estimates. Numbers are PPP adjusted. Break in Series AUS (1998); AUSTRIA(1990); BEL(2003, 2005); CAN(1995); FRA(1995);
                                 GER(1992); JAP(1995); NET(1998, 2003); NOR(1999); SPA(1999, 2003); SWE(1993, 2001); SWI(1995); UK (1997. Starting in 1993 Belgium used a different
                                 methodology.
Growth in Total Health Expenditure Per Capita,
                                                U.S. and Selected Countries, 1970-2008
                                    $8,000


                                    $7,000
                               ed
Per Capita Spendin - PPP Adjuste




                                    $6,000

                                                                                                                                                         United States
                                    $5,000
                                                                                                                                                         Switzerland
                 ng




                                                                                                                                                         Canada
                                    $4,000
                                                                                                                                                         OECD Average
                                                                                                                                                         Sweden
    C




                                    $3,000
                                    $3 000
                                                                                                                                                         United Kingdom

                                    $2,000


                                    $1,000


                                       $0
                                             1970   1975   1980       1985          1990           1995           2000          2005
             Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-
             en (Accessed on 14 February 2011).
             Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are
             PPP adjusted. Break in series: CAN(1995); SWE(1993, 2001); SWI(1995); UK (1997). Numbers are PPP adjusted. Estimates for Canada and Switzerland in
             2008.
Total Health Expenditure per Capita
                                                     and GDP per Capita,
                                              US and Selected Countries, 2008
                                                               Countries
                          $8,000
                                                                                                                 USA
                          $7,000
                          $7 000
Pe Capita Heal Spending




                          $6,000

                                                                                 Austria
                          $5,000                                                               Switzerland
             lth




                                                     Germany
                                                                                   Canada                                                           Norway
                                                                   Belgium
                          $4,000                    France
                                                                                               Netherlands
                          $3,000                    Italy                 U.K.     Australia
 er




                                                               Japan                   Sweden
                          $2,000                     Spain


                          $1,000


                             $0
                              $25,000         $30,000          $35,000           $40,000         $45,000          $50,000           $55,000          $60,000          $65,000

                                                                                           GDP Per Capita


                 Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-
                 en (Accessed on 14 February 2011).
                 Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates.
We are in for a rough ride!!!!
      BAD NEWS                             WORSE NEWS
          CURRENT                               MEDICARE’S
         UNFUNDED                                CURRENT
        LIABILITY OF                            UNFUNDED
      SOCIAL SECURITY                           LIABILITY IS
          IS ABOUT                                ABOUT

      $11 TRILLION                    +     $66 TRILLION!
                 = $250 000 per person
                   $250,000
                         (310,000,000 est. pop. 2010)

                    Who’s paying for this???
Source: Orlikoff & Associates, Inc. 2008
Population Data
                   Are these groups motivated to pay the debt????

And to pay for us as we age???




                 $39k

   $21k                          $37k       $31k




                   AGE GROUPS
Projected National Health Expenditures in the United
        States,
        States by Source of Payment, 2010
                             Payment
                                                                                                Where the money comes from……
                                            Private Health
                                              Insurance

                                                                          32%


                         Other Private
                           Spending
                                                       7%                                                   21%              Medicare


                        Out-of-Pocket                     11%
                         Payments

                                                                       12%                    16%

                                             Other Public                                            Medicaid and
                                              Spending                                                  CHIP1


                           Total National Health Expenditures, 2010 = $2.6 Trillion
NOTES: 1Includes Children’s Health Insurance Program (CHIP) and Children’s Health Insurance Program expansion (Title XIX). Percentages do not sum to 100% due
to rounding.
SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, Updated National Health Expenditure Projections 2009-2019, January 2011.
Distribution of National Health Expenditures, by Type
                           of Service, 2009
                              Service
                                                                                            Where it goes……

                                                                                                    Hospital
                                                        Other Health                              Care, 30.5%
                                                         Spending,
                                                           15.9%

                                                Other
                                              Personal
                                             Health Care,
                                               14.9%




                          Home Health
                           Care, 2.7%
                                                          Prescription
                                                                 p
                            Nursing Home                 Drugs, 10.1%
                             Care, 5.5%                                                   Physician/
                                                                                           Cli i l

Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment,
etc. O h Health Spending includes, for example, administration and net cost of private health insurance, public health activity,
     Other H l h S     di i l d      f         l   d i i    i      d          f i       h lhi                bli h l h    i i
research, and structures and equipment, etc.
Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the
Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health
Expenditures by type of service and source of funds, CY 1960-2009; file nhe2009.zip).
Distribution of National Health Expenditures,
                      by Type of Service,
                                  Service
                         1999 and 2009




                Hospital        Physician/       Prescription  Nursing  Home Health                       Other     Other Health
                 Care            Clinical           Drugs     Home Care    Care                          Personal    Spending
                                 Services                                                               Health Care

Notes: Percentages may not total 100% due to rounding. Other Personal Health Care includes, for example, dental and other professional health
services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private h lth insurance,
    i     d bl        di l     i     t t Oth H lth S         di i l d     f        l    d i i t ti      d t      t f i t health i
public health activity, research, and structures and equipment, etc.
Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National
Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service
and source of funds, CY 1960-2009; file nhe2009.zip).
Concentration of Health Care Spending
              in th U S P
              i the U.S. Population, 2008
                              l ti
         Percent of To Health Care Spending


                                              100%
                                                           Is heathcare a right?                                     96.9%



                                              80%
                                                         Is rationing on the way?                        80.2%
                                                                                             73.4%
                                                                                63.6%
                                              60%
                            h




                                                                    47.5%

                                              40%
                     otal




                                                       20.2%
                                                       20 2%
                                              20%

                                                                                                                                  3.1%
                                               0%
                                                      Top 1%       Top 5%      Top 10%     Top 15%      Top 20%     Top 50%      Bottom
                                                                                                                                  50%
                                                     (≥$44,338)    (≥$16,336) (≥$9,148)      (≥$6,074)    (≥$4,374)   (≥$825)
                                                                  Percent of Population, Ranked by Health Care Spending           (<$825)

Note: Dollar amounts in parentheses are the annual expenses per person in each percentile. Population is the civilian noninstitutionalized
population, including those without any health care spending. Health care spending is total payments from all sources (including direct
payments from individuals, private insurance, Medicare, Medicaid, and miscellaneous other sources) to hospitals, physicians, other providers
(including dental care), and pharmacies; health insurance premiums are not included.
Source: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare
Research and Quality, Medical Expenditure Panel Survey (MEPS), 2008.
Hospitals
Number of Public Community Hospitals,
                              1990-2008
                              1990 2008




Notes: Includes nonfederal (i.e., state and local government), short-term general and specialty hospitals whose facilities are available to the public.
                            ( ,                   g            ),             g             p     y     p                                       p
Public community hospitals represent 23% of all community hospitals, and community hospitals represent about 85% of all hospitals. Federal
hospitals, long term care hospitals, psychiatric hospitals, institutions for the mentally retarded, and alcoholism and other chemical dependency
hospitals are not included.
Source: American Hospital Association Annual Surveys: 1990-1998 data from Hospital Statistics, 2002, Table 1; 1999-2008 data from AHA Annual
Surveys, Copyright 2010 by Health Forum LLC, an affiliate of the American Hospital Association, at http://www.ahaonlinestore.com.
Hospital Patient Volume
Hospital LOS
Aggregate Total Community Hospital Margins,
                        1980-2008
                        1980 2008




Note: Total Community Hospital Margin calculated as the difference between total net revenue and total expenses, divided by total net revenue.
Source: American Hospital Association and Avalere Health, Avalere Health analysis of 2008 American Hospital Association Annual Survey data,
for community hospitals, Trendwatch Chartbook 2010, Trends Affecting Hospitals and Health Systems, Table 4.1, p. A-32, at
http://www.aha.org/aha/trendwatch/chartbook/2010/appendix4.pdf.
Community Hospital Payment-to-Cost
           Ratios, b Source of Revenue, 1980 2008
           R ti    by S      fR         1980-2008




Note: Payment-to-cost ratios show th degree to which payments f
N t P         tt    t ti      h   the d      t  hi h        t from each payer cover th costs of treating its patients. They cannot be
                                                                      h              the     t f t ti it        ti t Th          tb
used to compare payment levels across payers, however, because the service mix and intensity vary. Data are for community hospitals.
Medicaid includes Medicaid Disproportionate Share payments.
Source: American Hospital Association and Avalere Health, Avalere Health analysis of 2008 American Hospital Association Annual Survey
data, for community hospitals, Trendwatch Chartbook 2010, Trends Affecting Hospitals and Health Systems, Table 4.4, p. A-35, at
http://www.aha.org/aha/trendwatch/chartbook/2010/appendix4.pdf.
Health Insurance Coverage 2007
                       Other Private                  Uninsured
                       24,500,000                                            Medicaid
                                                                             39,600,000
                                                  45,700,000



                                                                                     Medicare
                                                                                     41,400,000




                                                                                  Military
                                                                                  4,000,000
               Employer
               177,400,000


Source: U.S. Census Bureau: Income, Poverty, and Health Insurance Coverage in the United States 2007
Payment Sources for Uncompensated
                     Care, 2004
                             Private Dollars
                                $6 Billion
                                 (15%)




                                                                                                           Federal Dollars
                                                                                                             $24 Billion
                                                                                                               (58%)


                     State Dollars
                      $11 Billion
                        (27%)




                                                   Total = $40.7 Billion

SOURCE: Kaiser Commission on Medicaid and the Uninsured analysis of data from Hadley, J. and J. Holahan. 2004. The Cost of Care for
the Uninsured: What Do We Spend, Who Pays, and What Would Full Coverage Add to Medical Spending? KCMU, Issue Update, May 2004.
Growth in Workers by Type of Industry,
                    2000 to 2005
                             +5.6 million




                                                                          -2.0 million

     Growth in Workers in Industries                                Decline in Workers in Industries
    where Employer-Sponsored Health                                where Employer-Sponsored Health
        Coverage is Less Common                                       Coverage is More Common


Notes: Excludes those aged 65+. Uninsured rates are 23% in industries where coverage is less common, such as
construction and agriculture; 10% where coverage is more common, such as education and manufacturing.
Source: Urban Institute analysis of the 2001 and 2006 March CPS for KCMU, 2006.
Cumulative Changes in Health Insurance Premiums and
            Workers’ Earnings, 2001-2007




Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2001-2007; Bureau of Labor Statistics, Seasonally Adjusted Data from the
Current Employment Statistics Survey, 1988-2007 (April to April).
Average Annual Worker Premium Contributions Paid by Covered
       Workers for Single and Family Coverage 1999 2010
                                     Coverage, 1999-2010




*Estimate is statistically different from estimate for the previous year shown
(p
(p<.05).
      )
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2010.
Average Annual Health Insurance Premiums and
             Worker Contributions for Family Coverage,
                                           y       g
                            2000-2010
                                                                    $13,770
                                                      114%
                                                     Premium
                                                     Increase



                         $6,438
                                                  147% Worker
                                                   Contribution
                                                   C t ib ti
                                                    Increase




Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits,
2000-2010.
HMO Median Medical Expense Ratios, 1995-
                          2002




Note: Medical expense ratio calculated as Total Medical Expenses/(Total Revenue - Investment Revenue).

Source: InterStudy Publications, The InterStudy Competitive Edge 13.2, Part II: HMO Industry Report, (reporting data as of January 1,
2003), October 2003, Figure 9, p. 60.
The storm cometh ….
Nope… it’s already here!!!
The Perfect Storm
•   Looming physician shortages
•   Elderly population rises
•   Health care population rises
                 p p
•   Specialists refuse to take “call” from ED
•   Higher unemployment: uninsured
•   Employees begin to pay more for care
•   Increased regulatory environment
•   Malpractice environment
        p
Total Number of Active Physicians per
                            1,000 Persons,
                             1980 – 2004




                      (1)                                                                                              (2)




Source: CDC, NCHS Health United States, 1982, 1996-97, 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006.
(1) 1980 does not include doctors of osteopathy.
(2) 2004 includes both federal and non-federal physicians. Prior to 2003, data included non-federal physicians only.
First-Year M.D. Enrollment per 100,000
  Population Has Declined Since 1980
          i          i    Si




Source: AAMC 2006; U.S. Census Bureau
Average Physician Income
          Adjusted f I fl ti 1995 2003
          Adj t d for Inflation 1995-2003




Source: Community Tracking Study Physician Survey Center for Studying Health System Change
Mean Time Spent with Physician (
                                   p            y      (in
                               Minutes), 1989-2006
Minutes




      Note: Includes ambulatory care visits made to nonfederally employed physicians’ offices in the United States (excluding physicians in the
      specialties of anesthesiology, radiology, and pathology). Visits to private, nonhospital-based clinics and HMOs are included if they are not
      federally operated facilities or hospital-based outpatient departments. Only visits where face-to-face contact with the physician occurred are
      included. Time spent with th physician excludes ti
      i l d d Ti           t ith the h i i          l d time spent waiting t see th physician, receiving care f
                                                                    t   iti to      the h i i          i i       from someone other th th
                                                                                                                                 th than the
      physician without the presence of the physician, or time spent by the physician in reviewing patient records and/or test results.
      Source: Center for Disease Control and Prevention, National Center for Health Statistics, Division of Health Care Statistics: 2006 data at
      National Health Statistics Reports, No. 3, August. 6, 2008, National Ambulatory Medical Care Survey: 2006 Summary, Table 28, p.36, at
      http://www.cdc.gov/nchs/data/nhsr/nhsr003.pdf.
LOOMING PHYSICIAN SHORTAGE

  • Retiring physicians
         – 250,000 physicians will retire in the next 10-20 years
                                                      10-
           …JUST WHEN THE BOOMERS HIT 70
         – 9,000 physicians retired in 2000
            • 23,000 WILL RETIRE IN 2025
  • Decreasing medical student matriculation
    per thousand population
  • 2020 E ti t of th shortage of physicians
          Estimate f the h t     f h i i
         – 85,000 TO 200,00


Association of American Medical Colleges
Medicare Enrollment, 1966-2010

                                                                                                                                                 46.1   47.0
                                                                                                                                     45.4
                                                                                                                          44.0
                                                                                                              43.3
                                                                                                   42.5
Number in millions:                                                                    39.6
                                                                            37.6

                                                                34.2
                                                     31.1
                                         28.5

                              25.0

                  20.5
      19.1




NOTES: Numbers may not sum to total due to rounding. People with disabilities under age 65 were not eligible for Medicare prior to 1972.
SOURCE: Centers for Medicare & Medicaid Services, Medicare Enrollment: Hospital Insurance and/or Supplemental Medical Insurance Programs for Total,
Fee-for-Service and Managed Care Enrollees as of July 1, 2008: Selected Calendar Years 1966-2008; 2009-2010, HHS Budget in Brief, FY2011.
Medicare Beneficiaries as a Percent of State
                      Populations, 2010
                        p         ,
                                                        National Average, 2010 = 15%

                                                                                                                         18%
                      14%                                                                                                           20%
                                            17%                17%                                                                             16%
                                                                             15%
                    16%                                                                                                                   16%
                                                                                                                         15%
                                                                                        16%                                              17%
                                14%                            17%                                  16%
                                               14%                                                                                    16%
                                                                                                                     18%              15%
                                                                                17%
                                                                  15%                                    16%                           16%
                        13%                                                               14% 15%                                     14%
                                     10%                                                                       21%
                                                   12%              15%                                                14%
                                                                                   17%                                                   DC 13%
                13%                                                                                   17%
                                                                                                                      16%
                                                                                                   16%
                                   14%           15%                   16%          18%                            17%
                                                                                                                                  9%-14% (14 states and DC)
                                                                                            17% 18%          12%
                                                                                                                                  15% (8 states)
                                                                    12%             15%
                                                                                                                                  16% (12 states)
               9%                                                                                                                 17%-21% (16 states)
                                                                                                                     18%


                                                     16%



NOTES: Percent enrollment calculated using U.S. Census Bureau July 2009 population estimates.
SOURCE: Centers for Medicare & Medicaid Services (CMS) Management Information Integrated Repository (MIIR), February 16, 2010. Medicare beneficiaries as a
share of state population estimates are based on July 1, 2009 state-level population estimates from the U.S. Census Bureau.
Number of Medicare Beneficiaries 1970-2040
    Enrollment in the Medicare Program is projected to nearly double in the next 30 years.


                                        Actual                   Projected
        Enrollment (millions)
        E          (




.
Source: Medicare Trustees Report 2006
Doctor Visits Are Sharply Higher
                 for Those O
                 f Th       Over 65




Source: National Ambulatory Medical Care Survey, 1980, 1990, 2000, and 2003
Prepared by AAMC Center for Workforce Studies
Growth in Medicare Expenditures 1970–2015
     Dollars in billions




Note: Figures for 2010 and 2015 are projected.

Source: The Commonwealth Fund; Data from 2006 Medicare Trustees’ Report.
Medicare % of U.S. Population 1970-2030
                          p
               The U.S. population will age rapidly through 2030, when 22 percent of the
                                populationwill be eligible for Medicare.


                                                                                                 22.0%

                                                                                         18.5%    2.4


                                                                                 15.0%    2.7
                                                                         13.9%
                                                                 13.1%
                                                 12.1%
                                                                          1.9     2.4
                                                                 1.2
                                   9.5%           1.3



                                    9.5           10.8            11.9   12.0     12.6   15.8    19.5




       Total Number of
     Medicare Beneficiaries:         20.4          28.4           34.3   39.6     46.5   61.6    78.6
           (millions)



Source: Social Security Administration, Office of the Actuary.
Median out-of-pocket health care spending
            as a percent of income continues to rise for
                        people on Medicare
                              l   M di




                                                                                  AARP IS A VERY BIG LOBBY


                      Median Out of Pocket Health
                             Out-of-Pocket
                      Spending as % of Income




SOURCE: Kaiser Family Foundation analysis of CMS Medicare Current Beneficiary Survey Cost and Use Files, 1997-2006.
Health Care Spending as a Share of Social Security
      Income for a Typical 65-Year-Old Medicare
                  Beneficiary, 2022
                  B    fi i
                                                      Average Social Security
                      $25,560                             Income, 2022                                          $25,560




                                                         Beneficiary Spending
                                                              as a share of
                                                        Social Security Payment



            Traditional Medicare                                                          “Path to Prosperity” Proposal
SOURCE: Kaiser Family Foundation analysis. Beneficiary health care spending under Medicare (extended baseline scenario) and Mr. Ryan’s proposal is
calculated based on data in the CBO letter to Chairman Paul Ryan dated April 5, 2011. Social Security income for an average wage 65-year old retiring
 at age 65 is based on Social Security Administration data (Table VI.F10 of the 2010 Trustees Report) adjusted to current dollars (based on annual CPI
projections in Table VI.F6. See http://www.ssa.gov/OACT/TR/2010/lr6f6.html factors).
Prescription Drug Coverage
                          Among Medicare Beneficiaries, 2010
                                                        No Drug
                                                        Coverage
                                                                                                            Stand-
                                                                                                             Alone
                                                                 4.7
                                                                                                          Prescription
                                                                million
                                                                                                           Drug Plan
                           Other Drug                           10%
                                                                                                             (PDP)
                           Coverage1             5.9
                                                million
                                                                                                                                    Total in
                                                                                                  17.7
                                                                                                  17 7                               Part D
                                                13%
                                                                                                 million
                                                                                                 38%                                 Plans:
                                                                                                                                      27.7
                                                                                                                                    Million
                                               8.3                                                                                  (60%)
                   Retiree Drug               million
                    Coverage2                 18%

                                                                            9.9
                                                                            99
                                                                           million
                                                                           21%
                                                                                             Medicare Advantage
                                                                                                 Drug Plan

                            Total Number of Medicare Beneficiaries = 46.5 Million
NOTES: Numbers do not sum to 100 percent due to rounding. 1Includes Veterans Affairs, retiree coverage without RDS, Indian Health Service, state pharmacy
assistance programs, employer plans for active workers, Medigap, multiple sources, and other sources. 2Includes Retiree Drug Subsidy (RDS) and FEHBP and
TRICARE retiree coverage.
SOURCE: Centers for Medicare & Medicaid Services, 2010 Enrollment Information (as of February 16, 2010).
Standard Medicare Prescription Drug Benefit, 2011

        CATASTROPHIC                                   Enrollee          Plan pays 15%;
                                                       pays 5%                                                                          Catastrophic
          COVERAGE                                                      Medicare pays 80%                                             Coverage Limit =
                                                                                                                                         $6,448 in
                                                                                                                                      Total D
                                                                                                                                      T t l Drug Costs
                                                                                                                                                 C t

                                                        Brand-name drugs
                                                        Enrollee pays 50%;
             COVERAGE                                50% manufacturer discount
               GAP                                               Generic drugs
                                                              Enrollee pays 93%;
                                                                 Plan pays 7%
                                                                                                                                            Initial
                                                                                                                                       Coverage Limit =
                                                                                                                                          $2,840 in
                                                                                                                                       Total Drug Costs

              INITIAL                          Enrollee
             COVERAGE                           pays                         Plan pays 75%
              PERIOD                            25%

                                                                                                                            $310 Deductible

SOURCE: Kaiser Family Foundation illustration of standard Medicare drug benefit for 2011 (standard benefit parameter update from Centers for Medicare & Medicaid
Services, April 2010). Amounts rounded to nearest dollar.
Percent of Medicare Part D Enrollees Who Reached the
           Coverage Gap and Catastrophic Coverage in 2007
                  g     p             p           g

          Excludes Part D Enrollees Who Receive Low-Income Subsidies and Non-Users


                                                                                                         Remained
                                                                                                           in the
                                                                                                         coverage
                                                                                                            gap



          Did not reach the                                                                                             Reached the
            coverage gap                                                                                                coverage gap


                                                                                                           Reached
                                                                                                         catastrophic
                                                                                                                   hi
                                                                                                          coverage
                                                                                                             level




NOTES: Estimates based on analysis of retail pharmacy claims for 1.9 million Part D enrollees in 2007.
SOURCE: Georgetown University/NORC/Kaiser Family Foundation analysis of IMS Health LRx database, 2007.
Components of Average Health Care Spending
                   by Medicare Households, 2009
                                                                                  Share of Total Spending




                                                                                                  9.8%                  Health Insurance
                                                                                                ($3,038)
                                                                                                ($3 038)                (65.7%
                                                                                                                        (65 7% of Health Care
                                                                                                                        Spending)
               Other                                      Health
             Household                                     Care
             Spending                                     14.9%
              85.1%

                                                                                                  2.6%
                                                                                                                        Medical Services (17.4%)
                                                                                                 ($804)

                                                                                                  2.1%
                                                                                                  2 1%                   Prescription Drugs
                                                                                                 ($654)                  (14.2%)

                                                                                            0.4% ($125)                Medical Supplies (2.7%)


     Average Total Spending = $30,966
     A       T   lS    di     $30 966                                          Average Health Care S
                                                                               A       H l hC      Spending = $4 620
                                                                                                       di     $4,620

NOTES: Numbers may not sum to total due to rounding.
SOURCE: Kaiser Family Foundation analysis of the Bureau of Labor Statistics Consumer Expenditure Survey Interview and Expense Files, 2009.
Medicare’s Share of National Personal Health
        Expenditures,
        Expenditures by Type of Service 2010
                                  Service,




                                                       Expenditures in Billions
 Medicare             $489                    $31                   $235                    $62                   $105                       $29
 Total              $2,142                    $77                   $789                   $260                   $536                   $149

NOTES: Total also includes dental care, durable medical equipment, other professional services, and other personal health care/products.
SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Expenditure Projections 2009-2019, February 2010.
Historical and Projected Number of Medicare
    Beneficiaries and Number of Workers Per Beneficiary

          Number of Beneficiaries (in millions)                                             Number of Workers Per Beneficiary




SOURCE: 2010 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.
Solvency Projections of the Medicare Hospital
                Insurance Trust Fund, 1970-2011
              Projected Number of Years to Insolvency and Projected Year of Insolvency:
                                      (1972)

                                                                                        (1994)

                                                                                    (2003)

                                                                                        (2005)

                                                      (1999)

                                                      (2001)

                                              (2001)
Report
 Year                                                                                           (
                                                                                                (2015)
                                                                                                     )
                                                                                                                                         (2029)

                                                                                                                            (2026)

                                                                                            (2020)

                                                                                 (2019)

                                                               (2017)

                                                                                                            (2029)

                                                                                    (2024)



Source: Intermediate projections from 1970-2011 Annual Reports of the Boards of Trustees of the Federal Hospital Insurance and Federal
Supplementary Medical Insurance Trust Funds.
Medicare is less generous than FEHB and other
                  large employer plans
                                       Share of Total Spending Paid by Plan in 2007

                            Total Average Medical Spending = $
                                l           di l S    di     $14,270
                                                                 2 0




                                                                         85%                                        83%
                              74%




                             Medicare                    Typical Large Employer PPO Plan                  FEHBP Standard Option

NOTE: The FEHBP (Federal Employees Health Benefits Program) standard option is offered through Blue Cross Blue Shield. Employer plans include
dental benefits.
SOURCE: Hewitt Associates analysis for the Kaiser Family Foundation, 2008.
The Perfect Storm
•   Our patients are sicker
        p
•   Our patients are older
•   There are more of them
•   They must all be seen and treated faster
•   ….in less number of hospital beds
•   ….in less days
•   ….for less money
•   ….with much improved quality
    – ….TRANSLATION: without any errors!!!!
THE COMMODITIZATION and
GLOBALIZATION OF HEALTH CARE

WHOLESALE TO RETAIL
 RETAIL CLINICS
  QUALITY & PRICE
  INFORMATION
   MEDICAL TOURISM
   MARKET
   SEGMENTATION
HEART SURGERY WITH A WARRANTY!
        SU G

Geisinger Health System ProvenCare:
•Flat rate for Bypass surgery $25,000 – $30,000
•Includes any complications 90 days post-op
 Includes                            post op
•Relies on following 40 Best Practice Guidelines
•In 117 cases,
   •mortality rate 0 from 1.5%
   •30 day readmission 5.1% from 6.6%
   •Hospital charges d
    H     it l h       dropped 5 2%
                             d 5.2%
NOV. 2007 HEADLINE: “DENNIS QUAID’S
 NEWBORN TWINS GIVEN 1,000 TIMES
INTENDED DOSE OF BLOOD THINNER”

• The CMO At CEDARS-SINAI MEDICAL
  CENTER in LA Stated:
  “As a result of a preventable error, the
  patients
  patients’ IV Catheters were flushed with
  heparin from vials containing a
  concentration of 10 000 units per milliliter
                    10,000
  instead of from vials containing a
  concentration of 10 units per milliliter ”
                                 milliliter.
• Multispecialty group Northern Central NJ
  – 120 physicians
  – 1700 patients per day
• 40+ Acres
• 250,000 sq ft facility
• Urgent Care facility
  – 10 exam rooms
  – 3000 sq ft
Accountable Care Organizations




                                 75
PATIENT CENTERED MEDICAL HOME

       The following principles were written and agreed upon by the four
       Primary Care Physician Organizations – the American Academy of
       Family Physicians, the A
       F il Ph i i        th American A d
                                   i   Academy of P di t i th
                                                   f Pediatrics, the
       American College of Physicians, and the American Osteopathic
       Association.

              Principles:
                  Ongoing relationship with personal physician
                  Physician di t d
                  Ph i i directed medical practice
                                       di l      ti
                  Whole person orientation
                  Coordinated care across the health system
                  Quality d f t
                  Q lit and safety
                  Enhanced access to care
                  Payment recognizes the value added


                                                                       76
Source: PCPCC (www.pcpcc.net)
Defining the Medical Home
                                                                                        •Specialist care is coordinated, and
                                                                                         systems are in place to prevent
              •Patients can easily make appointments and select                          errors that occur when multiple
                                                                                                                      p
               the d
               th day and ti
                          d time.                                                        physicians are involved.
              •Waiting times are short.                                     Care        •Follow-up and support is provided.
  Superb      •eMail and telephone consultations are offered.            Coordination
 Access to    •Off-hour service is available.
   Care                                                                                 • Integrated and coordinated team care
                                                                                          depends on a free flow of communication
                                                                                          among physicians, nurses case
                                                                                                  physicians nurses,
                                                                                          managers and other health professionals
                                                                                          (including BH specialists).
              •Patients have the option of being informed and                           • Duplication of tests and procedures is
               engaged partners in their care.                           Team Care        avoided.
              •Practices provide information on treatment plans,
               preventative and follow-up care reminders,
  Patient
    at e t     access to medical records, assistance with self-
Engagement     care, and counseling.
                                                                                        • Patients routinely provide feedback to
                                                                                          doctors; practices take advantage of low-
  in Care                                                                                 cost, internet-based patient surveys to
                                                                                          learn from patients and inform treatment
              •These systems support high-quality care,                                   plans.
               practice-based learning, and quality improvement.           Patient
              •Practices maintain patient registries; monitor
               Practices                                                  Feedback
               adherence to treatment; have easy access to lab
               and test results; and receive reminders, decision
  Clinical     support, and information on recommended
Information    treatments.                                                               •Patients have accurate, standardized
  Systems                                                                                 information on physicians to help
                                                                                          them choose a practice that will meet
                                                                                          their needs.
                                                                                                needs
                                                                           Publically
                                                                           P bli ll
                                                                           available
                                                                          information
                                                                                                                                77
                                     Source: Health2 Resources 9.30.08
                                                                                                                                      8
WHY IS IT IMPORTANT?
    • In the U.S., PCP supply is consistently associated with
                 ,        pp y                y
      improved health outcomes for conditions like cancer,
      heart disease, stroke, infant mortality, low birth
      weight,
      weight life expectancy, and self rated care
                   expectancy       self-rated care.
    • In England, each additional PCP per 10,000 persons is
      associated with an approximate decrease in mortality
      of 6%.
          %
    • In the U.K., an increase in PCP’s resulted in a
      significant decrease in both acute and chronic hospital
      admissions.


Starfield B. Shi L, and Macinko J. Contributions of Primary Care to Health Systems and Health, Millbank Quarterly, Vol. 83, No. 3,
2005 (457-502)
WHY IS IT IMPORTANT?
                                 U.S. adults who reported having a PCP
                                 rather than a specialist as their regular
                                 source of care had lower 5 year mortality
                                 rates after controlling for initial differences in
                                 health status, demographics, health
                                 insurance status, health perceptions,
                                 reported diagnosis, and smoking status.




Starfield B. Shi L, and Macinko J. Contributions of Primary Care to Health Systems and Health, Millbank Quarterly, Vol. 83, No. 3, 2005 (457-502)
WHY IS IT IMPORTANT?

                                 Patients who use a particular doctor for their
                                 care have more preventive care, more
                                                 p               ,
                                 accurate diagnosis, fewer diagnostic tests,
                                 fewer prescriptions, fewer ER visits, and
                                 fewer h it li ti
                                 f     hospitalizations, resulting i l
                                                             lti in lower cost t
                                 of care.




Starfield B. Shi L, and Macinko J. Contributions of Primary Care to Health Systems and Health, Millbank Quarterly, Vol. 83, No. 3, 2005 (457-502)
WHY IS IT IMPORTANT?
                               In the U.S., when adults have a medical
                               home, access to needed care, receipt of
                               routine preventive screenings, and
                                                  screenings
                               management of chronic conditions improve
                               substantially.
                                           y




A. C. Beal, M. M. Doty, S. E. Hernandez, K. K. Shea, and K. Davis, Closing the Divide: How Medical Homes Promote Equity in Health Care: Results From The
Commonwealth Fund 2006 Health Care Quality Survey, The Commonwealth Fund, June 2007
PCMH as Foundation for Accountable
                   Care Organizations




                                      ACOs are defined as a
                                      group of providers that has
                                      the legal structure to receive
                                      and    distribute    incentive
                                      payments to participating
                                      providers.




Source: Premier Healthcare Alliance                             82
What is an Accountable Care Organization?

     •   The PPACA Section 3022 definition
          – Organization of health care providers that agrees to be
            accountable f quality, cost and overall care of Medicare
                         for                                 f
            beneficiaries who are enrolled in traditional fee-for-service
            program and who are assigned to it
          – For each 12-month period, participating ACOs that meet
            specified quality performance standards eligible to receive
            share of any savings if actual per capita expenditures for
                       y       g           p     p      p
            assigned Medicare beneficiaries are sufficient percentage
            below specified benchmark amount
     • A partnership among health care providers to coordinate
       and deliver efficient care
          – Assumes joint accountability for improving quality and slowing
            cost growth


83
ACO Envisions Integrated Care
                                    Hospital



                                                       Other
                  Payers                             Healthcare
                                                     Providers
                                     Patients




                                                 Primary
                      Specialists                 Care
                                                Providers

      Purpose of ACOs is to create incentives for providers to collaborate
      to treat patients across health care settings
84
Basic Requirements for ACOs
• ACOs are required to:
  – Operate as a single integrated organization that
    accepts shared responsibility for the cost and quality
    of care provided to a specific population of patients
    cared for by the groups’ clinicians
  – Operate consistently with principles of a patient-
    centered medical home and other requirements of
    State legislation on ACOs
  – Have a formal legal structure to receive and distribute
    savings
  – Comply with federal requirements related to ACOs
                                                         85
Functional R
  F   ti   l Requirements f ACO
                 i     t for ACOs
• At a minimum, ACOs are required to have or provide
  through contractual arrangements:
   – Clinical service coordination, management, and delivery functions
   – Population management functions, including Health Information
                               functions
     Technology (HIT)
   – Financial management capabilities
   – Contract management capabilities
   – Quality measures to report on performance
       • There is a performance penalty if ACO fails to achieve certain quality
         measures
   – Patient and provider communication functions
   – Ability to provide behavioral health services within ACO or by
     contractual arrangements

                                                                            86
Eligibility Criteria for Forming ACOs
• Under PPACA, ACOs may be formed by:
             ,        y            y
   – ACO professionals (physicians and practitioners) in
     group practice arrangements
   – Networks of individual practices of ACO professionals
   – Partnerships or joint venture arrangements between
     acute care hospitals and ACO professionals
   – Acute care hospitals employing ACO
     professionals
• CMS roughly estimates th t th t t l average start-up
             hl    ti t that the total            t t
  investment and the first year of operating expenses for
  an entity forming an ACO to participate in the Medicare
  Shared Savings P
  Sh d S i          Program would b approximately $1 7
                                 ld be        i t l $1.7
  million                                                 87
Participation in ACOs

• SNFs, long-term care hospitals, and
  federally qualified health centers may not
  form ACOs, but may participate in
  established ACOs
• Participation in ACOs is voluntary



                                               88
Beneficiary Assignment to ACOs
•   Beneficiaries are assigned to an ACO based on p
                          g                             primary care
                                                                y
    services rendered by physicians in general practice, internal
    medicine, and geriatric medicine
•   Under PPACA, an ACO is required to have at least 5,000
    beneficiaries assigned to it to qualify to participate in shared savings
•   Assignment is made on a retrospective basis
•   Beneficiaries do not enroll in a specific ACO and ACOs do not know
    which beneficiaries are assigned to it until the end of the year
•   Two reasons CMS proposed retrospective assignment of
    beneficiaries:
     – “… the ACO should be evaluated on the quality and cost of care
       furnished to those beneficiaries who actually chose to receive care from
       ACO participants during the course of the performance year.”
     – “… to encourage the ACO to redesign its care processes for all
       Medicare FFS [Fee for Service] beneficiaries, not just for the subset of
       beneficiaries for whom the ACO is being evaluated.”


                                                                            89
Medicare B
M di     Beneficiaries’ F d
             fi i i ’ Freedom of Ch i
                               f Choice


 • The assignment of a patient to an ACO in
   no way restricts a Medicare FFS patient’s
   freedom of choice in selecting physicians
   and other health care providers and
   suppliers from whom he/she wishes to
   receive services


                                               90
Payment Model – Shared Savings

• CMS will develop a performance benchmark for ACOs to
  assess whether they qualify for shared savings
• ACOs will receive a share of any savings if the actual per
  capita expenditures of their assigned Medicare
  beneficiaries are below the benchmark
• ACOs will select either:
     – A one-sided risk payment model (sharing of savings only for the
        first two years, and sharing of savings and losses in the third
        year); or
     – A two-sided risk payment model ( h i of savings and l
           t      id d i k        t   d l (sharing f     i       d losses
        for all three years)
•   CMS has no authority to specify how shared savings will be
    distributed by ACOs
                    y

                                                                        91
Quality Measures and
              y
       Performance Thresholds
• 65 quality measures are proposed for the first
  year (January 1, 2012 through December 31,
  2012) in the following 5 areas:
  –   (1) Patient/Caregiver Experience of Care
  –   (2) Care Coordination
  –   (3) Patient Safety
  –   (4) Preventative Health
  –   (5) At Risk Population/Frail Elderly Health
          At-Risk
• ACOs which do not meet quality performance
  thresholds for all proposed measures would
  be ineligible for shared savings
                                                    92
Patient Protections
• ACOs are required to ensure access by disabled
  individuals and other individuals with chronic or complex
  medical conditions to appropriate specialty care
• ACOs are required to accept all patients regardless of
  payor or clinical profile
• The Office of Patient Protection is directed to establish
  regulations relating to consumer appeals of ACO
  determinations
• The DHCFP is required to:
   – Safeguard against underutilization of services and inappropriate
     denials of services or treatment
   – Safeguard against, and impose penalties for, inappropriate
     selection of low cost patients and avoidance of high cost patients
     by ACOs and ACO network providers

                                                                    93
How should patients navigate the
    system in such a “ f t storm”?
       t   i     h “perfect t     ”?
        Do Your Homework!
• Is the physician taking new patients?
• Does the physician accept your insurance?
• Is the physician part of a group?
• What are the office hours?
• Where did th physician attend medical
  Wh         the h i i        tt d   di l
  school?
• Is the physician board-certified?
Let s
Let’s start with a “Day in the Office”
                    Day        Office
• How many of you have been kept waiting
  for a scheduled appointment?
  – Did it make you angry?
• How many of you have been late for an
  appointment?
Start of the Day’s Schedule
                Day s
• 730am: Staff shows up to begin the day
• 8:00am: First patient shows up for
  scheduled 8am 20min appointment
• What needs to happen during this visit?
  – Staff brings you to the room
  – BP, P, Temp, Wt, medication list, allergies
  – Verify complaint
  – Update data on EMR
Enter the Physician…
                     Physician
• It’s now 8:07am…
  It s
• The physician
   –   Patient history: Wassuppp!
   –   Physical exam: any findings?
   –   Order any testing
   –   Counsel the patient on assessment
        • Dx, medication, expected course, instructions, what to watch
          for, f/u Q/A etc
          for f/u, Q/A, etc….
   – Write/dictate the medical record of encounter
• All of this needs to get done in 13 min!
Suggestions
• Request copies that require your signature
  ahead of time to allow reading them
• Come in 15 min earlier…
  – To register
     • Have insurance card
  – To have EMR updated so that visit can begin
    on time
• Have meds/OTC/herbs list for updating
• Is your scheduled visit enough time?
ASK QUESTIONS!!!




  -Newsweek: September 1, 2003, page 17
   Newsweek:
Schreck’s Top 10
    Value Considerations f P i
    V l C     id    i    for Patients

•   Get a PCP to help you         •   Keep list of your current meds
    NAVIGATE                      •   Physician EMR utilization
•   Physician
    Ph i i credentials:
                  d ti l          •   Discuss end-of-life decisions with
    Board-Certified                   your PCP (have family member with
    Fellow of the College             you to hear your wishes)
•   Physician accessibility       •   “One stop shopping”
                                       One       shopping
•   Physician’s personality       •   ACTIVELY PARTICIPATE IN YOUR
•   Understand insurance policy       CARE !!!
Closing Comments

•   Do your homework
•   Ask
    A k questions
              ti
•   Not all conditions are “cut and dry”
•   Be active and participate in your own care
    – Your medical care is a TEAM EFFORT!
• Government has been trying to herd the
  medical system

• B t getting physicians t d anything i
  But tti      h i i     to do  thi is
  like herding CATS!!!!
Answer
• There is no “extra” dollar -> depends on
               extra          >
  accounting basis (“balance”):

 Friends:            Motel:          Clerk:

 -$30 (motel fee)    +$30 (motel fee) +$5 (refund)
 + 3 (refund)        - 5 (refund)     -$3 (“commission”)
 -$27 net loss
  $27                +$25 net gain
                            t i        +$2 net gain
                                             t i

            -$27 balances + $27
             $27
            NO EXTRA DOLLAR!
Prescription Drug Coverage Among
              Medicare Beneficiaries, by Income, 2008

                                                                             23%                  26%
                                                        30%
                                                                                                                      Part D ­ Stand­alone 
                                                                                                                      PDP
                                   49%
                                                                                                                      Part D ­ Medicare 
              66%                                                            19%                  16%                 Advantage Drug Plan
                                                                                                                               g     g
                                                        24%                            1%                   1%        Self­Purchased Only

                                                                   1%                                                 Employer­Sponsored
                                   25%
                                                                             44%                  48%                 Other Public/Private
                                                        31%
                                              1%
              20%
                                   13%                                                                                No Drug Coverage
                        <1%                                        1%                  <1%
               5%                             1%
                        <1%                                                                                 <1%
                                   12%                  14%                  13%
               8%                                                                                  9%

       $10,000               $10,001-              $20,001-               $30,001-               $40,001
        or less               20,000                30,000                 40,000                or more
     (5.9 million)          (8.9 million)          (6.8 million)         (6.4 million)         (7.7 million)

NOTES: Percents rounded to the nearest whole number. Numbers may not sum due to rounding.
SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Access to Care File, 2008.
Understanding Health Care
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Understanding Health Care

  • 1. “The Perfect Storm The Storm” Health Care Trends Impact on Patient Care: How t N i t th S t H to Navigate the System David M. Schreck, MD, FACEP, FACP, FHM Chairman, Department of Emergency Medicine Summit Medical Group S it M di l G
  • 2. Introductions David M. Schreck, MD, MS, FACP, FACEP, FHM  Chairman – Department of Emergency Medicine, SMG  Private practice - IM  Specialist - Hospital Medicine  Clinical Asst Prof Med - RWJ  Adj Professor - Stevens Tech  MS Biomedical engineering  Past-Vice Chairman, Medicine Overlook
  • 3. Agenda • How did we get here? – You will get angry!!! • The “Perferct Storm Perferct Storm” – You will get angrier!!! • N i ti th system Navigating the t – You will try to hurt me!!! • Questions and Answers So … Don’t Shoot the Messenger!
  • 4. Beware Data Analysis • 3 f i d d i t Fl id friends drive to Florida • They stop at a motel • Motel l k h M l clerk charges $30 per night i h • Each of the friends pay $10 for the motel fee • Manager found that they were overcharged $5 per night (should have been $25 per night) • C Clerk instructed to refund $ f $5…
  • 5. Data Analysis • …However, the clerk decided to pocket $ $2 figuring the friends would never find out. • So the clerk refunded $3 to the friends… • How much did each of the friends pay ??? • How much did the clerk pocket ??? WHERE S WHERE’S THE EXTRA DOLLAR ???
  • 6. Viewpoint • There are no “bad guys” • Physicians p their p y put pants on “one leg at a g time” • Patients have a need (and a right) to know • Is healthcare a right? • Wh t i quality…who d id ? What is lit h decides? • This is a very complex situation….
  • 7. Patients are at the center… Employers Hospitals H i l Doctors Media Patients Insurers Pharmacy Govt: Bio- President industry Legislators
  • 8. Bias • But there are biases out there…. • Physicians have experience based preferences … “preferences”… • Insurance companies have shareholders • Th There are “ambulance chasers”… “ b l h ” • Patients want they think is best… – (ie, antibiotics for a “cold”) • Media sensationalism…
  • 9. Sensationalism • “Merck's Vioxx scandal widens: Drug maker knew Vioxx was deadly for years before risk was made public (opinion)” • January 26, 2011, 11:13 pm “Breast Implants Linked to Rare Cancer” • The Vaccine Victim
  • 10. Real Issues Do Exist • Who is “passing the buck” • We cannot legislate morality – 10% of us give us 90% of the headaches • …but where does the buck stop? • Quality…who pays for it? • Technology advances…who pays for it? • Access to care who pays for it? care…who • Convenience…who pays for it? • Unscheduled urgencies who pays for it? urgencies…who
  • 12. USA ED Visits 1984 2008 1984-2008 “America’s safety net: ~ $100 Billion”
  • 13. National Health Expenditures p National Health Expenditures 2020 $4,638.40 $4,346.50 2018 $4,080.00 $3,849.50 2016 $3,632.00 $3,417.90 2014 $3,227.40 $2,980.40 Projected 2012 $2,823.90 $2,708.40 $2 708 40 2010 $2,584.20 $2,486.30 Year 2008 $2,391.40 $2,283.50 2006 $2,152.10 $2.7 TRILLION $2,021.00 2004 $1,877.60 $1,740.60 2002 $1,607.90 $1,358.50 1999 $1,270.30 $1 270 30 $1,129.70 Reported 1993 $916.50 $717.30 1980 $254.90 $0.00 $0 00 $500.00 $500 00 $1,000.00 $1 000 00 $1,500.00 $1 500 00 $2,000.00 $2 000 00 $2,500.00 $2 500 00 $3,000.00 $3 000 00 $3,500.00 $3 500 00 $4,000.00 $4 000 00 $4,500.00 $4 500 00 $5,000.00 $5 000 00 Billions Source: www.cms.gov
  • 14. National Health Expenditures and Their Share of (GDP) 1980-2020 ( ) $5,000.00 25% National health spending is projected to continue to increase as a $4,500.00 share of GDP over the next decade. 20% $4,000.00 Projected 20% Actual $3,500.00 17.7% $3,000.00 15% $2,500.00 $2,000.00 $2 000 00 10% $1,500.00 $1,000.00 , 5% $500.00 $0.00 0% 80 90 93 97 99 00 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 19 19 19 19 19 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 National Health Expenditures % GDP Source: CMS, Office of the Actuary, National Health Statistics Group.
  • 15. National Health Expenditures and Their Share of Gross Domestic Product 1960 2009 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, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; file nhegdp09.zip).
  • 18.
  • 19. Total Health Expenditure as a Share of GDP, U.S. and Selected Countries, 2008 18% 16% 14% 12% As Percentage of GDP 10% 8% 16.0% 6% 11.2% 11 2% 0 % 10.5% 10.5% 0 % 10.7% 10 7% 11.1% 11 1% 9.9% 10.4% 9.0% 9.1% 9.4% 8.5% 8.5% 8.7% 4% 8.1% 2% 0% Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350- en (Accessed on 14 February 2011). Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted.
  • 20. Total Health Expenditure per Capita, Per Capita Health Spending, 2002 U.S. and Selected Countries, 2008 $8,000 Each year, the US spends roughly 2x the amount on $7,538 health care as the next most spending country $7,000 $6,000 Per Capita Spending - PP Adjusted $5,003 $5,000 $4,627 PP $3,970 $4,063 $4,079 $4,000 $3,677 $3,696 $3,737 $3,353 $3,470 $3,129 $2,870 $2,902 $3,000 $2,729 $2,000 $1,000 $0 Anderson GF, Hussey PS, Frogner BK, Waters HR. Health spending in the United States and the rest of the industrialized world. Health Aff (Millwood ). 2005;24:903-914.
  • 21. Total Expenditure on Health as a Share of GDP, U.S. and Selected Countries, 1970, 1980, 1990, 2000, 2008 18% 16% 14% Health Spending as Percent of GDP 12% 10% 8% 1970 6% 1980 1990 4% 2000 2008 2% 0% Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350- en (Accessed on 14 February 2011). Notes: Data from Australia and Japan are 2007 data. 2008 figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. 200 figures for Belgium are OECD estimates. Break in Series AUS (1998); AUSTRIA(1990); BEL(2003, 2005); CAN(1995); FRA(1995); GER(1992); JAP(1995); NET(1998, 2003); NOR(1999); SPA(1999, 2003); SWE(1993, 2001); SWI(1995); UK (1997). Starting in 1993 Belgium used a different methodology.
  • 22. Total Health Expenditure Per Capita, U.S. and Selected Countries, 1970, 1980, 1990, 2000, 2000 2008 $8,000 $7,000 apita Spending - PPP Adjusted $6,000 $5,000 1970 1980 $4,000 1990 2000 $3,000 2008 Per Ca $2,000 $1,000 $- $ Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2011). Notes: Data from Australia and Japan are 2007 data. 2008 figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. 2000 figured for Belgium are OECD estimates. Numbers are PPP adjusted. Break in Series AUS (1998); AUSTRIA(1990); BEL(2003, 2005); CAN(1995); FRA(1995); GER(1992); JAP(1995); NET(1998, 2003); NOR(1999); SPA(1999, 2003); SWE(1993, 2001); SWI(1995); UK (1997. Starting in 1993 Belgium used a different methodology.
  • 23. Growth in Total Health Expenditure Per Capita, U.S. and Selected Countries, 1970-2008 $8,000 $7,000 ed Per Capita Spendin - PPP Adjuste $6,000 United States $5,000 Switzerland ng Canada $4,000 OECD Average Sweden C $3,000 $3 000 United Kingdom $2,000 $1,000 $0 1970 1975 1980 1985 1990 1995 2000 2005 Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350- en (Accessed on 14 February 2011). Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted. Break in series: CAN(1995); SWE(1993, 2001); SWI(1995); UK (1997). Numbers are PPP adjusted. Estimates for Canada and Switzerland in 2008.
  • 24. Total Health Expenditure per Capita and GDP per Capita, US and Selected Countries, 2008 Countries $8,000 USA $7,000 $7 000 Pe Capita Heal Spending $6,000 Austria $5,000 Switzerland lth Germany Canada Norway Belgium $4,000 France Netherlands $3,000 Italy U.K. Australia er Japan Sweden $2,000 Spain $1,000 $0 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65,000 GDP Per Capita Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350- en (Accessed on 14 February 2011). Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates.
  • 25. We are in for a rough ride!!!! BAD NEWS WORSE NEWS CURRENT MEDICARE’S UNFUNDED CURRENT LIABILITY OF UNFUNDED SOCIAL SECURITY LIABILITY IS IS ABOUT ABOUT $11 TRILLION + $66 TRILLION! = $250 000 per person $250,000 (310,000,000 est. pop. 2010) Who’s paying for this??? Source: Orlikoff & Associates, Inc. 2008
  • 26. Population Data Are these groups motivated to pay the debt???? And to pay for us as we age??? $39k $21k $37k $31k AGE GROUPS
  • 27. Projected National Health Expenditures in the United States, States by Source of Payment, 2010 Payment Where the money comes from…… Private Health Insurance 32% Other Private Spending 7% 21% Medicare Out-of-Pocket 11% Payments 12% 16% Other Public Medicaid and Spending CHIP1 Total National Health Expenditures, 2010 = $2.6 Trillion NOTES: 1Includes Children’s Health Insurance Program (CHIP) and Children’s Health Insurance Program expansion (Title XIX). Percentages do not sum to 100% due to rounding. SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, Updated National Health Expenditure Projections 2009-2019, January 2011.
  • 28. Distribution of National Health Expenditures, by Type of Service, 2009 Service Where it goes…… Hospital Other Health Care, 30.5% Spending, 15.9% Other Personal Health Care, 14.9% Home Health Care, 2.7% Prescription p Nursing Home Drugs, 10.1% Care, 5.5% Physician/ Cli i l Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. O h Health Spending includes, for example, administration and net cost of private health insurance, public health activity, Other H l h S di i l d f l d i i i d f i h lhi bli h l h i i research, and structures and equipment, etc. Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2009; file nhe2009.zip).
  • 29. Distribution of National Health Expenditures, by Type of Service, Service 1999 and 2009 Hospital Physician/ Prescription Nursing Home Health Other Other Health Care Clinical Drugs Home Care Care Personal Spending Services Health Care Notes: Percentages may not total 100% due to rounding. Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private h lth insurance, i d bl di l i t t Oth H lth S di i l d f l d i i t ti d t t f i t health i public health activity, research, and structures and equipment, etc. Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2009; file nhe2009.zip).
  • 30. Concentration of Health Care Spending in th U S P i the U.S. Population, 2008 l ti Percent of To Health Care Spending 100% Is heathcare a right? 96.9% 80% Is rationing on the way? 80.2% 73.4% 63.6% 60% h 47.5% 40% otal 20.2% 20 2% 20% 3.1% 0% Top 1% Top 5% Top 10% Top 15% Top 20% Top 50% Bottom 50% (≥$44,338) (≥$16,336) (≥$9,148) (≥$6,074) (≥$4,374) (≥$825) Percent of Population, Ranked by Health Care Spending (<$825) Note: Dollar amounts in parentheses are the annual expenses per person in each percentile. Population is the civilian noninstitutionalized population, including those without any health care spending. Health care spending is total payments from all sources (including direct payments from individuals, private insurance, Medicare, Medicaid, and miscellaneous other sources) to hospitals, physicians, other providers (including dental care), and pharmacies; health insurance premiums are not included. Source: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey (MEPS), 2008.
  • 32. Number of Public Community Hospitals, 1990-2008 1990 2008 Notes: Includes nonfederal (i.e., state and local government), short-term general and specialty hospitals whose facilities are available to the public. ( , g ), g p y p p Public community hospitals represent 23% of all community hospitals, and community hospitals represent about 85% of all hospitals. Federal hospitals, long term care hospitals, psychiatric hospitals, institutions for the mentally retarded, and alcoholism and other chemical dependency hospitals are not included. Source: American Hospital Association Annual Surveys: 1990-1998 data from Hospital Statistics, 2002, Table 1; 1999-2008 data from AHA Annual Surveys, Copyright 2010 by Health Forum LLC, an affiliate of the American Hospital Association, at http://www.ahaonlinestore.com.
  • 35. Aggregate Total Community Hospital Margins, 1980-2008 1980 2008 Note: Total Community Hospital Margin calculated as the difference between total net revenue and total expenses, divided by total net revenue. Source: American Hospital Association and Avalere Health, Avalere Health analysis of 2008 American Hospital Association Annual Survey data, for community hospitals, Trendwatch Chartbook 2010, Trends Affecting Hospitals and Health Systems, Table 4.1, p. A-32, at http://www.aha.org/aha/trendwatch/chartbook/2010/appendix4.pdf.
  • 36. Community Hospital Payment-to-Cost Ratios, b Source of Revenue, 1980 2008 R ti by S fR 1980-2008 Note: Payment-to-cost ratios show th degree to which payments f N t P tt t ti h the d t hi h t from each payer cover th costs of treating its patients. They cannot be h the t f t ti it ti t Th tb used to compare payment levels across payers, however, because the service mix and intensity vary. Data are for community hospitals. Medicaid includes Medicaid Disproportionate Share payments. Source: American Hospital Association and Avalere Health, Avalere Health analysis of 2008 American Hospital Association Annual Survey data, for community hospitals, Trendwatch Chartbook 2010, Trends Affecting Hospitals and Health Systems, Table 4.4, p. A-35, at http://www.aha.org/aha/trendwatch/chartbook/2010/appendix4.pdf.
  • 37. Health Insurance Coverage 2007 Other Private Uninsured 24,500,000 Medicaid 39,600,000 45,700,000 Medicare 41,400,000 Military 4,000,000 Employer 177,400,000 Source: U.S. Census Bureau: Income, Poverty, and Health Insurance Coverage in the United States 2007
  • 38. Payment Sources for Uncompensated Care, 2004 Private Dollars $6 Billion (15%) Federal Dollars $24 Billion (58%) State Dollars $11 Billion (27%) Total = $40.7 Billion SOURCE: Kaiser Commission on Medicaid and the Uninsured analysis of data from Hadley, J. and J. Holahan. 2004. The Cost of Care for the Uninsured: What Do We Spend, Who Pays, and What Would Full Coverage Add to Medical Spending? KCMU, Issue Update, May 2004.
  • 39. Growth in Workers by Type of Industry, 2000 to 2005 +5.6 million -2.0 million Growth in Workers in Industries Decline in Workers in Industries where Employer-Sponsored Health where Employer-Sponsored Health Coverage is Less Common Coverage is More Common Notes: Excludes those aged 65+. Uninsured rates are 23% in industries where coverage is less common, such as construction and agriculture; 10% where coverage is more common, such as education and manufacturing. Source: Urban Institute analysis of the 2001 and 2006 March CPS for KCMU, 2006.
  • 40. Cumulative Changes in Health Insurance Premiums and Workers’ Earnings, 2001-2007 Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2001-2007; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1988-2007 (April to April).
  • 41. Average Annual Worker Premium Contributions Paid by Covered Workers for Single and Family Coverage 1999 2010 Coverage, 1999-2010 *Estimate is statistically different from estimate for the previous year shown (p (p<.05). ) Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2010.
  • 42. Average Annual Health Insurance Premiums and Worker Contributions for Family Coverage, y g 2000-2010 $13,770 114% Premium Increase $6,438 147% Worker Contribution C t ib ti Increase Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2000-2010.
  • 43. HMO Median Medical Expense Ratios, 1995- 2002 Note: Medical expense ratio calculated as Total Medical Expenses/(Total Revenue - Investment Revenue). Source: InterStudy Publications, The InterStudy Competitive Edge 13.2, Part II: HMO Industry Report, (reporting data as of January 1, 2003), October 2003, Figure 9, p. 60.
  • 46. The Perfect Storm • Looming physician shortages • Elderly population rises • Health care population rises p p • Specialists refuse to take “call” from ED • Higher unemployment: uninsured • Employees begin to pay more for care • Increased regulatory environment • Malpractice environment p
  • 47. Total Number of Active Physicians per 1,000 Persons, 1980 – 2004 (1) (2) Source: CDC, NCHS Health United States, 1982, 1996-97, 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006. (1) 1980 does not include doctors of osteopathy. (2) 2004 includes both federal and non-federal physicians. Prior to 2003, data included non-federal physicians only.
  • 48. First-Year M.D. Enrollment per 100,000 Population Has Declined Since 1980 i i Si Source: AAMC 2006; U.S. Census Bureau
  • 49. Average Physician Income Adjusted f I fl ti 1995 2003 Adj t d for Inflation 1995-2003 Source: Community Tracking Study Physician Survey Center for Studying Health System Change
  • 50. Mean Time Spent with Physician ( p y (in Minutes), 1989-2006 Minutes Note: Includes ambulatory care visits made to nonfederally employed physicians’ offices in the United States (excluding physicians in the specialties of anesthesiology, radiology, and pathology). Visits to private, nonhospital-based clinics and HMOs are included if they are not federally operated facilities or hospital-based outpatient departments. Only visits where face-to-face contact with the physician occurred are included. Time spent with th physician excludes ti i l d d Ti t ith the h i i l d time spent waiting t see th physician, receiving care f t iti to the h i i i i from someone other th th th than the physician without the presence of the physician, or time spent by the physician in reviewing patient records and/or test results. Source: Center for Disease Control and Prevention, National Center for Health Statistics, Division of Health Care Statistics: 2006 data at National Health Statistics Reports, No. 3, August. 6, 2008, National Ambulatory Medical Care Survey: 2006 Summary, Table 28, p.36, at http://www.cdc.gov/nchs/data/nhsr/nhsr003.pdf.
  • 51. LOOMING PHYSICIAN SHORTAGE • Retiring physicians – 250,000 physicians will retire in the next 10-20 years 10- …JUST WHEN THE BOOMERS HIT 70 – 9,000 physicians retired in 2000 • 23,000 WILL RETIRE IN 2025 • Decreasing medical student matriculation per thousand population • 2020 E ti t of th shortage of physicians Estimate f the h t f h i i – 85,000 TO 200,00 Association of American Medical Colleges
  • 52. Medicare Enrollment, 1966-2010 46.1 47.0 45.4 44.0 43.3 42.5 Number in millions: 39.6 37.6 34.2 31.1 28.5 25.0 20.5 19.1 NOTES: Numbers may not sum to total due to rounding. People with disabilities under age 65 were not eligible for Medicare prior to 1972. SOURCE: Centers for Medicare & Medicaid Services, Medicare Enrollment: Hospital Insurance and/or Supplemental Medical Insurance Programs for Total, Fee-for-Service and Managed Care Enrollees as of July 1, 2008: Selected Calendar Years 1966-2008; 2009-2010, HHS Budget in Brief, FY2011.
  • 53. Medicare Beneficiaries as a Percent of State Populations, 2010 p , National Average, 2010 = 15% 18% 14% 20% 17% 17% 16% 15% 16% 16% 15% 16% 17% 14% 17% 16% 14% 16% 18% 15% 17% 15% 16% 16% 13% 14% 15% 14% 10% 21% 12% 15% 14% 17% DC 13% 13% 17% 16% 16% 14% 15% 16% 18% 17% 9%-14% (14 states and DC) 17% 18% 12% 15% (8 states) 12% 15% 16% (12 states) 9% 17%-21% (16 states) 18% 16% NOTES: Percent enrollment calculated using U.S. Census Bureau July 2009 population estimates. SOURCE: Centers for Medicare & Medicaid Services (CMS) Management Information Integrated Repository (MIIR), February 16, 2010. Medicare beneficiaries as a share of state population estimates are based on July 1, 2009 state-level population estimates from the U.S. Census Bureau.
  • 54. Number of Medicare Beneficiaries 1970-2040 Enrollment in the Medicare Program is projected to nearly double in the next 30 years. Actual Projected Enrollment (millions) E ( . Source: Medicare Trustees Report 2006
  • 55. Doctor Visits Are Sharply Higher for Those O f Th Over 65 Source: National Ambulatory Medical Care Survey, 1980, 1990, 2000, and 2003 Prepared by AAMC Center for Workforce Studies
  • 56. Growth in Medicare Expenditures 1970–2015 Dollars in billions Note: Figures for 2010 and 2015 are projected. Source: The Commonwealth Fund; Data from 2006 Medicare Trustees’ Report.
  • 57. Medicare % of U.S. Population 1970-2030 p The U.S. population will age rapidly through 2030, when 22 percent of the populationwill be eligible for Medicare. 22.0% 18.5% 2.4 15.0% 2.7 13.9% 13.1% 12.1% 1.9 2.4 1.2 9.5% 1.3 9.5 10.8 11.9 12.0 12.6 15.8 19.5 Total Number of Medicare Beneficiaries: 20.4 28.4 34.3 39.6 46.5 61.6 78.6 (millions) Source: Social Security Administration, Office of the Actuary.
  • 58. Median out-of-pocket health care spending as a percent of income continues to rise for people on Medicare l M di AARP IS A VERY BIG LOBBY Median Out of Pocket Health Out-of-Pocket Spending as % of Income SOURCE: Kaiser Family Foundation analysis of CMS Medicare Current Beneficiary Survey Cost and Use Files, 1997-2006.
  • 59. Health Care Spending as a Share of Social Security Income for a Typical 65-Year-Old Medicare Beneficiary, 2022 B fi i Average Social Security $25,560 Income, 2022 $25,560 Beneficiary Spending as a share of Social Security Payment Traditional Medicare “Path to Prosperity” Proposal SOURCE: Kaiser Family Foundation analysis. Beneficiary health care spending under Medicare (extended baseline scenario) and Mr. Ryan’s proposal is calculated based on data in the CBO letter to Chairman Paul Ryan dated April 5, 2011. Social Security income for an average wage 65-year old retiring at age 65 is based on Social Security Administration data (Table VI.F10 of the 2010 Trustees Report) adjusted to current dollars (based on annual CPI projections in Table VI.F6. See http://www.ssa.gov/OACT/TR/2010/lr6f6.html factors).
  • 60. Prescription Drug Coverage Among Medicare Beneficiaries, 2010 No Drug Coverage Stand- Alone 4.7 Prescription million Drug Plan Other Drug 10% (PDP) Coverage1 5.9 million Total in 17.7 17 7 Part D 13% million 38% Plans: 27.7 Million 8.3 (60%) Retiree Drug million Coverage2 18% 9.9 99 million 21% Medicare Advantage Drug Plan Total Number of Medicare Beneficiaries = 46.5 Million NOTES: Numbers do not sum to 100 percent due to rounding. 1Includes Veterans Affairs, retiree coverage without RDS, Indian Health Service, state pharmacy assistance programs, employer plans for active workers, Medigap, multiple sources, and other sources. 2Includes Retiree Drug Subsidy (RDS) and FEHBP and TRICARE retiree coverage. SOURCE: Centers for Medicare & Medicaid Services, 2010 Enrollment Information (as of February 16, 2010).
  • 61. Standard Medicare Prescription Drug Benefit, 2011 CATASTROPHIC Enrollee Plan pays 15%; pays 5% Catastrophic COVERAGE Medicare pays 80% Coverage Limit = $6,448 in Total D T t l Drug Costs C t Brand-name drugs Enrollee pays 50%; COVERAGE 50% manufacturer discount GAP Generic drugs Enrollee pays 93%; Plan pays 7% Initial Coverage Limit = $2,840 in Total Drug Costs INITIAL Enrollee COVERAGE pays Plan pays 75% PERIOD 25% $310 Deductible SOURCE: Kaiser Family Foundation illustration of standard Medicare drug benefit for 2011 (standard benefit parameter update from Centers for Medicare & Medicaid Services, April 2010). Amounts rounded to nearest dollar.
  • 62. Percent of Medicare Part D Enrollees Who Reached the Coverage Gap and Catastrophic Coverage in 2007 g p p g Excludes Part D Enrollees Who Receive Low-Income Subsidies and Non-Users Remained in the coverage gap Did not reach the Reached the coverage gap coverage gap Reached catastrophic hi coverage level NOTES: Estimates based on analysis of retail pharmacy claims for 1.9 million Part D enrollees in 2007. SOURCE: Georgetown University/NORC/Kaiser Family Foundation analysis of IMS Health LRx database, 2007.
  • 63. Components of Average Health Care Spending by Medicare Households, 2009 Share of Total Spending 9.8% Health Insurance ($3,038) ($3 038) (65.7% (65 7% of Health Care Spending) Other Health Household Care Spending 14.9% 85.1% 2.6% Medical Services (17.4%) ($804) 2.1% 2 1% Prescription Drugs ($654) (14.2%) 0.4% ($125) Medical Supplies (2.7%) Average Total Spending = $30,966 A T lS di $30 966 Average Health Care S A H l hC Spending = $4 620 di $4,620 NOTES: Numbers may not sum to total due to rounding. SOURCE: Kaiser Family Foundation analysis of the Bureau of Labor Statistics Consumer Expenditure Survey Interview and Expense Files, 2009.
  • 64. Medicare’s Share of National Personal Health Expenditures, Expenditures by Type of Service 2010 Service, Expenditures in Billions Medicare $489 $31 $235 $62 $105 $29 Total $2,142 $77 $789 $260 $536 $149 NOTES: Total also includes dental care, durable medical equipment, other professional services, and other personal health care/products. SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Expenditure Projections 2009-2019, February 2010.
  • 65. Historical and Projected Number of Medicare Beneficiaries and Number of Workers Per Beneficiary Number of Beneficiaries (in millions) Number of Workers Per Beneficiary SOURCE: 2010 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.
  • 66. Solvency Projections of the Medicare Hospital Insurance Trust Fund, 1970-2011 Projected Number of Years to Insolvency and Projected Year of Insolvency: (1972) (1994) (2003) (2005) (1999) (2001) (2001) Report Year ( (2015) ) (2029) (2026) (2020) (2019) (2017) (2029) (2024) Source: Intermediate projections from 1970-2011 Annual Reports of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.
  • 67. Medicare is less generous than FEHB and other large employer plans Share of Total Spending Paid by Plan in 2007 Total Average Medical Spending = $ l di l S di $14,270 2 0 85% 83% 74% Medicare Typical Large Employer PPO Plan FEHBP Standard Option NOTE: The FEHBP (Federal Employees Health Benefits Program) standard option is offered through Blue Cross Blue Shield. Employer plans include dental benefits. SOURCE: Hewitt Associates analysis for the Kaiser Family Foundation, 2008.
  • 68. The Perfect Storm • Our patients are sicker p • Our patients are older • There are more of them • They must all be seen and treated faster • ….in less number of hospital beds • ….in less days • ….for less money • ….with much improved quality – ….TRANSLATION: without any errors!!!!
  • 69. THE COMMODITIZATION and GLOBALIZATION OF HEALTH CARE WHOLESALE TO RETAIL RETAIL CLINICS QUALITY & PRICE INFORMATION MEDICAL TOURISM MARKET SEGMENTATION
  • 70. HEART SURGERY WITH A WARRANTY! SU G Geisinger Health System ProvenCare: •Flat rate for Bypass surgery $25,000 – $30,000 •Includes any complications 90 days post-op Includes post op •Relies on following 40 Best Practice Guidelines •In 117 cases, •mortality rate 0 from 1.5% •30 day readmission 5.1% from 6.6% •Hospital charges d H it l h dropped 5 2% d 5.2%
  • 71. NOV. 2007 HEADLINE: “DENNIS QUAID’S NEWBORN TWINS GIVEN 1,000 TIMES INTENDED DOSE OF BLOOD THINNER” • The CMO At CEDARS-SINAI MEDICAL CENTER in LA Stated: “As a result of a preventable error, the patients patients’ IV Catheters were flushed with heparin from vials containing a concentration of 10 000 units per milliliter 10,000 instead of from vials containing a concentration of 10 units per milliliter ” milliliter.
  • 72. • Multispecialty group Northern Central NJ – 120 physicians – 1700 patients per day • 40+ Acres • 250,000 sq ft facility • Urgent Care facility – 10 exam rooms – 3000 sq ft
  • 73.
  • 74.
  • 76. PATIENT CENTERED MEDICAL HOME The following principles were written and agreed upon by the four Primary Care Physician Organizations – the American Academy of Family Physicians, the A F il Ph i i th American A d i Academy of P di t i th f Pediatrics, the American College of Physicians, and the American Osteopathic Association. Principles: Ongoing relationship with personal physician Physician di t d Ph i i directed medical practice di l ti Whole person orientation Coordinated care across the health system Quality d f t Q lit and safety Enhanced access to care Payment recognizes the value added 76 Source: PCPCC (www.pcpcc.net)
  • 77. Defining the Medical Home •Specialist care is coordinated, and systems are in place to prevent •Patients can easily make appointments and select errors that occur when multiple p the d th day and ti d time. physicians are involved. •Waiting times are short. Care •Follow-up and support is provided. Superb •eMail and telephone consultations are offered. Coordination Access to •Off-hour service is available. Care • Integrated and coordinated team care depends on a free flow of communication among physicians, nurses case physicians nurses, managers and other health professionals (including BH specialists). •Patients have the option of being informed and • Duplication of tests and procedures is engaged partners in their care. Team Care avoided. •Practices provide information on treatment plans, preventative and follow-up care reminders, Patient at e t access to medical records, assistance with self- Engagement care, and counseling. • Patients routinely provide feedback to doctors; practices take advantage of low- in Care cost, internet-based patient surveys to learn from patients and inform treatment •These systems support high-quality care, plans. practice-based learning, and quality improvement. Patient •Practices maintain patient registries; monitor Practices Feedback adherence to treatment; have easy access to lab and test results; and receive reminders, decision Clinical support, and information on recommended Information treatments. •Patients have accurate, standardized Systems information on physicians to help them choose a practice that will meet their needs. needs Publically P bli ll available information 77 Source: Health2 Resources 9.30.08 8
  • 78. WHY IS IT IMPORTANT? • In the U.S., PCP supply is consistently associated with , pp y y improved health outcomes for conditions like cancer, heart disease, stroke, infant mortality, low birth weight, weight life expectancy, and self rated care expectancy self-rated care. • In England, each additional PCP per 10,000 persons is associated with an approximate decrease in mortality of 6%. % • In the U.K., an increase in PCP’s resulted in a significant decrease in both acute and chronic hospital admissions. Starfield B. Shi L, and Macinko J. Contributions of Primary Care to Health Systems and Health, Millbank Quarterly, Vol. 83, No. 3, 2005 (457-502)
  • 79. WHY IS IT IMPORTANT? U.S. adults who reported having a PCP rather than a specialist as their regular source of care had lower 5 year mortality rates after controlling for initial differences in health status, demographics, health insurance status, health perceptions, reported diagnosis, and smoking status. Starfield B. Shi L, and Macinko J. Contributions of Primary Care to Health Systems and Health, Millbank Quarterly, Vol. 83, No. 3, 2005 (457-502)
  • 80. WHY IS IT IMPORTANT? Patients who use a particular doctor for their care have more preventive care, more p , accurate diagnosis, fewer diagnostic tests, fewer prescriptions, fewer ER visits, and fewer h it li ti f hospitalizations, resulting i l lti in lower cost t of care. Starfield B. Shi L, and Macinko J. Contributions of Primary Care to Health Systems and Health, Millbank Quarterly, Vol. 83, No. 3, 2005 (457-502)
  • 81. WHY IS IT IMPORTANT? In the U.S., when adults have a medical home, access to needed care, receipt of routine preventive screenings, and screenings management of chronic conditions improve substantially. y A. C. Beal, M. M. Doty, S. E. Hernandez, K. K. Shea, and K. Davis, Closing the Divide: How Medical Homes Promote Equity in Health Care: Results From The Commonwealth Fund 2006 Health Care Quality Survey, The Commonwealth Fund, June 2007
  • 82. PCMH as Foundation for Accountable Care Organizations ACOs are defined as a group of providers that has the legal structure to receive and distribute incentive payments to participating providers. Source: Premier Healthcare Alliance 82
  • 83. What is an Accountable Care Organization? • The PPACA Section 3022 definition – Organization of health care providers that agrees to be accountable f quality, cost and overall care of Medicare for f beneficiaries who are enrolled in traditional fee-for-service program and who are assigned to it – For each 12-month period, participating ACOs that meet specified quality performance standards eligible to receive share of any savings if actual per capita expenditures for y g p p p assigned Medicare beneficiaries are sufficient percentage below specified benchmark amount • A partnership among health care providers to coordinate and deliver efficient care – Assumes joint accountability for improving quality and slowing cost growth 83
  • 84. ACO Envisions Integrated Care Hospital Other Payers Healthcare Providers Patients Primary Specialists Care Providers Purpose of ACOs is to create incentives for providers to collaborate to treat patients across health care settings 84
  • 85. Basic Requirements for ACOs • ACOs are required to: – Operate as a single integrated organization that accepts shared responsibility for the cost and quality of care provided to a specific population of patients cared for by the groups’ clinicians – Operate consistently with principles of a patient- centered medical home and other requirements of State legislation on ACOs – Have a formal legal structure to receive and distribute savings – Comply with federal requirements related to ACOs 85
  • 86. Functional R F ti l Requirements f ACO i t for ACOs • At a minimum, ACOs are required to have or provide through contractual arrangements: – Clinical service coordination, management, and delivery functions – Population management functions, including Health Information functions Technology (HIT) – Financial management capabilities – Contract management capabilities – Quality measures to report on performance • There is a performance penalty if ACO fails to achieve certain quality measures – Patient and provider communication functions – Ability to provide behavioral health services within ACO or by contractual arrangements 86
  • 87. Eligibility Criteria for Forming ACOs • Under PPACA, ACOs may be formed by: , y y – ACO professionals (physicians and practitioners) in group practice arrangements – Networks of individual practices of ACO professionals – Partnerships or joint venture arrangements between acute care hospitals and ACO professionals – Acute care hospitals employing ACO professionals • CMS roughly estimates th t th t t l average start-up hl ti t that the total t t investment and the first year of operating expenses for an entity forming an ACO to participate in the Medicare Shared Savings P Sh d S i Program would b approximately $1 7 ld be i t l $1.7 million 87
  • 88. Participation in ACOs • SNFs, long-term care hospitals, and federally qualified health centers may not form ACOs, but may participate in established ACOs • Participation in ACOs is voluntary 88
  • 89. Beneficiary Assignment to ACOs • Beneficiaries are assigned to an ACO based on p g primary care y services rendered by physicians in general practice, internal medicine, and geriatric medicine • Under PPACA, an ACO is required to have at least 5,000 beneficiaries assigned to it to qualify to participate in shared savings • Assignment is made on a retrospective basis • Beneficiaries do not enroll in a specific ACO and ACOs do not know which beneficiaries are assigned to it until the end of the year • Two reasons CMS proposed retrospective assignment of beneficiaries: – “… the ACO should be evaluated on the quality and cost of care furnished to those beneficiaries who actually chose to receive care from ACO participants during the course of the performance year.” – “… to encourage the ACO to redesign its care processes for all Medicare FFS [Fee for Service] beneficiaries, not just for the subset of beneficiaries for whom the ACO is being evaluated.” 89
  • 90. Medicare B M di Beneficiaries’ F d fi i i ’ Freedom of Ch i f Choice • The assignment of a patient to an ACO in no way restricts a Medicare FFS patient’s freedom of choice in selecting physicians and other health care providers and suppliers from whom he/she wishes to receive services 90
  • 91. Payment Model – Shared Savings • CMS will develop a performance benchmark for ACOs to assess whether they qualify for shared savings • ACOs will receive a share of any savings if the actual per capita expenditures of their assigned Medicare beneficiaries are below the benchmark • ACOs will select either: – A one-sided risk payment model (sharing of savings only for the first two years, and sharing of savings and losses in the third year); or – A two-sided risk payment model ( h i of savings and l t id d i k t d l (sharing f i d losses for all three years) • CMS has no authority to specify how shared savings will be distributed by ACOs y 91
  • 92. Quality Measures and y Performance Thresholds • 65 quality measures are proposed for the first year (January 1, 2012 through December 31, 2012) in the following 5 areas: – (1) Patient/Caregiver Experience of Care – (2) Care Coordination – (3) Patient Safety – (4) Preventative Health – (5) At Risk Population/Frail Elderly Health At-Risk • ACOs which do not meet quality performance thresholds for all proposed measures would be ineligible for shared savings 92
  • 93. Patient Protections • ACOs are required to ensure access by disabled individuals and other individuals with chronic or complex medical conditions to appropriate specialty care • ACOs are required to accept all patients regardless of payor or clinical profile • The Office of Patient Protection is directed to establish regulations relating to consumer appeals of ACO determinations • The DHCFP is required to: – Safeguard against underutilization of services and inappropriate denials of services or treatment – Safeguard against, and impose penalties for, inappropriate selection of low cost patients and avoidance of high cost patients by ACOs and ACO network providers 93
  • 94. How should patients navigate the system in such a “ f t storm”? t i h “perfect t ”? Do Your Homework! • Is the physician taking new patients? • Does the physician accept your insurance? • Is the physician part of a group? • What are the office hours? • Where did th physician attend medical Wh the h i i tt d di l school? • Is the physician board-certified?
  • 95. Let s Let’s start with a “Day in the Office” Day Office • How many of you have been kept waiting for a scheduled appointment? – Did it make you angry? • How many of you have been late for an appointment?
  • 96. Start of the Day’s Schedule Day s • 730am: Staff shows up to begin the day • 8:00am: First patient shows up for scheduled 8am 20min appointment • What needs to happen during this visit? – Staff brings you to the room – BP, P, Temp, Wt, medication list, allergies – Verify complaint – Update data on EMR
  • 97. Enter the Physician… Physician • It’s now 8:07am… It s • The physician – Patient history: Wassuppp! – Physical exam: any findings? – Order any testing – Counsel the patient on assessment • Dx, medication, expected course, instructions, what to watch for, f/u Q/A etc for f/u, Q/A, etc…. – Write/dictate the medical record of encounter • All of this needs to get done in 13 min!
  • 98. Suggestions • Request copies that require your signature ahead of time to allow reading them • Come in 15 min earlier… – To register • Have insurance card – To have EMR updated so that visit can begin on time • Have meds/OTC/herbs list for updating • Is your scheduled visit enough time?
  • 99. ASK QUESTIONS!!! -Newsweek: September 1, 2003, page 17 Newsweek:
  • 100. Schreck’s Top 10 Value Considerations f P i V l C id i for Patients • Get a PCP to help you • Keep list of your current meds NAVIGATE • Physician EMR utilization • Physician Ph i i credentials: d ti l • Discuss end-of-life decisions with Board-Certified your PCP (have family member with Fellow of the College you to hear your wishes) • Physician accessibility • “One stop shopping” One shopping • Physician’s personality • ACTIVELY PARTICIPATE IN YOUR • Understand insurance policy CARE !!!
  • 101. Closing Comments • Do your homework • Ask A k questions ti • Not all conditions are “cut and dry” • Be active and participate in your own care – Your medical care is a TEAM EFFORT!
  • 102. • Government has been trying to herd the medical system • B t getting physicians t d anything i But tti h i i to do thi is like herding CATS!!!!
  • 103. Answer • There is no “extra” dollar -> depends on extra > accounting basis (“balance”): Friends: Motel: Clerk: -$30 (motel fee) +$30 (motel fee) +$5 (refund) + 3 (refund) - 5 (refund) -$3 (“commission”) -$27 net loss $27 +$25 net gain t i +$2 net gain t i -$27 balances + $27 $27 NO EXTRA DOLLAR!
  • 104. Prescription Drug Coverage Among Medicare Beneficiaries, by Income, 2008 23% 26% 30% Part D ­ Stand­alone  PDP 49% Part D ­ Medicare  66% 19% 16% Advantage Drug Plan g g 24% 1% 1% Self­Purchased Only 1% Employer­Sponsored 25% 44% 48% Other Public/Private 31% 1% 20% 13% No Drug Coverage <1% 1% <1% 5% 1% <1% <1% 12% 14% 13% 8% 9% $10,000 $10,001- $20,001- $30,001- $40,001 or less 20,000 30,000 40,000 or more (5.9 million) (8.9 million) (6.8 million) (6.4 million) (7.7 million) NOTES: Percents rounded to the nearest whole number. Numbers may not sum due to rounding. SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Access to Care File, 2008.