Educational workshop presented by WealthTrust-Arizona and world-renowned guest Robert K. Smoldt, Chief Administrative Officer Emeritus at Mayo Clinic and Associate Director of Healthcare Delivery & Policy Programs at Arizona State University. Mr. Smoldt has been involved in health care administration for more than 30 years and is currently pursuing U.S. health reform in close partnership with Mayo Clinic’s Emeritus President and CEO.
At this workshop Robert examines a number of general statements that are, in his view, fallacious.
Our biggest problem in healthcare is efficiency (quality of care per dollar spent) and Obamacare doesn't solve it. Our spending is off the charts by any measure (growth over time, % of GDP, per capita) Consumerism as a force of change in Healthcare is just getting started, but there are many barriers in place that serve to protect existing stakeholders in the industry. Knocking down these barriers to competition is what the GOP should be focusing on, but it's not. "Repeal and replace" seems to be a slogan, not a plan. Do Republican lawmakers have the will to make changes that might upset entrenched players?
While the health care reform bill is a step in the right direction, medicare for all or single payer is what is really needed to control costs and insure all.
Our biggest problem in healthcare is efficiency (quality of care per dollar spent) and Obamacare doesn't solve it. Our spending is off the charts by any measure (growth over time, % of GDP, per capita) Consumerism as a force of change in Healthcare is just getting started, but there are many barriers in place that serve to protect existing stakeholders in the industry. Knocking down these barriers to competition is what the GOP should be focusing on, but it's not. "Repeal and replace" seems to be a slogan, not a plan. Do Republican lawmakers have the will to make changes that might upset entrenched players?
While the health care reform bill is a step in the right direction, medicare for all or single payer is what is really needed to control costs and insure all.
Dr. James Mongan spoke about "Health Reform, Past and Present" at the 10th annual William E. Petersen Symposium on Physician Leadership at the University of St. Thomas.
Achieving Universal Coverage through Comprehensive Health Reform: The Vermont...soder145
Presentation by Ronald Deprez at the AcademyHealth Annual Research Meeting adjunct State Health Research and Policy Interest Group meeting panel, "Early Results from the State Health Access Reform Evaluation (SHARE) Program," Chicago, IL, June 27 2009.
Economic Impact on Minnesota's Health Care Delivery Systemsoder145
Presentation by Lynn Blewett to the Minnesota State Legislature at a joint meeting of the health care and human services finance and policy committees in Saint Paul, MN, February 10 2009.
As Medicare costs continue to rise fueled in large part by new devices and pricey drugs, the federal government now spends 50% more on health care than it does to fund the department of defense—a monumental figure. Cardiovascular disease (CVD) remains the largest driver of health care costs in the United States. By 2030 43.9 per cent of Americans are projected to have some form of CVD, driving a more than $550 billion increase in the total costs of CVD care annually.
COST FACTORS & STRATEGIESReasons for increasing costs of healt.docxvanesaburnand
COST FACTORS & STRATEGIES
Reasons for increasing costs of health care and
Some strategies for managing them
Page
No.
(1)
Admin/
Providers’
Strategies
(2)
Gov’t &
Payors' Strategies
(3)
Societal Factors
Which Increase
Costs
Advanced Technology
Aging Population
AIDS
Capitation
Cardiac Catheterization Lab
Care Mapping/Clinical Pathways
Case Rates and Per Diems
CAT Scanner
Change of Reimbursement System from Charge-Based, to Cost-Based, to Flat-Fee to Capitation
CON (Certificate of Need)
Concurrent Review
Cost Shifting
Cost Accounting System
Deductibles and Co-Payments
Defensive Medicine
Gatekeepers
Global Payments/ Bundling of Services
Increased Chronic, Long-Term Illnesses
Increased Long-Term Care
Inflation
Information Systems Technology
Joint Replacements
Just-in-Time Delivery
Large Jury Awards
Litigation
Medicaid Tightened Eligibility Restrictions
Mergers and Acquisitions
MRI
Neonatal ICU
Organ Transplants
Part-Time Workers Replacing Full-Time Workers
Payment System
Penalties for Services Outside of HMO Network w/o Prior Approval
Point of Care
Preadmission Certification and Second Opinions
Prospective Payment (DRG)
Prospective Payments
Provider Networks
Reengineering/Redesign
Retrospective Review
Rising Expectations
Shift to Outpatient Services
Steerage and Discounts
The Uninsured
Total Quality Management
NAME OF STUDENT:
�Introduction�
Never before have health care professionals faced such complex issues and practical dif-
ficulties trying to keep their organizations financially viable (see Perspective 1–1). With
C h a p t e r O n e
THE CONTEXT OF HEALTH CARE
FINANCIAL MANAGEMENT
Learning Objectives
AAfftteerr ccoommpplleettiinngg tthhiiss cchhaapptteerr,, yyoouu wwiillll bbee aabbllee ttoo::
� Identify key factors that have led to rising health care costs.
� Identify key approaches to controlling health care costs.
� Identify key ethical issues resulting from attempts to control costs.
Introduction
Rising Health Care Costs
The Payment System
Technology
The Aging Population
Prescription Drugs
Chronic Diseases
Compliance and Litigation
The Uninsured
Efforts to Control Costs
Efforts by Payors to Control Health Care
Costs
DRGs
Capitation
Global Payments
APCs
Cutting Delivery Costs
Shift to Outpatient Services
Cost Accounting Systems
Information Services Technology
Mergers and Acquisitions
Reengineering/Redesign
Cost Control Issues with Ethical
Overtones
Summary
Key Terms
Chapter Outline
063123098X-01.qxd 9/11/02 6:34 PM Page 1
turbulent changes taking place in payment, delivery, and social systems, health care pro-
fessionals are faced with trying to meet their organization’s health-related mission in an
environment of extreme cost pressure. In order to provide a context for the topics covered
in this text, .
Dr. James Mongan spoke about "Health Reform, Past and Present" at the 10th annual William E. Petersen Symposium on Physician Leadership at the University of St. Thomas.
Achieving Universal Coverage through Comprehensive Health Reform: The Vermont...soder145
Presentation by Ronald Deprez at the AcademyHealth Annual Research Meeting adjunct State Health Research and Policy Interest Group meeting panel, "Early Results from the State Health Access Reform Evaluation (SHARE) Program," Chicago, IL, June 27 2009.
Economic Impact on Minnesota's Health Care Delivery Systemsoder145
Presentation by Lynn Blewett to the Minnesota State Legislature at a joint meeting of the health care and human services finance and policy committees in Saint Paul, MN, February 10 2009.
As Medicare costs continue to rise fueled in large part by new devices and pricey drugs, the federal government now spends 50% more on health care than it does to fund the department of defense—a monumental figure. Cardiovascular disease (CVD) remains the largest driver of health care costs in the United States. By 2030 43.9 per cent of Americans are projected to have some form of CVD, driving a more than $550 billion increase in the total costs of CVD care annually.
COST FACTORS & STRATEGIESReasons for increasing costs of healt.docxvanesaburnand
COST FACTORS & STRATEGIES
Reasons for increasing costs of health care and
Some strategies for managing them
Page
No.
(1)
Admin/
Providers’
Strategies
(2)
Gov’t &
Payors' Strategies
(3)
Societal Factors
Which Increase
Costs
Advanced Technology
Aging Population
AIDS
Capitation
Cardiac Catheterization Lab
Care Mapping/Clinical Pathways
Case Rates and Per Diems
CAT Scanner
Change of Reimbursement System from Charge-Based, to Cost-Based, to Flat-Fee to Capitation
CON (Certificate of Need)
Concurrent Review
Cost Shifting
Cost Accounting System
Deductibles and Co-Payments
Defensive Medicine
Gatekeepers
Global Payments/ Bundling of Services
Increased Chronic, Long-Term Illnesses
Increased Long-Term Care
Inflation
Information Systems Technology
Joint Replacements
Just-in-Time Delivery
Large Jury Awards
Litigation
Medicaid Tightened Eligibility Restrictions
Mergers and Acquisitions
MRI
Neonatal ICU
Organ Transplants
Part-Time Workers Replacing Full-Time Workers
Payment System
Penalties for Services Outside of HMO Network w/o Prior Approval
Point of Care
Preadmission Certification and Second Opinions
Prospective Payment (DRG)
Prospective Payments
Provider Networks
Reengineering/Redesign
Retrospective Review
Rising Expectations
Shift to Outpatient Services
Steerage and Discounts
The Uninsured
Total Quality Management
NAME OF STUDENT:
�Introduction�
Never before have health care professionals faced such complex issues and practical dif-
ficulties trying to keep their organizations financially viable (see Perspective 1–1). With
C h a p t e r O n e
THE CONTEXT OF HEALTH CARE
FINANCIAL MANAGEMENT
Learning Objectives
AAfftteerr ccoommpplleettiinngg tthhiiss cchhaapptteerr,, yyoouu wwiillll bbee aabbllee ttoo::
� Identify key factors that have led to rising health care costs.
� Identify key approaches to controlling health care costs.
� Identify key ethical issues resulting from attempts to control costs.
Introduction
Rising Health Care Costs
The Payment System
Technology
The Aging Population
Prescription Drugs
Chronic Diseases
Compliance and Litigation
The Uninsured
Efforts to Control Costs
Efforts by Payors to Control Health Care
Costs
DRGs
Capitation
Global Payments
APCs
Cutting Delivery Costs
Shift to Outpatient Services
Cost Accounting Systems
Information Services Technology
Mergers and Acquisitions
Reengineering/Redesign
Cost Control Issues with Ethical
Overtones
Summary
Key Terms
Chapter Outline
063123098X-01.qxd 9/11/02 6:34 PM Page 1
turbulent changes taking place in payment, delivery, and social systems, health care pro-
fessionals are faced with trying to meet their organization’s health-related mission in an
environment of extreme cost pressure. In order to provide a context for the topics covered
in this text, .
11 minutes agoJessica Dunne RE Discussion - Week 3COLLAPS.docxdrennanmicah
11 minutes ago
Jessica Dunne
RE: Discussion - Week 3
COLLAPSE
Top of Form
NURS 6050C: Policy and Advocacy for Improving Population Health
INITIAL POST
Economic Challenges of Healthcare Policy
The economics of the healthcare system in the United States is complex and fragmented. Costs associated with care and the prices healthcare consumers pay are determined by a wide variety of factors making it extremely difficult to find a one size fits all solution. Knickman and Kovner (2015) argue that healthcare is neither a commodity or a service, because of the high variabilities in need, cost, and consumption. The United States spends 80% of all healthcare revenue on just 20% of the population. Health insurance can be provided by the government, the private sector, or an employer. Some citizens do not have any form of healthcare coverage. Regardless of type, insurance coverage generally only pays a portion of the total healthcare cost leaving the consumer to pay the remaining balance. Moreover, reimbursement standards differ for facilities and providers. The government reimburses healthcare facilities, such as hospitals a fixed amount per patient, which creates a higher incentive to work efficiently. Healthcare providers, on the other hand, are reimbursed based on a fee for service model, meaning the more services they provide, the more money they are reimbursed (Knickman & Kovner, 2015).
Reindart (2010) maintains the passage of the Affordable Care Act (ACA) created more strain on the system by adding approximately 30 million uninsured Americans to the market. The projected cost to provide such coverage is around 8 billion to 1 trillion dollars over the next decade. However, the estimated expense of healthcare with no legislative intervention is 35 trillion dollars over the next decade (Reindart, 2010). Laureate Education (2012) contends that the human resources required to provide healthcare to an additional 30 million people is another consideration the ACA does not address. The United States is already experiencing staff shortages for key healthcare jobs like nurses and physicians. Additionally, with baby boomers retiring from the workforce and simultaneously needing more healthcare resources as they age will inevitably exacerbate the shortage of providers (Laureate Education, 2012).
Ethical Considerations
It is important to recognize that the private sector often follows the public sector when deciding what services will be covered (Knickman & Kovner, 2015). Therefore, the implications of Medicare deciding not to pay for a drug or service will likely affect the entire population. Stein (2010) asserts that cost should not be a consideration in determining if medications or services will be paid for by Medicare. Nonetheless, that is what happened with Provenge, a vaccine indicated for late stage prostate cancer patients. The drug prolonged the lifespan of patients by about four months. Provenge costs around 93,000 dollars per p.
Analytics-Driven Healthcare: Improving Care, Compliance and CostCognizant
In the face of skyrocketing costs, the healthcare industry is addressing inefficiencies by improving data sharing and collaboration across the industry value chain and applying analytics to improve operations and patient outcomes.
WealthTrust-Arizona - An Update on the State of the Arizona EconomyWealthTrust-Arizona
Workshop presented by WealthTrust-Arizona & Barry Broome, President and CEO of the Greater Phoenix Economic Council.
During the presentation Barry discusses the state of the Arizona economy, including real estate, local politics and possible growth opportunities to ensure a competitive, vibrant and self-sustaining regional economy.
WealthTrust-Arizona - Inflation/Deflation: Harvesting the Inflation OpportunityWealthTrust-Arizona
Workshop presented by WealthTrust-Arizona & special guest Walt Czaicki, vice president and senior portfolio manager from AllianceBernstein.
Presentations highlights how a well-diversified mix of inflation-sensitive assets, which dynamically moves to exploit global growth and inflationary pressures, may benefit your portfolio.
Educational workshop presented by WealthTrust-Arizona and world-renowned guest Robert K. Smoldt, Chief Administrative Officer Emeritus at Mayo Clinic and Associate Director of Healthcare Delivery & Policy Programs at Arizona State University. Mr. Smoldt has been involved in health care administration for more than 30 years and is currently pursuing U.S. health reform in close partnership with Mayo Clinic’s Emeritus President and CEO.
Educational workshop presented by WealthTrust-Arizona and special guest, Greg Anderson from Brokerage Professionals. Greg reviews issues surrounding long term care and how to best prepare for it financially.
WealthTrust-Arizona understands it is difficult to address the topic of death. We have put together a presentation to help you prepare for when you or a loved one passes on. We also made a free "Survivor's Journal" to accompany this presentation. The journal will walk you through the steps you will need to take to be prepared. Visit wealthtrust-arizona.com for the free download.
WealthTrust-Arizona is a fee-based investment advisory firm specializing in the integration of investment management with estate planning for high net worth individuals and families.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
2. Robert K. Smoldt Associate Director, ASU Healthcare Delivery and Policy Program Emeritus CAO, Mayo Clinic Wealth Trust Scottsdale, Arizona October 12-13, 2011
3. Three general aims for all health systems Some of the claims for meeting these three aims don’t meet the Smoldt common sense test
4. Fallacy 1: If physicians didn’t make so much money, the health cost problem would be gone
6. Average orthopedic surgeon pre-tax earnings (2008) Source: Laugesen and Glied, “Higher Fees Paid…….”, Health Affairs 30. No 9 (2011) 1647 -1656.
7. Are U.S. primary care doctors underpaid? Source: Laugesen and Glied, “Higher Fees Paid…….”, Health Affairs 30. No 9 (2011) 1647 -1656.
8. Average primary care pre-tax earnings (2008) Source: Laugesen and Glied, “Higher Fees Paid…….”, Health Affairs 30. No 9 (2011) 1647 -1656.
9. Specialist compensation vs. GDP per capita (2004) US$ ’000s Source: U.S. Health Care Spending: Comparison with Other OECD Countries, CRS report for Congress, 2007 GDP per capita Specialist compensation 20%
10.
11. Components of U.S. health spending (2008) Source: http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx?referrer=search Physician services
12.
13. Fallacy 2: If we just put in price controls and lowered the price we paid providers, the U.S. healthcare cost problem would be solved
14. “ It’s the price, stupid” by Gerald F. Andersen, et. al. Source: http://content.healthaffairs.org/content/22/3/89.full.pdf
15. Total Cost = Price Per Unit of Service X Use Rate of Services
18. *Payment ij = Payment for service “i” (e.g., chest X-ray) in geographic area “j” (e.g., Danville, PA) Source: “Part B News: A Plain English Guide” The formulas to determine what Medicare pays for physician services are complex Payment ij = RVUi 1 [(GPCIw j x w i %) + (GPCIoh j oh i %) + (GPCIm j m i %)] CF Payment ij = Payment for service “i” (e.g., chest X-ray) in geographic area “j” (e.g., Danville, PA) CF = conversion factor CF 08 = -10.1% CF 08 = CY 08 MEI 08 UAF 08 0.33 UAF 08 = Target 07 – Actual 07 Actual 07 0.75 + Target 4/96-12/07 – Actual 4/96-12/07 Actual 07 (1 + SGR 08 )
19. Total prices set* What was one reason we started this formula approach in the mid-1980s? Primary care underpaid 1,418,656 *21,026 line items and 1-449 geographic areas Medicare Part B prices
20. The complexity of price controls “ No matter how simply you begin, your controls will get more complex and voluminous. We started with…3 ½ pages of regulations and ended with 1,534. In an effort to correct one inequity, you create another.” C. Jackson Grayson Jr. Chair, U.S. Price Commission (1971-1973 ) Source: Wall Street Journal, 29 Mar 1993 Hospital cost reports for Mayo Clinic, Rochester hospitals for a single year
21.
22. So Medicare price controls have added complexity. But has it also led to a lower rate of cost growth than rest of healthcare?
23.
24. Despite the complex price-setting efforts, Medicare excess cost growth has outpaced that of the non-Medicare population Excess cost growth* (percentage points) *Excess cost growth refers to the number of percentage points by which the growth of spending on Medicare, Medicaid, or health care generally (per beneficiary or per capita) exceeded the growth of nominal gross domestic product (per capita) Source: Peter Orszag, “New Ideas About Human Behavior in Economics and Medicine”, Eighth Annual Marshall J. Seidman Lecture, Harvard Medical School, 2008
25. There is some evidence that private insurers are better at controlling costs than public payors
26. GDP per capita (nominal) Healthcare expenditures per capita (PPP$) Change in growth Growth in healthcare expenditures vs. GDP in the United States (1990-2009) Source: OECD, 2011 Everyone wants healthcare costs to grow in line with GDP; this has already happened during the HMO era Managed Care
27. Commercial payors have shown more success at managing healthcare spend and utilization Total spend per enrollee Medicare ratio McAllen to El Paso Commercial ratio* McAllen to El Paso 0.93 0.84 1.86 1.31 Indicator *Blue Cross and Blue Shield of Texas **Per 1,000 enrollees; Medicare ratio calculated based on hospital discharges in the last 2 yrs of life Source: Franzini et al.: “McAllen And El Paso Revisited: Medicare Variations Not Always Reflected In The Under-Sixty-Five Population”, Health Affairs , 2010; Dartmouth Atlas of Healthcare, 2007 Inpatient utilization** Outpatient spend per enrollee 0.69 1.32 Inpatient spend per enrollee 1.10 1.63
28. Why don’t price controls work in healthcare? The same reason they don’t work elsewhere in the economy
29. Price controls: Grayson’s maxim “ Add (price) controls and you will see ‘new’ services appear. Expect ‘unbundling’ of services with the price of individual units, when added together, totaling more than the original services.” C. Jackson Grayson Jr. Chair, U.S. Price Commission (1971-1973) Source: Wall Street Journal, 29 Mar 1993
31. Price controls do not lead to lower total spending Source: Letter to Medicare Payment Advisory Commission from Herb B. Kuhn, Director, Center for Medicare Management, CMS 4/7/06 as referenced by Dr. Stuart Guterman, The Commonwealth Fund Annual % change SGR-related expenditures/ fee-for-service beneficiary Physician fees 7.4 3.4 7.4 -0.7 -2 -1 0 1 2 3 4 5 6 7 8 1997-2001 2001-2005
32. *2007 data Source: The Commonwealth Fund, Multinational Comparisons of Health Systems Data, 2010 MRI scan and imaging fees (2009) Dollars Medicare already pays 40% less for imaging than Canada and additional rate cuts have been proposed
33. Healthcare reform reliance on across the board reductions in Medicare payments has severe implications for providers and patients "... the prices paid by Medicare for health services are very likely to fall increasingly short of the costs of providing these services. By the end of the long-range projection period, Medicare prices for hospital, skilled nursing facility, home health, hospice, ambulatory surgical center, diagnostic laboratory, and many other services would be LESS THAN HALF of their level under the prior law. Medicare prices would be considerably below the current levels paid by private health insurance. Well before that point, Congress would have to intervene to prevent the withdrawal of providers from the Medicare market and the severe problems with beneficiary access to care that would result." Source: Annual report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, 2011
34. Problem with present Medicare line item price control approach “ The secret is not, however, to re-jigger 10,000 prices in 3,000 counties so that we get them ‘right’ once and for all (until medical knowledge or technology or input prices change again).” Dr. Len M. Nichols (New America Foundation) testimony to U.S. Committee of the Budget, June 26, 2007 “ The secret is to pay for what we want – health – … while bundling ever-larger sets of services into one payment, which frees clinicians and providers to find the most efficient way to deliver health, given our particular circumstances.”
35. Medicare is committing significant effort to price paid per unit of service, when use rate is actually the more important variable The use rate is the direct function of the medical practice style in the delivery system
39. Dr. Elliott Fisher et al., Conclusion on quality and cost: “ Efforts to improve the quality and cost of U.S. health care have focused largely on fostering adherence to evidence-based guidelines, ignoring the role of clinical judgment in more discretionary settings. … Clinical judgment, not clinical guidelines, should be the focus of policy efforts to improve the quality of care and address disparities in spending.” Source: Health Affairs, May/June 2008
40. Case study: Elyria, Ohio Percutaneous Coronary Interventions, HRR (2007) Rate per 1000 enrollees Source: Dartmouth Atlas of Health Care Baltimore, MD 12.4 Cleveland, OH 11.2 Houston, TX 10.1 Rochester, MN 8.0 Boston, MA 7.0 Elyria 26.8 Locations of top 5 U.S. News Best Hospitals: Heart & Heart Surgery 1 11 21 31
43. The high concentration of healthcare costs Source: “Health Care Costs: A Primer”, Kaiser Family Foundation, 2009 100% 100% 20% 80% 10% 64% % Total population % Total healthcare spending 1% 20% 80%
44.
45. Fallacy 3: The U.S. needs more physicians to improve access to care
46. U.S. has a similar supply of physicians Physicians per 1,000 population (2009)* *For US and UK data refer to practicing physicians, defined as those providing care directly to patients; For Canada data refer to professionally active physicians, including practicing physicians plus other physicians working in the health sector as managers, educators, researchers, etc. (adding another 5-10% of doctors) Source: OECD Health Data, 2011
47. Canada and UK have more generalists and fewer specialists than U.S. Density per 1,000 population (2009)* *Primary care includes: General practice, general pediatrics, obstetrics and gynecology; Specialist care includes: Psychiatry, medical group of specialties, surgical group of specialties, other Source: OECD Health data, 2011
48. Trade offs – fewer specialists in other countries part of longer waits there Percent of population waiting for specified periods for care (2010) Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries 21 UK 25 Canada 19 UK 41 Canada 7 U.S. 9 U.S. Wait ≥4 months for elective surgery Wait >1 month for specialist appointment 0 10 20 30 40 50 60
49.
50.
51.
52.
53.
54. Healthcare is a minor determinant of the overall health of the population Source: McGinnis et al: “The Case For More Active Policy Attention To Health Promotion”, Health Affairs , Mar-Apr 2002 40% Behavior 10% Health Care 15% Social circumstance 5% Environmental exposures
55. Life expectancy in the U.S. varies widely Source: OECD Factbook 2010: Economic, Environmental and Social Statistics; statehealthfacts.org Life expectancy at birth, OECD countries vs. best and worst US states (2005) Years OECD average U.S. average Top 10 OECD Bottom 10 OECD
56.
57. U.S. health system has some of the best and some of worst mortality outcomes in the world Mortality amenable to healthcare: Deaths before age 75 that are potentially preventable with timely and appropriate medical care (International data 2002-2003, State data 2004-2005) Deaths per 100,000 population U.S. Top 5 states Minnesota Bottom 5 states *Top 5 states: MN, UT, VT, CO, NE; Bottom 5 states: LA, MS, AR, TN, AL; excludes District of Columbia data Sources: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2009; Nolte and McKee: “Measuring The Health Of Nations: Updating An Earlier Analysis”, Health Affairs , Jan-Feb 2008
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66. ICU results: Mortality 30 25 20 15 5 0 Jan 02 Feb 03 Mar 04 Apr 05 May 06 Jun 07 Jul 08 10 Hospital Mortality (01-01-02 to 01-31-09) Percent Least squares fit
67. ICU results: Use rate Length of stay (01-01-02 to 01-31-09) Days 6 5 4 3 2 1 Jan 02 Feb 03 Mar 04 Apr 05 May 06 Jun 07 Jul 08 Least squares fit
68. Banner Health pre and post iCare ICU Measure ICU days ICU mortality Risk adjusted result -31% -30%
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71. Huge system variability in healthcare resource utilization *Based on Inpatient days and Inpatient physician visits among chronically ill Medicare beneficiaries; excludes District of Columbia data Source: Commonwealth Fund State scorecard, 2009 Hospital care intensity index, last two years of life (2009)* States All states median Bottom 5 states Top 5 states Rate Ratio to benchmark (Top 5 states average) 0.556 0.949 1.289 Benchmark 1.7 2.3
72. Even teaching hospitals show wide variability in outcomes and utilization *COTH = Council of Teaching Hospitals and Health Systems; n = 269 COTH member facilities; excludes COTH member VA and Children’s hospitals; excludes facilities with <50 actual deaths in 2009 Source: https://www.aamc.org/members/coth/ ; MedPar 2009 Best hospital in category Worst hospital in category Teaching hospital average Mortality ratio >1.0 = better than expected LOS ratio >1.0 = better than expected 1.34 0.63 1.01 2.06 0.65 1.02 COTH hospitals*
73. Integrated systems have more efficient resource utilization – as much as 40-50% less: ICU utilization *Rounded Source: Dartmouth Atlas of Health Care Region (HRR) La Crosse, WI Temple, TX Salt Lake City, UT Danville, PA Integrated average United States Miami, FL Los Angeles, CA Integrated systems Days* Ratio to benchmark (integrated average) 1.2 1.5 1.8 2.5 1.7 3.7 10.1 7.5 Benchmark 2.1 5.8 4.3
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75. Who can do more to improve U.S. healthcare? Members of Congress or you?
76. Healthcare is a minor determinant of the overall health of the population Source: McGinnis et al: “The Case For More Active Policy Attention To Health Promotion”, Health Affairs , Mar-Apr 2002 40% Behavior 10% Health Care 15% Social circumstance 5% Environmental exposures