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US population – 320 million Medicare – 40 million elderly and 8 million disabled Medicaid – 58 million Commercial Insurance – +/- 200 million 32 million uninsured $9,000/person X 320 million = $2.9 TRILLION
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$2.9 Trillion dollars spent on healthcare in 2013 17.9% of US GDP Median family income in Mass is $61,000 Family healthcare costs -- $24,000 Is something wrong??
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Britai Britain Canada ada Fra ranc nce Germany many USA USA MRI Scan $187 $304 $398 $632 $1,009 Normal Childbirth $2,792 $2,667 $3,768 2,147 $8,435 Appendectomy $3,456 $3,810 $2,795 $3,285 $13,123 Average Hospital Stay Not Available $7,707 $4,715 $4,718 $14,427 Cataract Surgery $1,299 $927 $3,352 Not Available $14,764 Hip Replacement $9,637 $10,753 $12,629 $15,329 $34,454 Bypass Surgery $13,998 $22,212 $16,325 $27,237 $59,770
Source: International Federation of Health Plans
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V = Q/C Value will win out in the end What is the risk of standing still in a changing world? What is the risk of moving ahead in a changing world? How will you assess these two choices?
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In the FFS world, “the more I do, the more I make”. In the Global Payment world, “the more I do, the less
I make”.
Global Payment – long range view -- incentive is
higher quality higher quality care resulting in decreased decreased expense
Examples – colon cancer screening, cholesterol and
BP control
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Leadership Governance – roles of PCPs and specialists differ Quality of providers and services Information Technology Contracts Quality measures Reduction of Total Medical Expense (TME)
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Accurate coding Pharmacy management – costs now higher than in-patient! RN Care Management NP Home Visits
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NP Housecalls program Nurse care managers Referral to community home care services Disease management programs Clinical pharmacists
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Data and analytics to measure and monitor
quality and utilization
Care coordination among specialists,
providers, hospitals
Predictive modeling to identify and target
high-risk patients
Registry to plan and track care, ensure follow
up
Resources to support patient education and
self-management
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1.
Palliative Care/Hospice Care
2.
Diabetes
3.
Congestive Heart Failure
4.
COPD
5.
Chronic Kidney Disease
6.
Behavioral Health
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Information technology Clinical infrastructure Culture and leadership Physician, advanced care
practitioner, RN and hospital collaboration
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PCPs and Advanced Practice
Providers serve as the backbone
Primary Care structure based on
shared culture and geography
Primary Care Leader training Specialists engagement
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Management of Quality measures Interoperability for EMRs and
data center
Risk stratification Efficiency and utilization
reporting
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Complete understanding of all expenditures Admits, OBS Pharmacy Radiology Specialty visits and procedures Lab
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Transparent sharing of data between groups “Best practices” benchmarks of utilization Mechanism for sharing of data and demonstrating progress
- ver time
Practice pattern variation analysis for common diagnoses, e.g.
GERD, sinusitis and joint pain
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Emergency department (ED)
engagement
Inpatient case management Skilled Nursing Facility (SNF)
strategy
Post-acute care
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Moving more care into patients’ homes and other non-
acute settings
Increased patient care self management Ongoing initiatives to reduce excess utilization Constant emphasis on improving quality, and patients
and families experience of care
Finding innovative ways to increase specialist
engagement
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