Transcript HealthePeople - Achieving a Healthy America

NAPA Session: Health Care Reform in an Age of Fiscal Scarcity
November 20, 2008
Building
A
Healthy America
Yes We Can (And Must)
www.BuildingAHealthyAmerica.org
www.viaFuture.org
Gary A. Christopherson
Building A Healthy America
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Yes,We Must.
Yes, We Have Options.
Yes, We Can.
Yes, Here’s How.
Yes, Let’s Build A Healthy
America.
Yes,We Must.
None of the key indicators – health status,
accessibility, quality, affordability – are
acceptable for a nation spending 1/6th (and growing)
of its economy on health.
• Accessibility – Over 40 million Americans are uninsured for health
care and millions more are underinsured. Most Americans are
uninsured or underinsured for long term care.
• Quality – Health status and outcomes produced by the American
health “system” are inadequate given the needs of the American
people.
• Affordability – The unaffordability of health care is challenging
America as a nation and Americans as individuals and families.
• Health Status - Among the six nations of Australia, Canada, Germany,
New Zealand, the United Kingdom, and the United States, the U.S.
ranks last in terms of achieving health outcomes.
Yes, We Have Options.
Solving the Un- and Underinsured Problem
Elements for Constructing Alternatives for Solving Un- and Underinsured Problem
Govern
-ment
Covers
All w/
Govt
Insurance
Government
Continues
Medicare for
Medicare
Eligibles
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Alternatives for
Solving
Un- and
Underinsured
Problem
Government
Mandates All
Covered
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Govern
-ment
Pays
for All
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Govern
-ment
Pays
for
Those
Unable
to Pay
Government
Provides
Alternative for
Those
Wanting Govt
plan
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Coverage for
"high
value"
benefits
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Contain
Cost
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Ensure
Quality
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Ensure
Access
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Private
Insurance
and/or
Health
Plans
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Ensure
"Virtual
Health
System"
(EHR,
PHR,
standards,
exchange)
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X
Solving The Un- and Underinsured Problem, Gary Christopherson 2004.
Yes, We Can.
National Health Expenditures With and Without GDP Adjustment
$5.00
$4.28
$4.50
$4.01
$3.76
$4.00
NHE (Trillions)
$3.50
$3.00
$2.50
$2.00
$1.60
$1.50
$1.00
$1.60
$1.73 $1.85
$1.73 $1.85
$1.97
$1.97
$2.11
$2.11
$2.25
$2.25
$2.39
$2.39
$2.56
$2.73
$2.56 $2.68
$2.91
$2.82
$3.10
$2.95
$3.31
$3.09
$3.52
$3.23
$3.38
$3.53
$3.69
2011 - $100+ B Savings
$0.50
$0.00
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
Year
National Health Expenditures w/o Adjustment
National Health Expenditures Adjusted to GDP Growth
National Health Expenditures With and Without GDP Adjustment.
Expenditures and Projections by Office of Actuary, Centers for Medicare & Medicaid Services, 2008.
GDP Adjustment by Gary Christopherson, 2008.
Yes, Here’s How.
Over 50 supportive strategies for reducing
costs and slowing down the rate of growth
• Prevention:
• Call upon and lead Americans to healthier life styles.
• Use evidence-based prevention to prevent preventable illness and injury, especially those that have
major long term consequences.
• Make special efforts at those preventable illnesses and injuries that have the greatest negative impact
across America.
• Use behavioral and other models that help people change to more healthy behaviors.
• Care Coordination and Management:
• Coordinate and integrate care.
• Support disease management programs for chronic illnesses.
• Quality:
• Improve the quality of the care delivered – right care at the right time to the right person.
• Move to more person-based approaches to health care that recognizes the uniqueness of the individual
and treats them accordingly as individual persons.
• Substantially increase the proportion of care that is based on evidence or consensus and decrease the
proportion of care that is not.
• Invest in better information about the effectiveness of alternative treatments.
• Disparities:
• Tackle disparities unique to certain populations and with major negative consequences.
• Medication:
• Improve the effectiveness, efficacy and safety of prescription drugs.
• Increase use of generics.
• Increase competition in drug markets, including the potential use of drug reimportation.
• Lower drug benefit costs for Medicare Part D.
• Uncompensated Care:
• Make health insurance universal to reduce spending on uncompensated care.
Over 50 supportive strategies for reducing
costs and slowing down the rate of growth
• Insurance:
• Give small business and self-insured more access to group plans and/or government plans with their
lower costs.
• Provide reinsurance for catastrophic costs to lower the risk related part of insurance costs.
• Increase insurance company competition.
• Reduce insurance overhead and underwriting costs.
• Beneficiary/Patient Incentives:
• Beneficiaries/patients should be given incentives to choose to receive care from high-quality, efficient,
high-value providers and delivery systems.
• More consumer cost-sharing only if it does not inhibit appropriate access, e.g. to needed preventive,
primary care, care coordination/management.
• Regulation:
• Increase government regulation of providers but not over-regulation.
• Increase government regulation of insurers but not over-regulation.
• Health Information Technology:
• Use health information technology to reduce duplication of testing and care, provide decision support
at the time of care, to create a better partnership between provider and person/patient via personal
health systems/records, to assess effectiveness of care within a provider site and with other providers
locally, regionally and nationally, to lower billing errors and costs.
• Use health information technology to appropriately share health information among a person’s health
providers.
• Have a system of national standards (data, exchange, EHR and PHR function) for health information
technology
• Transparency:
• Provide transparency on quality and cost of care.
Over 50 supportive strategies for reducing
costs and slowing down the rate of growth
• Payment:
• Slow down the rate of increase in prices to growth in GDP in all private and public sector plans.
• Implement an “all-payer” system of payment for all payers, including self-pay, private insurance,
public insurance, e.g., Maryland has an all-payer system of establishing hospital payment rates.
• Differential rates among payers (self, Medicare, Medicaid, private insurers) should be eliminated.
• Fundamental provider payment reform with broader incentives to provide high-quality and efficient
care over time
• Increase payment for primary care services relative to sub-specialty care and advanced imaging.
• Tie payment and other incentives/disincentives to achieving excellence in care, e.g. pay for outcomes,
performance, efficiency, effectiveness, and safety.
• Pay-for-performance should not create inappropriate incentives to treat the healthy and low cost and to
not treat the less healthy and higher cost.
• Reduce waste and abuse for all payers.
• Do not pay for avoidable medical errors and not allow the costs to be passed on to other payers,
including self-payers.
• Eliminate payments resulting from avoidable infections and other complications that occur in the
hospital (“never events”)
• Improve current payment system, e.g. by a blend of the modified fee-for-service and bundled perpatient payment systems.
• Pay physician practices a per-person/patient fee for serving as a patient-centered health/medical home
that partners with person/patient, coordinates care, meets standards and demonstrates better outcomes
for patients
• Expand the units of service used for payment, often referred to as "expanding payment bundles."
• Pay global fee for hospital acute-care episodes including the hospital admission and post-acute care,
inpatient physician services, and all inpatient or emergency care for 30 days after the hospital
discharge
Over 50 supportive strategies for reducing
costs and slowing down the rate of growth
• Payment (Continued):
• Full population prepayment—a single payment for the full continuum of services for a given patient
population and period of time—should be encouraged. Such payments should be adequately riskadjusted to avoid adverse patient selection. If full population prepayment is not feasible, payers should
encourage:
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Global case payments for acute hospitalizations. These payments also should be riskadjusted to avoid adverse patient selection.
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Alternative payment structures for primary care. Primary care practices that provide
comprehensive, coordinated, patient-centered care (e.g., certified medical homes) should
be offered an alternative to fee-for-service payment. Use shared accountability for
resource use
• Revise the resource-based relative value schedule (RBRVS) to increase payments for primary care
• Pay for transitional care services, such as phone calls to high-risk patients following hospital discharge
• Reduce physician fees for unusually high-priced, high-volume services
• Reduce diagnosis-related group payments for unusually profitable hospital services, such as some
cardiac and orthopedic procedures.
• Financial incentives/penalties for hospitals based on their 30-day readmission rates
• Reimbursement for durable medical equipment should be based on competitive bidding with Medicare
paying a price based on the distribution of bids
• Pay managed care plans, including Medicare Advantage plans, the right amount.
• Link payment levels more closely to the costs of effective/efficient providers, not average providers.
• The Sustainable Growth Rate formula underlying Medicare physician payment should be replaced
with a budget target for Medicare outlays per beneficiary across all Medicare services
• Medicare should negotiate pharmaceutical prices
• Medicare should achieve savings by adjusting payment updates in high-cost geographic areas
• .............
Yes, Let’s Build
A Healthy America
Budgeting
Legislation and
Implementation
No Significant Cost
Increase
Off-setting
Revenue
Off-setting
Cost
Reductions
Stimulus
w/
Recovering
Stimulus
w/o
Recovering
Near-term
Deficit
Long-term
Deficit
Comprehensive plan.
Pass all at once and
implement ASAP.
Comprehensive plan.
Pass all but phase in.
Comprehensive plan.
Pass in phases.
Comprehensive plan.
Pass initial step and
then revisit each
year/Congress.
No comprehensive
plan. Pass initial step
and then revisit each
year/Congress.
Comprehensive Health Reform for American Health System That Is Accessible
(Including Insurance), Is Affordable (For All Payers (Including Self–Payers and Taxpayers),
Increases Quality, and Improves Health for All.
Gary A. Christopherson
To fit the budget environment
and get the maximum effect in the
shortest time, a comprehensive
plan that a) we pass all at once and
implement ASAP and b) treat as a
stimulus that we recover the added
cost within 5-10 years has
substantial merit.
Endgame Strategy
A high performance,
American health and
long term care system for
all Americans that is selfperpetuating, affordable,
accessible, “e” enabled,
and producing high
health quality, outcomes
and status
Vision
Achieving
Healthy
Americans
&
A Healthy
America
Background
Materials
Institute of Medicine Six Aims & Person’s
Perspective on Health
Personal
Perspective
on Health &
LT Care
Needs
Staying healthy
Getting better
Living with
illness or
disability
Coping with the
end of life
Aims for Health & LT Care Performance/Quality
Safe
Effective
Person/
Patientcentered
Timely
Efficient
Equitable
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Gary A. Christopherson
Person-Centered Health Model
Health
Environment
Health &
Long Term Care
Human
Factors
Health
Factors
Well
Severe
Disability
Environment
Factors
NonHealthcare
Health
Support
Status
Genes
History Infrequent
Acute
Exposures
Person(s)
Severe
Chronic
Self-care
Behavior
Motivation
Ability
Provider
Care Settings
eHealth Services
Frequent
Acute
Mild/Mod
Chronic
Person-Centered
Health
Coordination/Management
“Care in the
Community”
Settings
Virtual
Health System
(EHRs, PHS/Rs, Standards, Info Exchange)
Gary A. Christopherson
Building High Performance, Virtual US Health
System – Strategic Improvement & Behavior Model
Performance Improvement
Changes in
Health Inputs/Environment
BEM
Changes in
Personal Behavior
High Health/Functional Status
BEM
Optimized Outcomes
Changes in
Provider Behavior
Target Health & LT Care
Current Health & LT Care
Current Health/Functional Status
BEM
Gary A. Christopherson
Strategies for Achieving a Healthier America
Strategies to Improve Health & Function
Supportive environment for high performance, quality,
affordability, accessibility
Achieve Supportive
Health Environment
Strongly apply “public health” model for everyone
Aligned strong core health benefits for all payers
Aligned strong core LTC benefits for all payers
Strong person-centered care coordination/management
All-payer Pay for Performance (P4P) (effective care & effective
resource use (efficiency))
Aligned high performance measures for all payers and for
all/across care settings
Strong performance/quality improvement for all payers and for
all/across care settings
All care settings reasonably accessible physically for everyone
Strong virtual health (info) system with EHRs, PHS/Rs,
standards & interoperability/exchange
Achieve High Care
Coordination/
Management
Performance
Achieve High Managed
Care Performance
Achieve High Performance Care with:
• Clinic / Physician
Office
• Hospital
• ESRD
• Home Health
• Nursing Home
Optimized Outcomes
The most vulnerable persons provided all needed health & LTC
support
High Health/Functional Status
All needed care reasonably accessible financially for everyone
Achieve High PersonCentered Health
Performance
Target Health & LT Care Affordable, Accessible, “e” Enabled, High Quality
Strong person-centered health w/ high personal choice & self
care & strong partnership between person & their provider
Gary A. Christopherson