Transcript The Medicare Marketplace

Bending the Cost Curve: The Role of Employers
Karen Bray, PhD, RN
VP, Clinical Care Services, Optima Health
November 4, 2011
Creating a Culture of Health
• Employer Group Focus
• Member/Employee Focus
• Physician Focus
Challenges of Health Cost
Management
Health Care Costs
• Health Care Costs are exploding
– In 2008 healthcare represented 17% of GDP
– Expected to reach 20% in 2017
• Employers are looking for fast and effective cost-reduction
alternatives relative to health care premiums.
• Chronic care costs are exploding.
– The numbers of people with diabetes is up by 50 percent
since 1990.
• New technologies are expanding the scope and reach of
care.
• Heroic medicine is commonplace … and very expensive.
– Miracles happen routinely.
Cost Per Person Per Year
Health care costs by age group
$10,000
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
Age Group
Source: Milliman USA 2002 Health Cost Guidelines
International perspective
Health Care Spending per Capita, 2005
16
15
14
11.5
12
11.1
% GDP
10.1
10
9.9
9.3
8
7.9
7.7
6
4
2
0
United States Switzerland
Percent of GDP
15
11.5
Source: OECD Health Data 2007
Germany
France
Canada
Australia
Japan
United
Kingdom
11.1
10.1
9.9
9.3
7.9
7.7
Health status and outcomes
Life Expectancy at Birth, 2004-5
83
82
82
81.3
80.9
81
80.3
80.2
Years
80
79
79
79
78
77.8
77
76
75
Life Expectency at Birth
United
States
Switzerland Germany
77.8
Source: OECD Health Data 2007
81.3
79
France
Canada
Australia
Japan
United
Kingdom
80.3
80.2
80.9
82
79
Health status and outcomes
Infant Mortality, 2004-5
Deaths per 1,000 live births
8
7
6.8
6
5.3
5.1
5
5
4.2
3.9
4
3.6
2.8
3
2
1
0
United States Switzerland
Series1
6.8
Germany
France
Canada
Australia
Japan
United
Kingdom
3.9
3.6
5.3
5
2.8
5.1
4.2
Source: OECD Health Data 2007
Financing
Where the Health Care Dollar Went, 2003
Program
Administration
and Net Cost
Prescription
7%
Drugs
11%
Other
Spending
23%
Nursing Home
Care
7%
Physician and
Clinical
Services
22%
Hospital Care
30%
Source: Centers for Medicare & Medicaid Services, Office of the Actuary,
National Health Statistics Group
American health care
"gets it right“
54.9%
of the time.
McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the
United States. N Engl J Med 2003; 348(26):2635-45 (June 26).
Other statistics:
• Patient non-compliance causes 125,000 deaths annually
in the U.S. – “Compliance Packaging: A Patient
Education Tool,” D. Smith, American Pharmacy
• 50 percent of all prescriptions filled are taken incorrectly.
– U.S. Chamber of Commerce
• $177 billion is spent by the U.S. health care system
every year to treat medication error-related problems.
– Med Ad News, 2001
Variations in Medicare Spending
• Dartmouth Atlas Report
• Dramatic variations in spending between 1992 and
2006
• Miami increase by 5% annually
• San Francisco increase by 2.4% annually
• Medicare savings of $1.42 Trillion if all regions grew at
SF rate
• Technology as the culprit?
• Evidence from regions based on fee-for-service
• Differences in organizational and local physician
decision-making are key
Virginia Variations:
Medicare spending per enrollee
Adjusted for inflation
$8,000
$6,000
$4,000
Range of 2.90% Richmond
to 4.66% Winchester
1992
2006
Winchester
Roanoke
Richmond
Norfolk
Newport
News
Lynchberg
Charlottesville
$0
Arlington
$2,000
End of Life Care
• Miami, last six months of life
– You will see doctors (mostly specialists) 46 times
– You will spend > 6 days in ICU, and have a 27%
chance of dying in the ICU
• Portland, last six months of life
– You will see doctors (mostly primary care) 18 times
– You will spend 1 day in ICU, and have a 13%
chance of dying in the ICU
– You will likely die at home with hospice support
• 27% of Medicare annual $327 M budget is for last year
of life
Dartmouth Atlas Project, 2009
Rising Employee
Health Costs
The Employer’s
Perspective
Chronic Disease Conundrum
• 75%+ of health care dollars spent on
chronic conditions
–
–
–
–
Diabetes
Obesity
Cardiovascular Disease
Asthma
• Most preventable
through positive health habits
• Chronic disease continues to rise at
alarming rate
Wellness Program Conundrum
• Historically, wellness programs achieved
modest results
• Appeal to healthy employees who are already
committed to health
• Significant health improvements achieved
when employees with greatest health concerns
– Engaged &
– Motivated to make healthy choices
• Carrot Approach
– Reward employees
– Reduce insurance premiums
Engaging Leadership:
The Cost of Doing Nothing
• Assumptions
– Annual Employee Health Care Costs of
$1,325,000
– 480 Employees
– 8% Annual Cost Increase
– 33% of employees are obese
– 20% of employees smoke
The Cost of Doing Nothing
$2,500,000
$2,000,000
$1,500,000
$1,000,000
$500,000
$0
2008
2009
2010
2011
2012
Projected Costs
Wellsteps.com ROI calculator
2013
2014
Reduce Obesity from 33% to 25%
$60,000
$50,000
$40,000
$30,000
$20,000
$10,000
$0
2008
2009
2010
2011
2012
2013
2014
Savings Due to Obesity Reduction
In an employee group of 480, obesity decreases from 158 employees to 120
Wellsteps.com ROI calculator
Obesity and Absenteeism
$50,000
$45,000
$40,000
$35,000
$30,000
$25,000
$20,000
$15,000
$10,000
$5,000
$0
2008
2009
2010
2011
2012
2013
Savings in Absenteeism Due to Reduced Obesity
Wellsteps.com ROI calculator
2014
Reduce Tobacco Use from 20% to 15%
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
2008
2009
2010
2011
2012
2013
Savings Due to Fewer Smokers
In an employee group of 480, tobacco use decreases from 96 to 72
Wellsteps.com ROI calculator
2014
Smoking and Absenteeism
$30,000
$25,000
$20,000
$15,000
$10,000
$5,000
$0
2008
2009
2010
2011
2012
2013
Savings in Absenteeism Due to Reduced Tobacco Use
Wellsteps.com ROI calculator
The Cost of Doing Nothing
$2,500,000
$2,000,000
$1,500,000
$1,000,000
$500,000
$0
2008
2009
2010
2011
Projected Costs
Wellsteps.com ROI calculator
2012
2013
Projected Savings
2014
Employer Group: Clinical Report
Health Risk Factors/Presence of Chronic Illness
Identified for Sample Group
Heart Disease
15.8%
Respiratory Disease
Diabetes
Pregnancy
Other
0.6%
9.8%
43.8%
7.6%
Heart Disease
Heart Disease
Heart Disease
Respiratory Disease
Respiratory Disease
Diabetes
Pregnancy
Other
Other
Other
Other
Other
Acute Cardiac Event
Hyperlipidemia/HLD
Hypertension/HTN
Asthma
COPD
Diabetes
Pregnancy
Drug Use Recorded
Tobacco Use Recorded
BMI > 25 and < 30 Recorded
BMI > 30 Recorded
Depression Screening Positive
195
10264
10948
3030
684
4790
274
18
136
3128
3910
12
0.4%
21.0%
22.4%
6.2%
1.4%
9.8%
0.6%
0.0%
0.3%
6.4%
8.0%
0.1%
Employer Group: Financial Report
The Employee Focus
Total Health: How Long, How Well We
Live
~ 40%
~ 30%
Behavior: tobacco use, nutrition,
Weight, MDD (movement deficit disorder)
Genetics
~20%
Environment/public health
~10%
Health Care Delivery
US Dpt of Health and Human Services, Public Health Service. Healthy People 2010: National Health Promotion
And Disease Prevention Objectives.
Engagement Tactics
• Methods to Engagement:
– Trinkets and T-shirts 10-15%
– Merchandise Raffles (iPods, WII) 15-30%
– Cash Incentives (under $100) 35-75%
– Healthcare Premium Reductions 50-80%
– Rewards to Healthcare spending vehicle 5080%
The Physician Focus
Primary Care Redesign
Creating
a Partnership
Challenges
of Transformation
• Foundations
–
–
–
–
Trust
Collaboration
Mutual Respect
Valuable Contributions
• Lessons Learned
Optima /
SMG
Clinical
Integration
Activities
– It takes time
– It is not easy
– Worth it!
Clinical
Analytics &
Operational
Coordination
Population Profiles
Monthly Meetings
Chronic Disease
Population
Management
Diabetes
Heart Failure
Incentive
Programs
P4P Program
PCMH Incentive
Program
Outcomes
Measurement
& Reporting
PCMH Outcomes
Study
Measurement &
Reporting
Population Analysis: Definition & Top ETGs
Member Count
Avg Age
Percent Female
Avg Months Enrolled
16823
43
58%
11
Per Member
Total
Projected TCC
12/09 – 11/10
$4,044
$68,032,212
TCC 12/08 – 11/09
$3,302
$55,549,546
Avg Forecasted Risk Index
%/w Acute Impact Score
>= 95
%/w Chronic Impact
Score >= 95
1.3
1.99%
10.53%
Episode Groups Summary
Diagnosis Category
# Members
Average Forecasted Risk Index
Average Cost
Total Cost
Degenerative Ortho disease
2006
2.7
$2,085
$4,181,559
Gastrointestinal Medicine
3154
2.36
$898
$2,831,220
Diabetes
1712
2.83
$1,528
$2,616,343
Psychiatric Disorders
3585
2.1
$691
$2,476,944
Preventive Health
8012
1.57
$287
$2,300,707
Hypertension
3923
2.33
$547
$2,147,520
Cardiovascular Medical
1706
2.6
$1,184
$2,019,898
Pregnancy, Delivered
281
1.51
$6,523
$1,833,086
Breast neoplasm
484
2.67
$3,571
$1,728,597
4796
2.16
$329
$1,579,135
Fracture
810
2.24
$1,834
$1,485,839
Female Genital neoplasm
595
2.03
$2,294
$1,365,040
Metabolic Disorders
Population Analysis: Pharmacy & Inpatient
Therapeutic Class Summary
# Members
Average Cost
Total Cost
%
DIABETIC THERAPY
1,320
$812
$1,071,624
2%
ANTIVIRALS
1,058
$789
$835,269
2%
ANTIARTHRITICS
3,845
$208
$798,025
2%
LIPOTROPICS
2,916
$261
$760,971
1%
PSYCHOSTIMULANTS-ANTIDEPRESSANTS
2,683
$280
$751,318
1%
BRONCHIAL DILATORS
1,901
$345
$656,372
1%
Therapeutic Class
Provider ID
Provider Name
Specialty
# Members Average Cost
Total Cost
IP-HOSP #1
HOSPITAL
311
$5,202
$1,617,861
IP-HOSP #2
HOSPITAL
165
$9,029
$1,489,865
IP-HOSP #3
HOSPITAL
136
$6,935
$943,113
IP-HOSP #4
HOSPITAL
80
$6,735
$538,837
IP-HOSP #5
HOSPITAL
81
$5,285
$428,050
IP-HOSP #6
HOSPITAL
37
$8,500
$314,486
IP-HOSP #7
HOSPITAL
9
$21,452
$193,064
IP-HOSP #8
MENTAL HEALTH FACILITY
43
$3,243
$139,461
IP-HOSP #9
HOSPITAL
9
$6,335
$57,017
IP-HOSP #10
HOSPITAL
1
$33,089
$33,089
SNF-HOSP #1
SKILLED NURSING FACILITY
10
$3,102
$31,020
IP-HOSP #11
FACILITY - SPECIALTY
UNKNOWN
1
$28,465
$28,465
Primary Care Is In Need of a Lifeline:
Current Model is Not Working
•
•
•
•
Chronic Disease Burden is Growing
- Increasing incidence of disease + aging population
U.S. healthcare Still Producing Marginal Quality
Escalating Healthcare Costs
- Primary Care most cost effective
Medical Student Specialty Trends
–
–
•
Stress of Overloaded Primary Care Practices
Compensation of PCP vs Specialists
Patient Care Growing Increasingly
Uncoordinated
Patients Are Feeling the Effects
• Patients are…
– Wanting more control, more
information, and more input
– Concerned about escalating
costs
– Unhappy with the increasingly
uncoordinated care
– Wanting better
“integration of care”
• Patients want the system
to be “Patient Centered”
36
Bringing it All Together to Benefit the
Patient
Care Team Capabilities and Optimized
Technology
• Providers Organized as Care
Teams, Each Performing at the
Highest Level of License
• Access to the Right Provider at
the Right Time
• Electronic Record and Registry
Capabilities to Coordinate Care
for the Chronic Disease Patient
• Improved Clinical Outcomes
• Fundamentally Redesigning the
Delivery of Primary Care
Primary Care Redesign
Guiding Principles
Imperative to Transform Primary Care
Scheduling
Today
Redesign
Between
Visit
Pre-Visit
Planning
PostVisit
Check-In
Visit
Alternative Visit
Considerations
Nurse
Visits
Group
Visits
eVisits
Home
Visits
Telephonic
Visits
The Evolution of Access
The Evolution of Access
The Evolution of Access
+
Before Same Day Appointments
• Claire is sick with a headache and
cough… and it’s 5pm.
• She calls the doctor’s office and gets
the After Hours nurse who
recommends calling her PCP in the
morning.
• Not feeling confident she can get an
appointment, Claire goes to the
closest Urgent Care or Emergency
Department instead.
The Need for Same Day Appointments
The Issue:
• Access to primary care has been
proven to provide better quality at
lower cost
• However…
• In some clinics, schedule nearly full at
the start of the day
• Many patients don’t bother calling
Here is an opportunity for change.
After Same Day Appointments
Now, Claire has 2 options:
Call tomorrow morning and see her personal physician OR
their partner.
2. Call the After Hours nurse that night, and she can be scheduled
for an 8 am appointment.
Goal: Reduce Avoidable ED Visits, Patient Satisfaction
Before Post-Hospital Discharge
Follow-Up Protocol
• Drew, a 61 year old male is admitted with
emphysema, cared for by a hospitalist, and
discharged with instructions to follow-up with
his PCP.
• Drew gets (expensive) new medicines, doesn’t
know what they’re for, and is unsure about
continuing his old medications without talking
to his PCP.
• Drew calls his PCP for a follow-up appointment
and is scheduled in his physician’s first open
slot – 3 weeks from the day he called.
• Relapse… readmission.
Follow-Up after Hospital
Discharge
Why this is Important:
• Vulnerable period
• 50% of patients do not know their
medications at the time of discharge
• 50% of patients do not understand their
discharge instructions
• F/u appointment with PCP not guaranteed
• Poorly managed “Transition” = readmission
• Early follow up reduces readmissions
After Hospital Discharge Follow-Up
Protocol
New Protocol:
• Drew’s doctor/nurse is notified of discharge
• Daily staff huddles to discuss patients like Drew
• Follow-up appointment scheduled within 7 days
• Medications reviewed/reconciled
• After-Visit Summary provided
The Result:
Drew recovers and returns to work
Goal: Reduce Readmissions by Managing
the Transition
Before MyHealth Champion
• James is a 62 year old with heart failure
who has been doing ok but has not
been seen in months.
• Hilga notes her husband’s weight is up
and calls the doctor’s office… but he is
out that day and the nurse refers him to
the ED.
• ED doctor discovers 20 lbs weight gain,
fluid in the lungs and James is admitted
to the hospital.
• “failed” outpatient management.
Introducing MyHealth Champion
A Valuable Addition to the Care Team:
• Embedded case manager
• Part of health team
− Continuous relationship
• Manages transitions, proactive outreach
• Works to coordinate care with different
health providers
• Objective:
− Reduce admissions, readmissions
− Reduce avoidable ED visits
After MyHealth Champion
New Protocol:
• Hilga calls when notes James’ weight is up
• MyHealth Champion recommends same day
appointment
• Arrives in office and is found 20 lbs over his
target weight
• Prompt intervention with MD, medications adjusted
• MyHealth Champion coaches diet, daily weights
• MyHealth Champion monitors between visits
Goal: Prevent Hospitalization Through
Effective Outpatient Care
Before Diabetes Registry
Today’s World – Bob
• Bob is a 56 year old construction worker
• Diabetes for 10 years, on medications
but is asymptomatic
• “I feel fine,” Bob says, “I don’t need to see a
doctor.”
• In reality… Bob is about to get a wake-up call.
• High cholesterol, uncontrolled BP and blood
sugars
• 1 AM wakes up with chest pain
• Admitted to hospital with heart attack
Patient MRN
Last Known
Office Visit
Next Office
Visit
Last
HBA1C
Value
Last LDL
Value
Systolic
Diastolic
Smoking
Status
Foot Exam Status
Eye Exam Status
00427493
7/22/2009
118
60
Never
Unknown
Unknown
50188672
2/1/2010
130
54
Never
Not Due
Overdue or NULL
73058454
5/3/2010
130
86
Never
Unknown
Unknown
50082258
5/13/2010
160
110
Yes
Not Due
Not Due
50416207
7/19/2010
6.5
99
108
60
Never
Not Due
Overdue or NULL
40299611
7/23/2010
8.7
81
160
80
Yes
Not Due
Not Due
50589863
8/2/2010
7.6
83
120
70
Never
Not Due
Not Due
72099740
8/30/2010
2/28/2011
6.4
74
120
62
Never
Not Due
Overdue or NULL
73018331
9/20/2010
2/24/2011
8.1
108
130
78
Never
Not Due
Overdue or NULL
40250195
9/27/2010
9.8
75
110
68
Yes
Not Due
Not Due
50331144
10/4/2010
6.3
57
100
70
Yes
Not Due
Not Due
50690710
10/27/2010
9.1
117
118
60
Quit
Not Due
Overdue or NULL
72531672
11/3/2010
7.3
123
142
60
Never
Not Due
Overdue or NULL
62489810
12/20/2010
4/20/2011
6.5
120
60
Never
Overdue or NULL
Overdue or NULL
40019332
12/30/2010
2/21/2011
6.1
60
132
80
Yes
Overdue or NULL
Overdue or NULL
40357137
1/6/2011
5/9/2011
9.6
112
152
82
Never
Not Due
Overdue or NULL
63248067
1/13/2011
2/17/2011
8.4
53
134
70
Yes
Not Due
Overdue or NULL
40275116
1/19/2011
3/2/2011
10.8
140
70
Yes
Not Due
Not Due
40280100
1/21/2011
3/14/2011
8.8
108
160
80
Never
Overdue or NULL
Not Due
50392379
1/24/2011
5/23/2011
7
117
136
80
Never
Not Due
Not Due
63172436
1/27/2011
2/17/2011
5.1
113
164
64
Never
Overdue or NULL
Overdue or NULL
50810007
1/31/2011
5.8
103
150
80
Never
Not Due
Not Due
40069359
2/2/2011
2/23/2011
6.5
146
90
Yes
Not Due
Not Due
40258476
2/3/2011
2/10/2011
7.1
143
140
70
Never
Not Due
Overdue or NULL
50223112
2/4/2011
2/24/2011
6.7
122
122
70
Quit
Overdue or NULL
Overdue or NULL
Never
Unknown
Unknown
39987302
7.2
2/7/2011
After Diabetes Registry
New Protocol:
• Bob identified through registry; no
office visit in 6 months
• Secretary sets up an appointment
• Labs before appointment indicate poor
control
• MyHealth Champion meets with patient,
reviews diet and glucose testing, and
arranges between visit care
• Physician focuses on medication
management
• Bob is offered/invited to a group visit
Goal: Improved DM Outcomes, Prevent Complications
Patient–Centered Impact of Transformation
Results of Transformation
•
•
•
•
•
•
•
•
•
The patient is the center of the care team.
Care is continuous.
Care is accessible.
Care is timely.
Care is comprehensive.
Care is coordinated.
Patients are engaged.
Providers are energized and enthusiastic.
Transformation creates and delivers excellence in
Patient-Centered Primary Care.
Creating an Effective Program within the
Employer Group
•
•
•
•
•
•
•
•
Engaged Leadership
Awareness
Risk Identification
Make it Easy, Make it Fun
Tracking and Monitoring
Targeted to Identified Needs
Effective incentives/disincentives
Company level reporting
Optima’s Integrated Clinical Care Services
• We manage every component ourselves
• Member-centric delivery of services
• Focused on employer group types
–
–
–
–
–
–
Health & Prevention
Pharmacy Management
Medical Care Management
Behavioral Health Management & EAP
Disease Management
Quality Improvement
• Population identification and stratification
• Predictive Modeling for future risk/service need
• Collaboration with Providers
• Easy to use
• Convenient
• All in one place
OptimaHealth.com/mylifemyplan
Sentara Healthcare’s IncentiveBased Health, Wellness &
Prevention Program
Mission: Health
Wellness Program
Complete
PHP
0-1
Risks
2-5
Risks
• Upon enrollment, member answers 5 biometric questions
• Data available from System-wide Mission Health Screenings
• Risks calculated as 0 - 5
• Premium reduction initiated (~$550 annual)
• Maintain reduction until following year
• If agree to meet with Coach and maintain contact quarterly,
premium reduction applied
• If fail to maintain contact, or never engage coach, premium
reduction removed with opportunity to join again in following year
Mission: Health
Biometrics
Cholesterol Level, Total and HDL
BMI calculated from height and weight
Blood Pressure
Tobacco Use
Exercise >/= 3 times week
Mission: Health
Disease Management Program
Health Coach/Member identifies opportunity
for Disease/Condition Management
Does not agree
to participate
Agrees to participate and
contacts program staff
Assigned to Health Coach
$20 Incentive
No Incentive
Requirements
1. Active participation with Health Coach based on assessment and stratification.
2. Completion of appropriate testing and treatment plan as per program protocol.
3. Adherence to medications as ordered by physician.
Adhere to requirements
Receive up to $220 incentive
biannually to HSA1
Does not
adhere to requirements
No incentive received
1Health
Spending Account
Mission: Health
2011 PHP Screening Results
Employees Covered by Medical Plan
325
3% 505
2340
4%
1562
19%
13%
Did Not Take PHP
Took PHP: 2+Risks; Never
Agreed to Work With Coach
Took PHP: 2+ Risks, Will Not
Work With Coach
61%
7280
Took PHP: Healthy (0-1 Risks)
Took PHP: 2+ Risks; Working
With Coach
Mission Health Modifiable Risk Factor
Report Four year period
Smoking No *
Clinical Variable
Exercise >/= 3X week *
BMI < 27
DBP < 90 *
SBP < 140 *
HDL > 40 *
Cholesterol < 200 *
0
1000
2000
2011
5,356 members answering
All questions in all four years
2010
3000
2009
4000
2008
Number of Members
5000
6000
Mission: Health
Disease Management Comparison
Medication Possession Ratio
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
49.0%
52.7%
6 Months
Prior
July 2008
Includes Total Mission: Health Population in Disease Management
80.8%
YE 2008
82.3%
YE 2009
83.0%
YE 2010
Mission: Health
Total Costs PMPM By Claim Type
247
Total
283
252
$157
Other
$182
$161
$29
$28
$22
Inpatient
$13
$17
$15
ED
$46
$56
$55
Pharmacy
$0
$50
$100
2009 PMPM
$150
2008 PMPM
Includes Total Mission: Health Population in Wellness and Disease Management Programs
Members in Program All Three Years
Claimants Over $70 K Removed From Analysis
$200
$250
2007 PMPM
$300
Mission: Health
Disease Management Group
PMPM Total Costs by Claim Type
452
Total
535
337
$238
Other
$306
$128
$75
$55
$34
Inpatient
$20
$21
$5
ED
$119
$153
$170
Pharmacy
$0
$100
$200
2009 PMPM
Includes total Mission Health population in Disease Management
Members in Program All Three Years
Claimants Over $70K Excluded
$300
2008 PMPM
$400
$500
2007 PMPM
$600
Mission: Health Program Cost
Actual versus Estimated
5.7% Increase Over
Expected in 2008
12.3% Decrease Over
Expected in 2009
Estimated Costs for 2008 Based on Actual 2007 Costs Plus 8% Medical Trend
Estimated Costs for 2009 Based on Estimated 2008 Costs Plus 8% Medical Trend
Costs Include All Program Operations and Incentives Paid
Based on Cohort Members Continuously Enrolled in All 3 Periods
Better Health
Easy to Use
A Great Value
Optima Health