Transcript Karen Davis` Presentation - Alliance for Health Reform

What Works to Control Costs:
Go Where the Money Is
Karen Davis
President
The Commonwealth Fund
www.commonwealthfund.org
[email protected]
Alliance for Health Reform
June 12, 2012
2
For Savings, Go Where the Money Is
•
10% of patients account for 65%
of costs
•
Focus efforts on patients with
highest costs
•
Three part strategy:
– Primary care/delivery system
reform
Distribution of health expenditures for
the U.S. population, by magnitude of
expenditure, 2009
Annual Mean
1%
Expenditure
5%
10%
$90,061
22%
– Payment reform
– Health information technology
•
Leadership can come from:
45%
$40,682
65%
$26,767
97%
$7,978
50%
– Federal government
– State government
– Employers
– Providers
– Insurers
– Collaboration among all
Source: D. Blumenthal, "Performance Improvement in Health Care—Seizing the Moment," New England Journal of
Medicine, April 26, 2012 366(17)1203–427.
3
What Is Already Underway? ACA Payment and Delivery
System Reforms Support a High Performance Health System
•
•
Primary Care and Medical
Homes: three new Medicare
pilots, several Medicaid
initiatives; increased payment
for primary care
Bundled payments: Medicare
pilots for hospital and postacute care, Medicaid initiatives
ACO: Broad responsibility for
quality and cost of patient care,
rewards for quality, shared
savings
•
Value-based purchasing
•
More transparency on quality
and cost
•
Meaningful use of health
information technology
Payment and Delivery System Integration
Global
Budget
Pioneer
ACOs
Payment Integration
•
CMMI Acute
Episode Bundled
Payment Pilots
Medicare
Shared
Savings
Plan
Comprehensive
Primary Care
Initiative
FFS and
DRGs
Small MD
practice;
unrelated
hospitals
Delivery System
Integration
Source: The Commonwealth Fund, The New Wave of Innovation: How the Health Care System Is Reforming, (New York:
Columbia Journalism Review, November 2011); A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, R. Nuzum, and D. McCarthy,
Organizing the U.S. Health Care Delivery System for High Performance (New York: The Commonwealth Fund, Aug. 2008); A.
Dreyfus, The Alternative Quality Contract and ACOs: Lessons for Policy-Makers, presentation to 2012 Bipartisan
Congressional Health Policy Conference, January 22, 2012.
Integrated
delivery
system
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Medicaid/State Government Innovations
•
About five percent of beneficiaries account for more than half of Medicaid spending; 83 cents of
every dollar spent in Medicaid goes to treat chronic diseases, including diabetes, asthma, and
hypertension
•
Community Care of North Carolina – regional organizations support primary care physicians and
provide care coordination – reduced hospitalization; started by Medicaid; now includes Blues
and Medicare
•
Vermont Blueprint for Health – community health teams, multi-insurer payment reform:
preliminary evidence on reduced health care expenditures per capita, 21% reduced
hospitalization, 32% reduced ER
•
Montana Health Improvement Project – community-based primary care, nurse care coordinators:
preliminary evidence on lower Medicaid costs for select conditions
•
Missouri Health Home – integrating behavioral health and primary care: 16% reduction in per
Medicaid beneficiary per month
•
Illinois Medicaid Medical Home – primary care case management: reduced Medicaid outlays
•
Commonwealth Care Alliance (MA) –
•
Indiana “Right Choices” – “ER frequent flyers” or numerous medications prescribed by different
physicians; ED use fell by 72 percent and use of controlled substances decreased by 38 percent
•
Care Transition Model deployed in 39 states to reduce expensive rehospitalizations; health
coach for patients with complex care needs and their families
Source: Takach M. Reinventing Medicaid: state innovations to qualify and pay for patient-centered medical homes
show promising results. Health Aff (Millwood). 2011 Jul;30(7):1325-34; K. Thorpe, Understanding and Addressing
“Hot Spots” Critical to Bending the Medicaid Cost Curve, (Washington: Partnership to Fight Chronic Disease, May
2012).
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Early Evidence from
Primary Care Medical Home Interventions
Geisinger Health System (Pennsylvania)
• 18 percent reduction in all-cause hospital admissions; 36% lower readmissions
• 7 percent total medical cost savings
Mass General High-Cost Medicare Chronic Care Demo (Massachusetts)
• 20 percent lower hospital admissions; 25% lower ED uses
• Mortality decline: 16 percent compared to 20% in control group
• 4.7% net savings annual
Guided Care - Geriatric Patients (Baltimore, Maryland)
• 24 percent reduction in total hospital inpatient days; 15% fewer ER visits
• 37 percent decrease in skilled nursing facility days
• Annual net Medicare savings of $1,364 per patient
Group Health Cooperative of Puget Sound (Seattle, Washington)
• 29 percent reduction in ER visits; 11% reduction ambulatory sensitive admissions
Health Partners (Minnesota)
• 39% decrease ED visits; 24% decrease hospital admissions
Intermountain Healthcare (Utah)
• Lower mortality; 5% relative reduction in hospitalization
• Highest $ savings for high-risk patients
Source: K. Grumbach and P. Grundy, Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the
Evidence from Prospective Evaluation Studies in the United States, (Washington: Patient Centered Primary Care Collaborative,
November 2010); T. Ferris et al. “Cost Savings From Managing High-Risk Patients” in The Healthcare Imperative: Lowering Costs
and Improving Outcomes: Workshop Series Summary, (Washington: National Academies Press, 2010).
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State Action to Reduce Avoidable
Rehospitalizations
•
STAAR program poised to inform public policy and initiatives related to care
transitions and readmissions – Michigan, Massachusetts, Washington.
•
Preliminary national survey of hospitals suggests that STAAR hospitals are
more likely to have adopted interventions such as enhanced assessments,
enhanced patient education and to have activated the post acute care delivery
system prior to discharge, compared to non STAAR hospitals.
•
Trend in STAAR cohort of hospitals in each state suggests reductions in
readmissions for certain groups of patients, on targeted units or hospital-wide.
– Top performers show up to 50% reduction in readmissions for targeted
patient population on specific units (e.g. high risk patients with CHF)
13%
12%
80
CL: 12.1%
60
11%
40
10%
20
9%
0
Aggregate % readmissions
LCL
# of hospitals reporting
UCL
centerline
15%
Percent Readmissions
Percent Readmissions
14%
STAAR: MA Hospitals Reporting All-Cause
30-Day Readmissions
100
(All
MA Reported Data)
CL: 12.6%
13%
STAAR: MI Hospitals Reporting All-Cause
30-Day Readmissions
(All MI Reported Data)
50
40
30
CL: 12.2%
20
11%
10
9%
0
Aggregate % readmissions
LCL
# of hospitals reporting
UCL
baseline
INTERACT – Improved Nursing Home Care
Reduces Hospitalization
•
Interventions to Reduce Acute Care
Transfers (INTERACT) II helps nursing
home staff identify, assess,
communicate, and document changes
in residents' status
•
Resulted in a 17 percent reduction in
hospital admissions
•
Three strategies:
–
identifying, assessing, and
managing conditions to prevent
them from becoming severe
enough to require hospitalization;
–
managing selected conditions,
such as respiratory and urinary
tract infections, in the nursing
home itself; and,
–
improving advance care planning
and developing palliative care
plans as an alternative to acute
hospitalization for residents at the
end of life
INTERACT II Shows Potential
to Reduce Hospital Admissions
Hospitalizations per 1,000 resident days
Source: J. G. Ouslander, G. Lamb, R. Tappen et al., "Interventions to Reduce Hospitalizations from Nursing Homes:
Evaluation of the INTERACT II Collaborative Quality Improvement Project," Journal of the American Geriatrics
Society, April 2011 59(4):745–53.
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International Examples: Disease Management
Programs in Germany
•
Conditions: Diabetes, COPD, coronary heart disease, breast cancer
•
Funding from government to ~115 private insurers (sickness funds)
–
Insurers receive extra risk-adjusted payments to cover patients with these conditions
–
Insurers pay primary care docs to enroll eligible patients into programs & provide periodic reports
back to the docs (the closest to coordination)
–
Patients: reduced cost sharing if enrolled
–
Care guideline protocols plus patient education
Disease Management Program
Participants
Non-participants
Amputation of lower leg or foot,
2007
0.48%
0.76%
Chronic renal insufficiency, 2007
0.36%
0.74%
Myocardial infarction, 2007
0.83%
1.10%
Stroke, 2007
0.91%
1.14%
US $5,273.99
US $5,896.54
Percent of diabetic patients :
Overall costs, 2007
Source: S. Stock, A. Drabik, G. Büscher et al., "German Diabetes Management Programs Improve Quality of Care
and Curb Costs,“ Health Affairs, Dec. 2010 29(12):2197–2205.
8
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International Examples: Community Approach to After-Hours
Care in the Netherlands to Reduce Use of ER
•
~130 large-scale after-hours primary care cooperatives serving 90%+ of
Dutch population
•
Nurse telephone triage and advice with back-up by physician, walk-in visits
and house calls
•
Evidence-based triage protocols and guidelines
•
GP average after-hours care workload dropped from 19 to 4 hours per week
•
Preliminary impacts for advanced model integrated with ER:
– 25% increase in primary care contact
– 53% reduction in contacts with emergency services
– 12% reduction in ambulance calls
Source: Grol R, Giesen P, van Uden C. After-hours care in the United Kingdom, Denmark, and the Netherlands: new
models. Health Aff (Millwood). 2006 Nov-Dec;25(6):1733-7.
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Cost Savings from Payment and Delivery System Reforms
• Innovations to date show promise of achieving savings by reducing
hospitalization and emergency room use and improving care
management for high cost patients
• Requires primary care foundation, aligned incentives, and
information systems
• Needs to be targeted on those who can best benefit
• Will take trial and error to find the most effective intervention
components – what works for whom under what circumstances
• Interventions and incentives need to be economically prudent
• Strategy should be quick data feedback on effects, continuous
improvement, and long-term commitment
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Thank You!
Tony Shih,
Executive Vice
President for
Programs,
[email protected]
Cathy Schoen,
Senior Vice
President for
Research and
Evaluation,
[email protected]
Anne-Marie Audet,
Vice President,
Health System
Quality and
Efficiency
[email protected]
For more information, please visit:
www.commonwealthfund.org
Stu Guterman,
Vice President,
Payment Reform
[email protected]
Melinda Abrams,
Vice President,
[email protected]
Kristof Stremikis,
Senior Research
Associate,
[email protected]