Transcript Colorado_HC_Cooperative_8.22.12 - Co

The Colorado Health
Care Cooperative
A Uniquely Colorado Solution
Senator Irene Aguilar, MD
SD 32, Denver
2010: 49.9 Million Uninsured
Government
Insurance
4 Million
2011 Colorado:
829,000 uninsured
CO Medicaid =
560,722
16% of population
CHP + = 69,008
Colorado: Only 57.6% Adequately Insured
Impact of the Recession on
Colorado Medicaid
FY20072008
FY20082009
FY20092010
FY20102011
Colorado
Medicaid
Colorado
CHP+
Total
391,962
59,365
451,327
436,812
63,247
500,059
498,797
70,285
569,082
560,722
69,008
629,730
40%
Colorado Department of Health Care Policy & Financing
FY2011-12 Medical Premiums Expenditure and Caseload Report, August 2011
2012 Federal Poverty Levels
Family
Size
1
Parents
60% FPL
$ 6702
Children
Expanded
100% FPL
133% FPL
$11,170
2
$ 9078
3
$14,856
SCHIP
225%
$25,133
400%
PPACA
$44,680
$15,130
$20,123
$34,033
$60,520
$11,454
$19,090
$25,390
$42,953
$76,360
4
$13,830
$23,050
$30,657
$51,863
$92,200
5
$16,206
$27,010
$35,923
$60,773
108,040
6
$18,582
$30,970
$41,190
$69,683
123,880
Average Annual Premiums for Single and Family
Coverage, 1999-2011
* Estimate is statistically different from estimate for the previous year shown (p<.05).
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2011.
Urban and Brookings Institute Tax Policy Center
50%
76%
90%
99%
$ 42,327
$ 88,317
$ 154,131
$ 506,553
May 12, 2011
Distribution of Health Plan Enrollment for Covered Workers,
by Plan Type, 1988-2011
1%
1%
1%
1%
* Distribution is statistically different from the previous year shown (p<.05). No statistical tests were conducted for
years prior to 1999. No statistical tests are conducted between 2005 and 2006 due to the addition of HDHP/SO as a
new plan type in 2006.
Note: Information was not obtained for POS plans in 1988. A portion of the change in plan type enrollment for 2005
is likely attributable to incorporating more recent Census Bureau estimates of the number of state and local
government workers and removing federal workers from the weights. See the Survey Design and Methods section
from the 2005 Kaiser/HRET Survey of Employer-Sponsored Health Benefits for additional information.
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2011; KPMG Survey of EmployerSponsored Health Benefits, 1993, 1996; The Health Insurance Association of America (HIAA), 1988.
Percentage of Covered Workers Enrolled in a Plan with a
General Annual Deductible of $1,000 or More for Single
Coverage, By Firm Size, 2006-2011
* Estimate is statistically different from estimate for the previous year shown (p<.05).
Note: These estimates include workers enrolled in HDHP/SO and other plan types. Because we do not collect information on
the attributes of conventional plans, to be conservative, we assumed that workers in conventional plans do not have a
deductible of $1,000 or more. Because of the low enrollment in conventional plans, the impact of this assumption is minimal.
Average general annual health plan deductibles for PPOs, POS plans, and HDHP/SOs are for in-network services.
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2006-2011.
Dr. Jonathan Gruber
Presentation to Colorado
Health Benefit Exchange Board
9/16/11
No Reform
With ACA
ACA Impact
2,630,000
2,600,000
-30,000
Small Firm ESI (1-50 employees)
560,000
540,000
-20,000
Other ESI
2,070,000
2,060,000
-10,000
Unreformed Non-group
340,000
60,000
-280,000
Reformed Non-group
0
620,000
620,000
Tax Credit Recipients
0
470,000
470,000
Non-Recipients
0
150,000
150,000
Public Insurance
550,000
710,000
160,000
Uninsured
860,000
400,000
-460,000
Total
4,390,000
4,390,000
ESI
→
→
Table 2: Estimate of ACA Effect, 2016
Dr. Jonathan Gruber
9/16/11
Dr. Jonathan Gruber
9/16/11
Health Care Expenditure per Capita
by Source of Funding, 2008
Dollars
8,000
7,538
7,000
912
Adjusted for Differences in Cost of Living
Out-of-pocket spending
Private spending
Public spending
6,000
5,003
5,000
3,119
4,627
756
4,079
35
4,000
1,424
3,000
467
3,737
3,696
487
273
548
600
616
382
3,540
3,470
489
543
60
86
3,353
605
484
2,000
3,129
347
197
2,683
154
4,213
3,507
2,736
2,863
2,869
2,875
2,991
2,841
2,263
1,000
2,585
372
2,158
0
US
NOR
SWIZ
CAN
* 2007.
Source: OECD Health Data 2010 (Oct. 2010).
GER
FR
DEN*
SWE
AUS*
UK
NZ
Since 2006, the cost of the state’s insurance program
has increased by 42 percent, or almost $600 million.
According to an analysis by the Rand Corporation, “in
the absence of policy change, health care spending in
Massachusetts is projected to nearly double to $123
billion in 2020, increasing 8 percent faster than the
state’s gross domestic product (GDP).”
US v. Other G7 Countries
Canada
France
Germ.
Italy
Japan
UK
Avg
USA
MD visits
per capita
5.8
6.4
7.4
7.0*
13.6
5.1
7.6
3.8
Hosp discharges
per 100 pop
8.4
28.4
22.0
13.9
10.6*
12.6
16.0
12.6
Avg hospital
LOS
7.3
5.4
7.9
6.7
19.2
7.5
9.0
6.6
144.0
83.2
Hospital days per
100 population
HC spending
per capita (PPP)
$3,696
$3,423
$3,464
$2,673
$2,581
$2,885
$3,120 $6,933
HC spending
as % of GDP
10.0
11.2
10.5
9.0
8.1
8.5
9.6
15.8
LE at birth
80.7
80.7
79.8
81.2*
82.4
79.1*
80.7
78.1
Infant deaths per
1000 live births
5.0
3.8
3.8
3.7*
2.6
5.0
4.0
6.7
John A. Nyman, PhD
University of Minnesota
*
*
2006 data from the OECD website accessed 23 Sept 2009: http://stats.oecd.org/index.aspx
The spending per capita numbers were converted from the currency of the country to US dollars by a PPP index.
*2005 data
*
16
APCDB
Insurance company profits
First Half 2011
Aetna
11%
Cigna
7.4%
Wellpoint
7.8%
United
7.7%
In the first quarter of 2011, the combined profits of the
five companies which cover one-third of the U.S.
population, surged 14% to $3.6 billion.
If the trend holds, they'll earn a record $14.4 billion in
profits in 2011.
MRI Scan and Imaging Fees, 2010
US Dollars
3,000
2,500
2,000
US 95th
$1,581 percentile
1,500
1,000
$874
$632
500
$187
$234
$304
SPA
CAN
$398
US
$1,009 Average
$500
0
UK
US
Medicare
(2009)
Source: International Federation of Health Plans, 2010 Healthcare Price Report, Medical and Hospital Fees by
Country.
FRA
GER
SWIZ
US
High U.S. Insurance Overhead:
Insurance-Related Administrative Costs
•
Fragmented payers + complexity = high
transaction costs and overhead costs
– McKinsey estimates adds
$90 billion per year*
•
Insurance and providers
– Variation in benefits; lack of
coherence in payment
– Time and people expense for
doctors/hospitals
$600
Spending on Health Insurance Administration
per Capita, 2007
$516
$500
$400
$300
$247
$220
$200
$198 $191
$140
$86
$100
$76
$0
US
FR
SWIZ
NETH
GER
CAN
* 2006
Source: 2009 OECD Health Data (June 2009).
* McKinsey Global Institute, Accounting for the Costs of U.S. Health Care: A New Look at Why Americans
Spend More (New York: McKinsey, Nov. 2008).
AUS*
OECD
Median
Price Levels:
Unequal and Incoherent
• States all-payer systems reveal 3 to 6 fold variation in payment
rates for same service
– Dominant provider systems higher rates
– Specialist rates up faster than primary care
• Methods vary as well payment rates
– Hospital per diems, case rates; occasional DRG
– Pay for performance contract bonuses
– Primary care: “medical home” member month in some
• Apparent “chaos” behind a veil of secrecy
• Medicaid and Medicare payment rates generally lower
– Primary care in some markets the exception
Cathy Schoen
9.25.11
Variations Among Academic
Medical Centers
UCLA
CMS Inpatient
Quality Score
81.5
Mass
General
85.9
Mayo
Clinic
90.4
Source: Elliot Fisher, Dartmouth Medical School
Care Delivery & Spending, last 6 months of life
Total Medicare
Spending
$50,522
$40,181
$26,330
Hospital Days
Physician Visits
19.2
52.1
2.9
17.7
42.2
1.0
12.9
23.9
1.0
Specialist/
Primary Care
Ratio
Massachusetts: Private, Medicare & Medicaid
Payment for Professional Procedures
Private Payer
Payment Variation
Min
Price
Max
Price
Office
Visit
$45
$330
MRI
Brain
$104
$646
Colonoscopy
$203
$1,045
Source: Massachusetts Division of Health Care Finance and Policy, Massachusetts Health Care Cost
Trends: Price Variation in Massachusetts Health Care Services, May 2011.
New Hampshire
Insurers Disparate Payments
What is the Price? Range for What Insurance
Pays to Health Care Provider Per Procedure
Colonoscopy
Mammogram
MRI (back)
(Outpatient)
Insurer A
1,353 - 4,611
227 - 881
645 - 2,790
Insurer B
1,270 - 3,121
161 - 564
640 – 2,292
1,195 - 3,524
129 - 612
732 - 2,659
Insurer C
Advanced
primary care
networks
Source: CMWF analysis of data retrieved October 2010 from:
http://www.nhhealthcost.org/costByProcedure.aspx
Costs and Health Care
• Medical Providers are paid “fee for service” –
paid more for doing more, not for outcomes
The most expensive piece of medical equipment
… is a physician’s pen
• Provider, Hospital & Equipment supply often
beget patient demand – without improved
outcomes!
Research shows significant variation in
health care spending.
Chart 1: Medicare Spending per Beneficiary, by Hospital Referral Region, 2006
National Average = $8,304
< $7,000
$7,000 – $7,500
$7,500 – $8,000
$8,000 – $9,000
> $9,000
Not populated
Source: The Dartmouth Atlas of Health Care. (2009). The Policy Implications of Variations in
Medicare Spending Growth. Link:
http://www.dartmouthatlas.org/atlases/Policy_Implications_Brief_022709.pdf.
Note: Data adjusted for age, race, and sex but not price. Category definitions as in source
document.
Total Hospital and Physician Costs for Select
Surgeries – International Comparisons
US
Dollars
CAN
FRA
GER
NETH
SPA
SWIZ
UK
US (avg)
US
(95th
%ile)
Appendectomy
$3,810
$2,795
$3,285
$4,624
$2,537
$2,570
$3,476
$13,123
$25,344
Hip
Replacement
10,753
12,629
15,329
12,737
9,327
6,683
9,637
34,454
75,369
Bypass
Surgery
22,212
16,325
27,237
19,180
15,802
11,618
13,998
59,770
126,182
Source: International Federation of Health Plans, 2010 Healthcare Price Report, Medical and Hospital Fees by Country.
Paying for Health Care:
Insurance is the Wrong Model
 1913: Few received medical care
 Life Expectancy 59.7 years
 2008: Everyone receives medical care

√
√
√
√
√
√
√
Life Expectancy 78.0 years
Preconception, Prenatal, Perinatal
Childhood & Adolescence
Adulthood & Senior Care
Chronic Disease Management
Catastrophic illness
Disability
Death
Percent of Total Health Care
Spending
Concentration of Health Care Spending in the
U.S. Population, 2008
(≥$44,338)(≥$16,336) (≥$9,148) (≥$6,074) (≥$4,374) (≥$825)
(<$825)
Note: Dollar amounts in parentheses are the annual expenses per person in each percentile. Population is the civilian noninstitutionalized
population, including those without any health care spending. Health care spending is total payments from all sources (including direct
payments from individuals, private insurance, Medicare, Medicaid, and miscellaneous other sources) to hospitals, physicians, other providers
(including dental care), and pharmacies; health insurance premiums are not included.
Source: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare
Research and Quality, Medical Expenditure Panel Survey (MEPS), 2008.
Distribution of Medicaid enrollment &
expenditures by eligibility category,
FY 2010-2011
SOURCE: CO Department of Health Care Policy & Financing, Executive Budget Request, Nov. 1, 2011
A Uniquely Colorado Solution:
The Colorado Health Care
Cooperative
What is a Health Care
Cooperative?
A nongovernmental, nonprofit, member- owned
and operated corporation
Residents of Colorado are the owner-members
The cooperative operates for the benefit of
Coloradans—providing quality health care for all,
while saving members’ money
Design Principles
UNIVERSAL
A Colorado Plan that includes
ALL Coloradans
Design Principles
AFFORDABLE
Everyone contributes
No deductibles and modest copayments
that can be waived based on income
and health conditions
Design Principles
ACCOUNTABLE & TRANSPARENT
Publicly elected board of directors accountable
for health spending & outcomes
Engage & inform members on design,
evaluation and revision of benefits
Equitable and Consistent
Design Principles
COMPREHENSIVE
Provide comprehensive, essential health care
benefits, emphasizing health and wellness
Statewide emergency access
Design Principles
CHOICE OF PROVIDER
Patient Centered Medical Home
Integrated Health Care System
Accountable Care Collaborative
Design Principles
INTEGRATED & COORDINATED CARE
No incentives to delay or deny care
Quality savings benefit all members
Sensitive to value
Design Principles
EFFICIENCY
Simplified, centralized billing
Dependable and simple reimbursements
Design Principles
MARKET BASED
Providers & Hospitals competing for
member based on service and quality
Negotiated pricing for medications &
durable medical equipment
Drug Prices for 30 Most Commonly
Prescribed Drugs, 2006–07
US is set at 1.0
1.00
1.0
0.77
0.8
0.76
0.63
0.6
0.51
0.49
0.45
0.44
0.4
0.34
0.2
0.0
US
Source: IMS Health.
CAN
GER
SWIZ
UK
AUS
NETH
FR
NZ
Design Principles
CONTINUOUS, PORTABLE COVERAGE
Provides access to health care
independent of employment
Design Principles
LETS BUSINESS FOCUS ON BUSINESS
Eliminate administration of health
benefits and provide predictable costs
Evaluate possibility of 24 hour coverage
Design Principles
MALPRACTICE REFORM
Fast & fair compensation
Control defensive medicine & cut costs
Attract physicians to Colorado
Design Principles
TECHNOLOGICALLY ADVANCED
Smart card to ensure access to medical
records, simplify billing, & prevent fraud
Collect data to determine best practices
Transparency of cooperative finances
Design Principles
COMPASSIONATE
Provide for vulnerable populations and
those with exceptional needs
Martin Luther King, Jr.
Cowardice asks the question: is it safe?
Expediency asks the question: is it politic?
Vanity asks the question: is it popular?
But conscience asks the question: is it right?
And there comes a time when one must
take a position that is neither safe,
nor politic, nor popular- but one must
take it simply because it is right.