Transforming Healthcare Collaboration among Payors, Providers and Community Leaders

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Transforming Healthcare Collaboration among Payors, Providers and Community Leaders. Vinod K. Sahney, PhD Senior Vice President and Chief Strategy Officer Presented at Purdue University November 29, 2006. Outline. Introduction Performance of U.S. Healthcare System
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Transforming HealthcareCollaboration among Payors, Providers and Community LeadersVinod K. Sahney, PhDSenior Vice President and Chief Strategy OfficerPresented at Purdue UniversityNovember 29, 2006Outline
  • Introduction
  • Performance of U.S. Healthcare System
  • Collaboration to Improve Access to Healthcare
  • Collaboration to Improve Healthcare Delivery System
  • Collaboration to Improve Quality of Care in Massachusetts
  • Growing Conflicts
  • Conclusions
  • Introduction: Key Messages
  • Healthcare Delivery – Non System
  • Lack of Aims for Improvement
  • System Performance Compares Poorly to Developed Nations
  • Focus on Medical Technology Gives False Sense of Quality
  • Enough Money in System to Cover All
  • Collaboration Initiatives – Improve Care and Health Status
  • Leadership by Community Organizations Needed
  • Per-Capita Health Spending in the United States in Constant 2000 DollarsMANAGED CAREPremium costs have risen five times faster than inflation and four times faster than wagesHealth Insurance Premiums Compared to Other IndicatorsPercent IncreaseSource: Employer Health Benefits Survey, KFF, 2004International Healthcare TrendsIn fact, the U.S. spends much more per person on healthcare than other countries, as well as a larger percent of Gross Domestic Product.International Health Spending per Capita 2002U.S.($5,267, 14.6%)Switzerland($3,446, 11.2%)Turkey($446, 6.6%)Canada($2,931, 9.6%)U.K.($2,160, 7.7%)Japan($2,077, 7.8%)Mexico($553, 6.1%)Poland($654, 6.1%)Note: Because these data are based on Purchasing-Power Parity values, they will differ slightly from earlier values cited herein.Source: Adapted from Anderson, GF et al. (2005) Health Affairs National Healthcare TrendsHealthcare expenditures are projected to more than double between 2000 and 2010, and healthcare is expected to account for 17% of the Gross Domestic Product by 2010.National Health Expenditures (NHE) and Percentage of GDP2000-2010*Projected by Centers for Medicare and Medicaid Services.Source: Adapted from Centers for Medicare and Medicaid Services (2005a)…and retirees are not faring any better
  • According to an analysis by the Urban Institute, by 2030 out-of-pocket expenses for retirees will consume:
  • • 30.3% of income for older unmarried adults, up from 17.3% in 2000, and
  • 35.1% of income for older married couples, more than double the 16% in 2000
  • Source: Henry E. Simmons, Pres. National Coalition on Health Care. November 14, 2005 address to International Foundation of Employee Benefit PlansNational Scorecard on U.S. HealthSystem Performance (Commonwealth Fund, September 2006)National Scorecard on U.S. HealthSystem Performance (Commonwealth Fund, September 2006)National Scorecard on U.S. HealthSystem Performance (Commonwealth Fund, September 2006)Why Are We In This Situation?
  • No national healthcare goals
  • No organized leadership for improvement
  • Cottage industry structure
  • Defined benefit with no planning
  • No accountability
  • No one owns enough of the system to enforce change
  • MassachusettsHealthcare ReformHealth Care Reform: The Genesis
  • October 31, 2003:
  • CONSENSUS DECLARED AT THE BCBSMA FOUNDATION: WE NEED A ROADMAP TO HEALTH CARE REFORMCONSENSUS DECLARED AT THE BCBSMA FOUNDATION: WE NEED A ROADMAP TO HEALTH CARE REFORMHealthcare Reform Timeline
  • Health care reform has dominated the political landscape for over one year.
  • House, Senate final bills/ conference committee appointedGovernor, Senate bills releasedHouse bill releasedGovernor signs into lawLegislation draftedLegislation finalized_________________Summer 2004 to early 2005October 2005November 2005April 2005April 4, 2006April 12, 2006Expanding the Focus
  • As first proposed, the concept of health care reform was about:
  • Lowering health care costs for employers
  • Efforts to enroll those eligible for Medicaid but unenrolled
  • Increasing access to care
  • Expanding the Focus
  • With input from BCBSMA, other issues were added to the mix:
  • Addressing the Quality of Care
  • Medicaid Provider Shortfalls
  • In the end, all the issues came together in one bill.Massachusetts:The Key Elements of Reform
  • Medicaid Expansions
  • Health Insurance Connector
  • Commonwealth Care – Premium Subsidy Program
  • Individual Mandate for all MA adult residents
  • Health Insurance Market Reforms
  • Employer Responsibilities (for firms > 11 employees)
  • Medicaid provider rate increases
  • MA Health Care Reform LawKey Components
  • $540+ million over next 3 years
  • Hospitals increases to be tied to quality standards in areas including addressing health disparities
  • Medicaid provider rate increases for hospitals, physicians and community health centersMA Health Care Reform Law: Key Components (cont’d)
  • Commonwealth Health Insurance Connector
  • New public authority (10-member board)
  • Administers “Commonwealth Care” low income premium subsidy program
  • Will offer “affordable” health insurance products to individuals and small businesses (50 or fewer employees)
  • MA Health Care Reform Law:Key Components (cont’d)
  • <100% FPL – fully subsidized, comprehensive benefits (including dental)
  • 100-300% FPL - sliding scale subsidies, no annual deductibles
  • Commonwealth Care Health Insurance Program (C-CHIP) – Premium Subsidy ProgramMass Health Care Reform Law Key Components (cont’d)
  • Individual Mandate for all MA adult residents
  • Enforcement mechanisms
  • Indicate insurance policy number on state tax return
  • Loss of state personal income tax exemption for tax year 2007
  • Fine for each month without insurance equal to 50% of affordable insurance product cost for tax year 2008
  • Mass Health Care Reform Law Key Components (cont’d)
  • Health Insurance Market Reforms
  • Non-group and small-group insurance markets merged
  • Young Adult plans for 19-26 year olds
  • Age for eligibility for dependent coverage for health insurance raised to 25 years
  • MA Health Care Reform LawKey Components (cont’d)
  • Employer Responsibilities (for firms > 11 employees)
  • Must offer access to pre-tax purchase of health insurance
  • “Fair share” assessment of no more than $295 per worker
  • Stakeholders
  • Health advocacy organizations
  • Organized labor
  • Business community
  • Hospitals
  • Health plans
  • Faith-based organizations
  • Physicians
  • Community Health Centers
  • Nurses
  • Appointed and elected officials
  • Health Care Delivery System:Introduction: Key Messages
  • Serious Problems in Quality
  • Great Degree of Variability
  • Source of Problems – Systems
  • Increased Quality and Cost Reduction Possible
  • Immediate Benefits by Improving Reliability of Healthcare Delivered
  • Conformance With Care Agreed byUS Health ExpertsAnd the Latest Large American Study…
  • McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)
  • 439 indicators of clinical quality of care
  • 30 acute and chronic conditions, plus prevention
  • Medical records for 6712 patients
  • Participants had received 54.9% of scientifically indicated care (Acute: 53.5%; Chronic: 56.1%; Preventive: 54.9%)
  • Conclusion: The “Defect Rate” in the technical quality of American health care is approximately 45%
  • Clinical Effectiveness
  • Focusing on effectiveness and efficiency of clinical processes
  • Great deal of variability within university hospitals:
  • Major surgery complications 49%
  • CHF re-admission rates 49%
  • Mortality 30%
  • Total direct costs/OR hour 24%
  • Total cost/adj. discharge 80%
  • Collaboration to Improve HealthcareDelivery System IHI Mission
  • The Institute for Healthcare Improvement is a not-for-profit organization driving the improvement of health by advancing the quality and value of health care.
  • IHI Vision
  • The Institute for Healthcare Improvement is a premier integrative force, an agent for profound change, dedicated to improving health care for all. Our measures of success include improved safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
  • IHI Initiatives
  • Breakthrough Series
  • Emergency Rooms
  • ICU
  • Surgical Infection
  • Ventilator Associated Pneumonia
  • Pursuing Perfection – 13 Hospitals
  • Impact Network – 210 Hospitals
  • Care at the Bedside
  • Patient Safety Officer Training
  • Executive Quality Academy
  • IHI Breakthrough Series(6 to 13 months time frame)Participants (10-100 teams)Select Topic (develop mission)PreworkCongress,Guides,Publicationsetc.PPDevelop Framework & ChangesPADADADExpert MeetingSSSLS 2LS 1LS 3Planning GroupSupportsEmail VisitsPhone Assessments Monthly Team ReportsIHI – 100,000 Lives Saved Campaign
  • Campaign: December 2004 - June 2006
  • Save 100,000 lives by improving reliability of healthcare within U.S. hospitals
  • Target 2,300 hospitals
  • Six proven initiatives
  • Six Initiatives
  • Deploy “Rapid Response Teams” at the first sign of patient decline
  • Deliver reliably, evidence-based care for acute myocardial infarction
  • Prevent adverse drug events by implementing medication reconciliation
  • Prevent central line infections – Implement bundles
  • Prevent surgical site infections – Implement bundles
  • Prevent ventilator associated pneumonia – Implement bundles
  • Accomplishments
  • Co-Sponsors:
  • Agency for Healthcare Research and Quality
  • American Medical Association
  • Association of American Medical Colleges
  • Center for Medicare and Medicaid
  • Joint Commission on Accreditation of Healthcare Organizations
  • National Patient Safety Foundation
  • University Health System Consortium
  • American College of Cardiology
  • Accomplishments (continued)
  • Co-Sponsors (continued):
  • Centers for Disease Control and Prevention
  • Society for Healthcare Epidemiology of America
  • American Nurses Association
  • Leapfrog
  • The National Business Group on Health
  • 20 State Hospital Associations
  • 3,300 Hospitals Voluntarily Signed Up
  • $15M Private Contributions
  • 122,000 Lives Saved
  • Collaboration to Improve Quality of Carein MassachusettsSeven Levers of Change
  • Governance Focus
  • Trustees as champions of New Quality Standards
  • Governance Practices Linked to Hospital Contracts
  • Quality and Safety Standards
  • Adoption of Standardized Quality Measures
  • Transparent Reporting of Performance Information
  • Public Recognition Programs to Highlight Extraordinary Achievements in Quality Improvement
  • Seven Levers of Change (cont’d)
  • Financing and Incentives
  • Incentives to Achieve New Quality Performance Standards
  • Partnerships with Multiple Quality Improvement Organizations Including IHI, Dartmouth, Rand
  • Funded 100,000 Lives Saved Campaign
  • $35K to each hospital
  • $5M contribution
  • $400M in Incentives Tied to Quality Goals
  • Redesign Payment Systems to Reduce Overuse and Misuse
  • Seven Levers of Change (cont’d)
  • Legislation and Regulation
  • Cost and Quality Council
  • Healthcare Reform
  • Public Engagement
  • Segmented Focus Groups
  • Seminar Series – Public Forums
  • Public Education
  • Eastern Massachusetts Health Collaborative
  • Seven Levers of Change (cont’d)
  • Technology
  • E-Health Collaborative
  • Three Communities
  • 500 Physicians
  • $50M Investment
  • Organizational Readiness
  • LEAD Organization
  • Capability Building
  • Growing ConflictsGrowing Conflicts
  • A. Demographics:
  • Beneficiaries vs. Contributors
  • Aging of population
  • Utilization increases exponentially with age:
  • 65 years vs. 45 years 2 times
  • 85 years vs. 45 years 4 times
  • 95 years vs. 45 years 8 times
  • Growing ConflictsGrowth Trends – Aging Baby BoomersGrowth Trends - Aging Baby Boomers
  • By 2030 one fifth of the population will be over 65 years of age
  • Elderly Population by Age, 1990 to 2050:Percent 65+ and 85+Health Spending and AgingSelected OECD Countries 2000Now over 16%U.S.SwitzerlandGermanyCanadaFranceNetherlandsAustraliaSwedenJapanU.K.IcelandSource: OECD Data, 2002Growing Conflicts
  • B. Acute Care vs. Chronic Care
  • Half of seniors have at least one chronic condition:
  • arthritis: 49%
  • hypertension: 36%
  • hearing impairment: 30%
  • cardiovascular disease: 27%
  • Chronic care now accounts for more than 70% of all healthcare expenditures:
  • acute care system trying to deliver chronic care
  • Growing Conflicts:Current Environment - Crumbling
  • C. Severe Workforce Shortages:
  • Nursing
  • Pharmacy
  • Radiology technicians
  • Physicians - specialties
  • Current Environment – Crumbling Foundation
  • D. Growing Complexity of Science and Technology:
  • Rapidly expanding knowledge base
  • Significant investment in R & D
  • New medical technologies:
  • transplantation
  • laparoscopic procedures
  • robotic surgery
  • CT/PET scanners
  • gene therapy
  • implants
  • E. Rising Uninsured and Underinsured
  • Growing Conflicts
  • Healthcare in the USA is at a crossroad:
  • Managed care rejected
  • Healthcare benefit cost increasing rapidly
  • ConclusionsConclusions
  • Large Country with Diverse Population
  • Time for Leadership
  • Healthcare Score Card
  • Aims for Regional Healthcare
  • Universal healthcare
  • Primary care and public health
  • Coordinated care
  • Transparency
  • Coalition for Healthcare System Change
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