Healthcare Reform, HITECH & The View from 2015

Transcription

1 Healthcare Reform, HITECH & The View from 2015 John Glaser, PhD CEO, Siemens Health Services September 1, 2010

2 Increasing Growth in Healthcare Costs Page 2

3 Uneven Care Quality Chronic Disease Under Control: Managed Care Plan Distribution, 2006 Diabetes Percent of adults with diagnosed diabetes whose HbA1c level <9.0% Hypertension Percent of adults with hypertension whose blood pressure <140/90 mmhg 100 Mean 90th %ile 10th %ile Mean 90th %ile 10th %ile Private Medicare Medicaid Private Medicare Medicaid Note: Diabetes includes ages 18 75; hypertension includes ages Data: Healthcare Effectiveness Data and Information Set (NCQA 2007). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance,

4 Factors Contributing to Heightened Pressure on Healthcare Particularly Costs Relentless increases in care costs to individuals and purchasers of care Cost increases occurring against an adverse economic backdrop Federal government deficits State government revenue shortages Lingering economic recession for businesses Slow job growth, underwater mortgages and evaporated retirement plans for consumers Suspicion that cost increases reflect monopolistic behavior rather than the true costs of care Lack of comparable increases in care quality and safety Problematic data on care quality Too much care variation Data that distinguishes no one Overall poor performance on global measures of health Page 4

5 Techniques for Limiting Growth In Health Spending and Likely Impact Very Limited Impact Encourage Greater Use of Preventive Services (Shortterm) Limited Impact Provide Better Price and Quality Information Require Patients To Pay More Restrict Use of Harmful Care Reduce Expense and Waste of Medical Mal-Practice System Reduce Administrative Costs of Insurance Develop and Use Government Supported Comparative Effectiveness Studies Greater Impact Restructure Payment System -- (Bundled Payment and Value Based Pricing) Restructure Delivery System (Integrated Care) Restrict Use of Marginally Useful Care Limit Supply of Expensive Services Incentives to Use Preventive Services (Long-Term) Expand and Restructure Primary Care --- Create Effective Medical Homes for Patients Create a Governmental High Cost Reinsurance System with Effective Disease Management Systems for Chronic Conditions Greatest Potential Impact Gov. Regulation of Payments To Providers Establish Global Budgets Source: Discussion at The Cash Catalyst Meeting, Stuart H. Altman, 7/15/10 Page 5

6 Health IT as a Critical Enabler for Healthcare Transformation Technology Adoption and Use - HITECH Transformational Change in Health Care Delivery and Population Health - ACA ? TIME Page 6

7 Examples of Meaningful Use Maintain an up-to-date problem list of current and active diagnoses Record smoking status for patients 13 and older At least 80% of patients seen or admitted have at least one entry At least 50% of patients seen or admitted have smoking status recorded Send reminders to patients per patient preference for preventive/follow-up care (M) Reminders sent to 20% of all patients seen that are over 65 years old Provide patients with an electronic copy of their health information At least 50% of patients who request an electronic copy are provided it within 3 business days Provide summary of care record for each transition of care or referral (M) Summary provided for at least 50% of all transitions of care or referrals Capability to provide electronic syndromic surveillance data to public health agencies (M) Perform at least one test of capacity to provide such data Page 7

8 CMS Estimates of the Number of Providers who will be Meaningful Users in 2011 Scenario Eligible Professionals Low 10% 13% 15% High 36% 40% 44% Hospitals Low 30% 35% 46% High 43% 58% 73% Baselines considerations (2008): 29% of hospitals have some level of medication CPOE (AHA) 4% of eligible professionals have a full function electronic health record Page 8

9 The Healthcare Reform Legislation Focused on Access but has Significant Payment Reform Provisions $940 billion over ten years 32 million now covered Closes Medicare donut hole Page 9 Copyright 2010 Siemens Medical Solutions USA, Inc. All All rights reserved.

10 Changing Perspective Provider-centric Person-centric Provider Provider Specialty Hospitals & Clinics Retail Clinics Provider Provider Provider Academic Medical Centers General Hospitals Provider Provider Provider Provider Independent Physicians Practices Employers Facilitated Patient Networks Networks That Profit From Health Page 10 Implications Data/information/knowledge focus (not function/ui focus) EHR focus shifts to coordination and collaboration Open, standards-based data exchange Move towards person controlled data access

11 HIT Market Evolution High Stakeholder Value Market Evolution Horizon 3 - Guide Horizon 2 - Orchestrate Horizon 1 - Exchange Low Page 11 Exchange Non-disruptive secure sharing of normalized patient data Respects privacy boundaries Directed push dominates Drivers MU stages 2, 3 Physician recruitment Federal/state grants Orchestrate Builds on Exchange Actionable, supports care coordination across settings Driven by care guidelines, caregiver arrangements Drivers Payment reform, bundled payments ACOs, medical homes Guide Builds on Orchestrate Provides care-givers with contextual knowledge at PoC Supports translational research Drivers Heightened reimbursement pressures Comparative effectiveness implementation

12 Lower Altitude but Still High Altitude Ramifications From now on Medicare/Medicaid payments will be materially based on effective use of EHRs Beginning with meaningful use And moving to payment reform Meaningful use pressure will snowball Payment reform and increased care accountability assume meaningful use Commercial health plan incentives may be based on an assumption that meaningful use has been achieved Maintenance of certification may have meaningful use requirements Will licensure and/or accreditation consider meaningful use status? Industry EHR development agenda will be increasingly dominated by certification, interoperability, meaningful use and ACA requirements The Federal agenda will define the EHR Page 12

13 Lower Altitude but Still High Altitude Ramifications The presence of a broadly adopted EHR will cease to be a competitive differentiator. Differentiation could occur in several areas: EHR-leveraged care improvement within the organization and with other providers Care analyses and secondary use of data Superior utilization of clinical decision support Engagement of the patient in their care The growth of exchange infrastructure will bring increased interdependence between the information systems agenda of provider and other stakeholder organizations A wide variety of new species will enter the healthcare information technology market They will focus on secondary use of data and delivering intelligence to the care process extending into the EHR Page 13

14 Health Plans (and others) are Making Moves Page 14

15 Health Plans (and others) are Making Moves Page 15

16 Near Term Ramifications for Information Technology Electronic health record Core EHR capabilities, e.g., manage a problem list and eprescribing, remain very relevant Other functions increase in importance Ability to identify and track a patient across multiple organizations Clinical decision support to deliver evidence-based guidelines, reminders, order sets and alerts Disease registries to provide analyses of care processes and outcomes for a population Care documentation Some functions are new Technologies to support care coordination and care team collaboration, e.g., discussion rooms and event messaging Health Information Exchange Enable tight interoperability with clinical affiliates Enable exchange of directed push transactions Support messaging of patient events, e.g., missed radiology procedure appointment Initial HIE efforts will be focused on a well defined set of clinical relationships Page 16

17 Near Term Ramifications for Information Technology Data Management Business intelligence tools to support Assessment of care quality and costs for cohorts of patients (episodes and bundles) Analyses of practice variations Examination of care delivery alternatives Predictive modeling to identify high risk patients Personal Health Records Provide patients with access to their EHR data Support communication with care team Enable direct entry of data Provide access to health information and self management tools Page 17

18 Impact on Care Documentation Because of the change in reimbursement care documentation will: Support a more extensive diversity of needs Require greater thoroughness Be shared by multiple care providers Face increased time pressures This will require efforts to: Compile necessary data from multiple sources; claims, processing of text, other providers and patients Enable the provider to focus on context-specific data Develop means to ease the documentation challenges of time and thoroughness Page 18

19 Identifying a CMP Patient Page 19

20 and Page Alerts Admissions and Discharges From: Care Management Program Admit Notification Sent: Thu 01/01/ :00 PM To: Neagle, Mary Subject: ABC Patient MRN Has Been Admitted to the ED at approx 17:26 on 07/10/2008 (AMN) Neagle, Mary, your patient ABC Patient MRN: Has Been Admitted to the ED at approx 12:00 on 01/01/2008 (AMN) With a Chief Complaint of: CP/ SOB *** This alert is generated when a patient is REGISTERED in the ED *** *** Clinical information may not be immediately available *** Page 20

21 Inpatient Census Real Time Page 21

22 Blurring of Information Technology Boundaries There has been a progressive erosion in the boundaries between the organization s IT infrastructure, staff and applications and the rest of the world Minicomputers Personal computers Remote computing services Outsourcing This erosion is accelerating Mobile devices Cloud computing Web 2.0 collaboration tools The mature form of this erosion is unclear. It is clear that the provider IT response will involve a collection of owned and sourced infrastructure, staff and applications Consider 71% of doctors consider a smart phone essential to their practice More than 500,000 Wi-Fi networks will be implemented in the US healthcare market in 2010, a 50% increase from Expected to double the 2010 figure to more than 1 million by % of Siemens software sold this year is hosted or in the cloud up significantly over prior years Siemens has nearly 900 customers with over half a million healthcare professionals using its hosted systems on any given day Source: Manhattan Research, 3/2010, ABI Research, 7/2010 & Siemens Healthcare 8/2010 Page 22

23 We are in for a Tumultuous but Exciting Period of Time Payment change is THE disruptive innovation in care delivery The Federal agenda defines several aspects of the healthcare information technology industry: Conceptual models of healthcare information technology Definition of the electronic health record Interoperability and exchanges Standards Adoption and implementation support (RECs) A wide range of new entrants with innovative ideas and diverse interests will enter the market Along the way we will see major advances in the technology and its delivery Cloud computing Mobile devices Web 2.0 collaboration tools Page 23

24 Early ACO Results Community Care of North Carolina Page 24 Formed in 1998; enhanced medical home supported by the state s Medicaid program Results: Saved roughly $3.3 million in the treatment of asthma patients and $2.1 million in the treatment of diabetes patients between 2000 and 2002, while reducing hospitalizations for both patient groups. In 2006, the program saved the state roughly $150 to $170 million Physician Group Practice (PGP) Demonstration Formed in 2005 and developed by Medicare; group of 10 provider organizations and physician networks to test shared savings. Performance payments are designed to reward both cost efficiency and performance on 32 quality measures Results: Through year three of the program, all ten participating sites achieved success on most quality measures, and five collectively received over $25 million in bonuses as a share of $32 million in Medicare cost reductions Pathways to Health, Battle Creek, Michigan Formed in 2006, Integrated Health Partners participated in a chronic disease initiative with Blue Cross Blue Shield of Michigan (BCBSM). Later restructured into Pathways to Health Results: BCBSM reports that hospitalizations for conditions that can be prevented via better ambulatory care have dropped 40 percent over the three-year life of the program Source: AHA, 6/2010

25 There are two ways this could go Page 25

26 Page 26

27 Or Page 27

28 We re Facing a Serious Horror Show Page 28

29 Comparing US Utilization to Other Countries * Per 100,000 pop. Avg. LOS (2005) Discharge Rate* (2005) Cardiac Catherization* (2003) Renal Dialysis* (2005) Liver Transplant* (2002) % of Total HC Spend on Pharma. US % Australia % Canada N/A % Germany N/A % UK % Page 29 Source: OBCD Health Data

30 A Comparative Look at Costs Phys. Fees Office Visit Head CT Scan Avg. Cost Per Hosp. Day Lipitor (Rx) Bypass Surgery Canada $30 $41-$530 $837 $33 $14,111 France $31 $212 $1050 $53 $11,916 Germany $22 $319 $550 $48 N/A Netherlands $32 $258 $502 $63 N/A Spain $15 $161 $579 $32 $15,761 USA - Medicare Page 30 UK USA N/A $59-$151 $72 $179 $950-$1,800 $300 N/A $3,181- $12,708 $2,200 $40 $125-$334 N/A $12,868 $56,472- $116,798 $22,092

31 Techniques for Limiting Growth In Health Spending and Likely Impact Very Limited Impact Encourage Greater Use of Preventive Services (Shortterm) Limited Impact Provide Better Price and Quality Information Require Patients To Pay More Restrict Use of Harmful Care Reduce Expense and Waste of Medical Mal-Practice System Reduce Administrative Costs of Insurance Develop and Use Government Supported Comparative Effectiveness Studies Greater Impact Restructure Payment System -- (Bundled Payment and Value Based Pricing) Restructure Delivery System (Integrated Care) Restrict Use of Marginally Useful Care Limit Supply of Expensive Services Incentives to Use Preventive Services (Long-Term) Expand and Restructure Primary Care --- Create Effective Medical Homes for Patients Create a Governmental High Cost Reinsurance System with Effective Disease Management Systems for Chronic Conditions Greatest Potential Impact Gov. Regulation of Payments To Providers Establish Global Budgets Source: Discussion at The Cash Catalyst Meeting, Stuart H. Altman, 7/15/10 Page 31

32 The Cost of Healthcare Reform Failure The number of uninsured Americans would increase from 49.4 million in 2010 to 59.7 million in 2015 and 67.6 million in A larger share of the uninsured would come from middle- and higher-income families. Premiums would become increasingly expensive for employers and their workers. Offers of coverage would fall significantly for workers in small and medium firms. Even in the best case, the rate of employer sponsored insurance coverage would fall to 53 percent in Medicaid and Children's Health Insurance Program (CHIP) enrollment and costs would increase substantially. Employers would see large increases in premium costs. Uncompensated care costs would more than double. Health care costs paid directly by families would increase significantly. Source: Robert Wood Johnson Foundation, 3/2010 Page 32

33 Questions Page 33