A. Sue Carlisle, PhD, MD Professor of Anesthesia and Medicine Associate Dean for UCSF at SFGH

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1 A. Sue Carlisle, PhD, MD Professor of Anesthesia and Medicine Associate Dean for UCSF at SFGH

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3 VIEW FROM 23RD STREET 10 10

4 100,000 individuals seen/year 600,000 outpatient visits 16,500 admissions 6000 operations-60% emergent or urgent 20% of all care given in the city 30% of all ambulance traffic Operating Expenses $584,158,000 Affiliation Agreement $86,000,000

5 Net Patient $245,996,000 DSH & SNCP $83,240,000 Health Care Coverage Initiative $19,234,000 HSF Enrollment Fees $20,908,000 Capitation/Mgd Care $26,722,000 Realignment $52,799,000 AB 1383 Hospital Fee $8,000,000 General Fund $155,789,000

6 Acute Inpatient Days (excludes 4A SNF & SFBHC) Uninsured 26% Medi-Cal 34% Outpatient Visits Clinics & Emergency Department Uninsured 34% Medi-Cal 28% Commercial 4% Other 8% Medicare 26% Commercial 2% Other 18% Medicare 18%

7 H.R Patient Protection and Affordable Care Act H.R Budget Reconciliation Bill Health Reform (these combined) requires that most US citizens and legal resident have health insurance Expands eligibility for Medicaid and Medicare Changes rules for private insurance Makes investment in public health

8 8 Temporary High-risk Pool Medicare Doughnut Hole Reductions Insurance Reforms Dependent coverage up to age 26 No dollar limits on essential benefits for No pre-existing condition exclusion for children group health plans Elimination of cost-sharing for prevention Individual Mandate Medicaid Eligibility Expansion DSH Reductions Employer Requirements Health Benefit Exchanges Premium and Cost-sharing Subsidies Insurance Reforms Guarantee issue and renewal No pre-existing condition exclusions Coverage of essential benefits for small group and individual plans

9 9 92% of U.S. residents will have insurance by 2016

10 Medicaid volume: expected to increase by 16 Million nationwide; 2 Million in CA DPH Reimbursement estimated to be $800,000/1% increase in volume Disproportionate Share Hospital Funding (DSH) Is programmed to decrease as Medicaid increases Difficult to predict the impact Impact on San Francisco Health Care Security Ordinance?

11 11 Physical Health ~36k new Medi-Cal eligibles in SF Increase of nearly 29% $800,000 in new revenue/1% shift from uninsured $23 million in additional revenue if all sought services from DPH Behavioral Health 17.5% CBHS Medi- Cal penetration rate Could result in 6,300 new eligibles in CBHS system Could result in as much as $19.8 million new revenue

12 Baseline FY Medicare DSH Baseline: 9,232,103 TOTAL MEDICARE DSH REDUCTION (beginning no later than 2014; may be phased-in over time) Estimated Reduction 6,924,077 FY Medicaid DSH Baseline: 65,586,000 Annual Medicaid DSH Reductions: % 2,892, % 3,470, % 3,470, % 10,412, % 28,924, % 32,395, % 23,139,977 TOTAL MEDICAID DSH REDUCTIONS 104,708,398

13 13 City and County implemented its own local reform effort with passage of Health Care Security Ordinance The principal goal of the Ordinance was to expand access to health care benefits for uninsured workers and residents via: Employer Spending Requirement (ESR) Office of Labor Standards Enforcement Healthy San Francisco (HSF) Department of Public Health Federal Health Reform will impact aspects of the Ordinance. However, the impact would likely not occur until 2014 when the major components of Health Reform become effective

14 14 Health Reform is beneficial to San Francisco on two fronts: Health Reform expands health insurance options Some HSF health care services costs now incurred by the General Fund will be funded under Health Reform - Health Reform creates an individual mandate, but unlikely that all will comply Full implementation of the Health Reform will decrease the number of adults eligible for and enrolled in HSF current estimate is enrollment could decrease by 60%

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16 Overall costs of US healthcare are now about $2.3 trillion dollars ICU s are about 1/16 th of that cost (~1% GDP) but are rising as percentage, with aging population Hospitals are building more ICU beds Traditionally about 10% of beds, now rising to 25% of beds

17 Average daily charge for a private hospital ICU day is about $30,000 Cost is about 40-50% of that and can be much higher if expensive drugs or diagnostics are used Personnel are biggest fixed expense Most iv antibiotics cost about $ /day Cost of neuro-ir suite may be $20,000 per procedure Blood products or novel biologics can cost up to $5000 per infusion

18 Average charges per patient (n=39) = $108,361 (range=$10,000-$630,000 Extrapolating the average cost to treat 442 shooting and stabbing trauma activations from 2007 = a total charges* of $47,895,831 Cost of Pedestrian injuries in US/year > $11.1 Billion

19 Personnel Nurses Respiratory therapists Physical therapists Pharmacists Dieticians Physicians Support staff

20 Newer Drugs Antibiotics Novel drugs e.g. Factor VIIa Newer Devices and therapies e.g. Wound -Vac, CAPH Special monitors e.g. brain O 2 Therapeutic hypothermia Complications leading to increased length of stay

21 Decrease Infection Rates e.g. Central lines, VAP, sepsis *Iowa Attributable Mortality rate = 35% *Iowa Estimated cost + $40,000/survivor *Pittet et al. JAMA 1994 **Boston Estimated Cost (medical/cardiac) = $3,961 **Dasta et al. Crit Care Med ***Canadian Attributable Mortality rate =16% ***Estimated cost = $12,321 ***Laupland et al. J Hosp Infect. 2006

22 Early appropriate nutrition Weaning Protocols to decrease LOS Avoidance of over sedation Specialized care e.g. stroke, renal failure *Decrease transfusion thresholds estimated saving $821.1 M in direct costs Avoid complications and associated costs *Zilberberg and Shorr 2007 BMC Health Serv Res.

23 Use of sites for alternative care Step-down units PACU care for special cases Use of Intensivists* remote tele units with intensivist monitoring Use of multidisciplinary team* pharmacists nutritionists Closed Units* End of Life Decisions *Pronovost et al. Curr Opin Crit Care 2006

24 Factors leading to potential Decrease in volume Insurance leads to earlier treatment Medical Homes-better management of chronic disease Better End-of-Life discussions Factors leading to potential Increase in volume More insured patients seeking care Patients living longer Ageing Population in general More technical options Disincentive to denying care since reimbursement available

25 Cost Containment essential More regulatory oversight is inevitable (and maybe even desirable) New technologies will change our practice and our payments New practice models will need to be implemented. NO ONE REALLY KNOWS