the american patientmeaningful use

the affordable care actaccountable care organizationspatient-centered medical home

Part One

THE American Patient

More and more in policymaking, the U.S. government is seeking to actively engage the American patient or their caregiver as a participant in the care management process. With chronic disease impacting nearly 140 million Americans today, it remains a critical factor to reining in health care spending. Experts believe one of the principal causes of chronic disease is that the American patient is unengaged and not held accountable for lifestyle choices made. The provider community can expect this point to be pressed in future policymaking and their ability to successfully deliver patient-centric care linked to reimbursement in the near future.

THE American patient

51%

49%

Percent of the U.S. population that is male (49 percent) & female (51 percent)

309Millions of people living in

the United States of America

78.7Life expectancy for all

genders & demographics in the U.S., as compared to 83.9 in Japan & 49.4

in South Africa40.3 Millions of Americans ages 65+ (17.3 percent live in Florida); this demographic is expected to grow to 88.5 million by 2050

1.4 Millions of men & women who serve as active duty military in defense of America

Percent of American adults who are obese

35.714.1

Billions of dollars spent on medical services directly attributed to childhood obesity alone

THE American patient

190Thousands of 2012 expected cancer deaths in the U.S. that are linked to obesity, physical inactivity & poor

nutrition - all of which is preventable

573Thousands of Americans who die

from heart disease, the leading cause of death in the U.S.

18.3Millions of Americas that were

physician-diagnosed with diabetes by 2008

7.1Millions of Americans that are estimated to have undiagnosed

diabetes

5.4Millions of Americans of all ages that

will have Alzheimer’s in 2012, the sixth leading cause of death in the

U.S.

2.7Trillions of dollars that was estimated

as the U.S. national health expenditure in 2011

20

Percent of U.S. adults who meet the criteria for substance dependence or

abuse

10

Percent of Americans ages 12+ who are on antidepressant medication, the third most commonly prescribed drug

in the U.S.

THE American Patient

31

Percent of U.S. health expenditures that are attributed to hospital care

Percent of U.S. health expenditures that are attributed to physician or other clinical

services

20

Percent of adult Americans with private health care coverage as of 2010

60

75Billions of dollars spent total on health care in the U.S. in 1970

250Billions of dollars that were spent on prescription drugs, representing 12

percent of personal health care expenditures in 2009

356Dollars per person that was spent on

health care in the U.S. in 1970

8,402Dollars per person that is spent on

health care in the U.S. today

4,072Dollars per person that is spent on health care in the Germany today

Enacted under the American Recovery and Reinvestment Act of 2009 (ARRA), HITECH promotes adoption of interoperable electronic health records (EHRs) by health care providers through financial incentives under the Medicare or Medicaid EHR Incentive Programs, also known as “Meaningful Use.” This piece of legislation is designed to reward and accelerate the adoption of interoperable, certified electronic health records (CEHRT). Meaningful Use was launched on Jan. 1, 2011, bringing the carrots of incentive dollars to many providers and hospitals. The threat of sticks for non-adoption lurks as of 2015 through payment adjustments in Medicare provider reimbursement.

meaningful use

meaningful use

51.3

Percent of all physicians in the U.S. who report that they intend to pursue the Meaningful Use incentives under

Medicare or Medicaid

57.6

Percent of physicians under age 45 who plan to apply for Meaningful Use,

as opposed to only 44 percent of physicians ages 55+

3,662Eligible hospitals that have registered

for the CMS Medicare & Medicaid EHR Incentive Program

163,748Eligible professionals that have

registered for the CMS Medicare EHR Incentive Program

81,029Eligible Professionals that have

registered for the CMS Medicaid EHR Incentive Program

3.7Billions of dollars that has been paid to eligible hospitals for successful

attestation to Stage 1 Meaningful Use

995Millions of dollars that has been paid

to eligibile professionals for successful attestation to Stage 1 Meaningful Use under Medicare

11,588Family practice physicians that have

successfully attested to Stage 1 Meaningful Use under Medicare

meaningful use

10,597Internal medicine physicians that have

successfully attested to Stage 1 Meaningful Use under Medicare

3,884Cardiologists that have successfully attested to Stage 1 Meaningful Use

under Medicare

852Millions of dollars that have been paid to eligible professions for successful Stage

1 Meaningful Use under Medicaid

44States that have launced the Medicaid

EHR Incentive Program

30,204Physicians that have attested to adopt, implement or upgrade (AIU) certified

EHR technology under Medicaid

8,045Mid-level eligible professionals who

have attested to to year one AIU under Medicaid; this includes Nurse

Practitioners (6,812), Mid-wives (886) & Physician Assistants (347)

2,237Dentists that have attested to year one

AIU under Medicaid

215Eligible professionals that have successfully attested to Stage 1 Meaningful Use under Medicaid

7,859Hospitals & eligible professionals that

have attested under the CMS EHR Incentive Programs in Texas for a total

of $483,550,804 in incentive payments (highest performing state)

101Hospitals & eligible professionals that

have attested under the CMS EHR Incentive Programs in North Dakota for

a total of $2,307,325 in incentive payments (lowest performing state)

THE AFFORDABLE CARE ACT

In March 2010, President Obama signed the most substantial bill transforming the delivery of health care in the U.S. into law since creating Medicare and Medicaid – The Affordable Care Act (ACA). On June 28, 2012, the Supreme Court of the United States (SCOTUS) ruled that ACA, including its individual mandate that virtually every American must buy health insurance, is constitutional. Under §3007 of ACA, the government will be using quality and cost data to move from being a purchaser of health care services into a purchaser of value. Beginning in 2015, HHS must establish a payment modifier for value-based purchasing to physicians and physician groups. These differential payments will be delivered by HHS under a fee schedule based on quality as compared to cost. Quality will be based on a combination of measures such as outcomes, functional status, shared decision-making, use of health IT, timeliness and patient experience (many of the items required under NCQA’s patient-centered medical home model). Cost measures will include such items as socioeconomic and demographic characteristics (e.g. race, ethnicity, language, etc.) and patient health status. The big point to note is that matters of establishing quality, costs and the value-based payment modifier are to be done totally by HHS without being subject to administrative or judicial review.

2,409Number of pages contained in the

Patient Protection & Affordable Care Act of 2010

55Number of pages contained in the

Health Care & Education Reconciliation Act of 2010

8Number of pages contained in the Constitution of the United States

193Number of pages in the Supreme Court’s final opinion of the ACA

73Number of times Accountable Care Organization is mentioned in ACA

15Number of times the Medical Home is

mentioned in ACA

84Number of times Value-Based is

mentioned as it relates to reforming hospital & provider reimbursement

36Number of times

Patient-Centeredness is referenced in ACA

12Number of times Payment Modifier is referenced as it relates to physician reimbursement for Meicare Part B

Physician Fee Schedules

58Number of times Federally Qualified Health Centers (27), Rural Health Clinics (14) & Community Health

Centers (17) are referenced

29Number of times Quality Reporting is discussed as it relates to clinical data

THE AFFORDABLE CARE ACT

Number of states enjoining lawsuit against the Medicaid Expansion issue of the ACA

Number of Justices who heard Oral Arguments on ACA’s Individual Mandate & Medicaid Expansion issues

Number of Justices rendering the majority favorable decisions on the constitutionality of the ACA

Number of times the Supreme Court Opinion mentions broccoli

THE AFFORDABLE CARE ACT

Created under ACA, CMS began contracting with Accountable Care Organizations (ACOs) to provide services for a defined population of Medicare patients with two launch dates: April 1, 2012 and July 1, 2012. There are three ACO models: one with no risk, one with risk and one deemed a “Pioneer” model. Each ACO will need to be armed with technology tools such as EHR, HIE and Patient Portals as a foundation for achieving cost-effective and patient-centric quality of care. The rules governing assignment of Medicare beneficiaries, the 33 quality measures, eligibility considerations for FQHCs and RHCs, NCQA’s ACO recognition program, and the desired reformation being sought by CMS were released in final on Oct. 20, 2011. Since that date, not only has CMS has been moving forward with this innovative care delivery model, but the private industry has also joined the mix.

Accountable Care Organizations

Accountable Care Organizations

118Hospital-sponsored ACOs in 22 states (99 in Oct. 2011)

70Physician-sponsored

ACOs in 23 states (38 in Oct. 2011)

8Community-Based

Organization-sponsored in 4 states

29Health Plan-sponsored

ACOs in 22 states

148Single Provider ACOs - meaning typically an integrated delivery

system that receives risk-based reimbursement from the payer

32Pioneer ACOs contracted to the Centers for Medicare and Medicaid Innovation (CMMI) under the Affordable Care Act

27 Medicare Shared-Savings ACOs contracted to CMMI under the Affordable Care Act

5 Advanced Payment ACOs contracted to CMMI under the Affordable Care Act

Accountable Care Organizations

221Number of public & private ACOs in the U.S. 45

Number of states with an ACO

States without an ACO:Delaware, Idaho, Rhode Island, South Dakota,

West Virginia

States with only one ACO: Alaska, Arkansas, Hawaii, Kansas, Louisiana, Mississippi, Nevada, Oklahoma, South

Carolina, Utah, Virginia, Wyoming

Number of ACOs in California, the state

with the highest number of ACOs

25

States advancing the Medicaid ACO models: Colorado, Minnesota, New Jersey, Oregon, Utah

Patient-centered medical home

The patient-centered medical home (PCMH) is a care delivery model that partners a primary care provider to other teammates for a coordinated effort at managing patients, the goal being to deliver quality of care and value to the patient as a care team. The returns on improved patient quality, improved patient health and reduced costs of care are measurable. Because prevention, wellness and long-term healing not only promotes quality of care but saves money, both public and private payers are beginning to pay differentially to providers with PCMH recognition. There are four organizations that offer PCMH accreditation, certification, achievement or recognition, namely: The National Committee for Quality Assurance (NCQA), The Joint Commission, URAC and the Accreditation Association for Ambulatory Health Care.

Patient-centered medical home

75Of the 149 NCQA PCMH 2011 factors that

directly relate to improving patient engagement, population management & care

management for primary care providers

4 MillionBlue Cross Blue Shield members in 39

states across the country that are benefiting from care delivered through

BCBS PCMH initiative

176Organizations & locations that have

received Joint Commission accreditation & Primary Care Medical Home

certification

8States that are strengthening primary care through ACA Section 2703 for improved outcomes & lower costs

under Medicaid (AL, IA, KS, MD, MT, NE, TX, VA)

41States that have adopted policies &

programs to advance medical homes

8Federal agencies are engaged in

PCMH research, technical assistance, demonstrations & funding projects, including AHRQ, CMS, DOD, HRSA,

SMAHSA, NIH, NCI & VA

24,020Providers & clinic sites recognized for either the NCQA PPC PCMH or the NCQA PCMH

2011 programs in the U.S.

$2.26Amount per patient increase in operating

costs that is realized on average for delivering PCMH levels of care

$18Amount per patient per month that is saved on average through the PCMH from reduced emergency department

visits & hospitilizations

Patient-centered medical home

10Percent of a given population on average that drives 60-70 percent of the total health care costs for that population

72Millions of obese adults in the U.S., representing one-third of the population; for U.S. children, 17 percent are obese

147Billions of dollars spent in the U.S. on overall medical care costs due to obesity

26Millions of people in the U.S. with

diabetes

79Millions of people in the U.S. with

pre-diabetes

174Billions of dollars spent in the U.S. directly or indirectly on costs related to diabetes

44Number of Type 2 diabetes cases per 1,000 patients that can be delayed with

early intervention & prediabetes screening over

a period of 3 years

5,455Dollars more that are spent per patient per year to care for the health of a smoker as compared to a non-smoker

443,000Americans who die eachyear because of smoking

or exposure to secondhand smoke

48.3Percent of smokers who quit in the past year after being advised to do so by

a physician

electronic Health Record Adoption & Health information Exchange

HIPAA privacy, Security & Breach NotificationPriority Primary Care Providers

Community Health CentersB.R.I.E.F SURVEY RESULTS

CITATIONS

Stay Tuned for Part Two