The Business of Health Care:A Persistent Search for ValuePresentation to Health Management Conference

International Foundation of Employee Benefit Plans

August 8, 2005

Merton D. Finkler, Ph.DLawrence University

Overview of Presentation

Introduction: Business Models and Markets Health Care Spending Growth: Character and

Distribution Key Contracts and Risk Sharing Decisions

Recent Marketplace History Choices for Purchasers The Search for Value

Business Model Components Objectives

Mission – Where value will be added Benchmarks – Performance comparisons to be made Ethics - Appropriate Behavior

How will objectives be achieved? Core Competencies Target Sources of Revenue Choosing an Efficient Cost Structure

Implementation strategies Short Term and Long Term Options To Overcome Barriers and Rent-Seeking Opposition

Three Challenging Questions:Three Affirmative Responses Is the Term “U.S. Health Care System”

an Oxymoron? Are There Toyotas in Health Care? Does “Moneyball” Apply to Health

Care?

Is the Term “U.S. Health Care System” an Oxymoron? J. D. Kleinke (2001) thinks so.

“Health care in America combines the tortured, politicized complexity of the U.S. tax code with a cacophony of intractable political, cultural, and religious debates about personal rights and responsibilities.”

Central reality: “the primary producers and consumers of medical care are uniquely, stubbornly self-serving as they chew through vast sums of other people’s money.”

Are There Toyotas in Health Care?Yes, But They Aren’t Easily Replicated Toyotas symbolize both high quality and good value. Molly Coye (HA 2001) notes that “Toyotas” will not

exist in health care until the payment structure is changed to reward production of “Toyotas”.

“Industrial strength quality in health care” requires both an example of such quality and business incentives to yield it.

Localized examples exist: LA, SF, Seattle, MPLS-SP Comprehensive, integrated, cost-effective care is not

easily transferable across markets, the way cars are.

Does “Moneyball” Apply to Health Care? Yes, If Buyers Desire Cost-Effective Care Michael Lewis (2003) argues that baseball

GMs can field winning teams by using measurement and predictive modeling to determine which players to sign with a limited budget.

Measurement and predictive modeling are also essential to determine which health care components and practitioners can be combined to yield the best health outcomes given limited budgets.

Key Players: Wide Variation in Scope, Degree of Integration, & Geographic Context Health plans – wide array of benefits and variation in

provider network scope Physicians – solo practice, single specialty groups,

multi-specialty groups, groups linked with hospitals, core of integrated healthcare

Hospitals – individual and system members; various ownership structures

Pharmaceuticals – similar to manufacturers In contrast w/ other components, no local barriers exist Not address, for the most part

Degree of Integration of Providers Varies Greatly Across Markets Full integration: Hospitals, MDs, and Insurance in one

package: Kaiser Permanente has all 3 components available locally and a common incentive structure

Partial integration: Physician/Hospital alliances Detroit, Henry Ford System Twin Cities, Allina and Health Partners Milwaukee, Aurora Healthcare St. Louis, Washington University.

Non integrated. Most common, insurers contract with all health care providers – especially where Blue Cross/Blue Shield, Wellpoint, United Healthcare, and Aetna play a major role.

Geographic Orientation Health Plans – local, regional, and national

1990s managed care – many local and regional players; post 2000, consolidated nationals rise

Consumer directed – national players Physician Groups – mostly local, some regional

Multiple and single specialty local groups National PPMC movement rose and fell in the 1990s Special case: travel to Mayo or Cleveland Clinics

Hospitals – mostly local and regional Local and regional systems are commonplace

Many have a religious orientation Tertiary component in regional systems

National chains influence diminished in last 10 years

Health Care Expenditures: A Few Recent Facts HC$ = (price/service) x (services/person) x (people served) 1990 – 2001 growth accounting breakdown

33% - general inflation 22% - medical price rises above inflation rate 16% - population/ demographic change 29% - intensity of service

Growth in inflation-adjusted HC$ per person driven by new technology and services per person Average - 3.6% per year since 1960 but not smooth

Not Unique to the US (1960 -2002) US HC$ growth = GDP growth + 2.7% Other G6 countries HC$ growth = GDP growth + 2.0%

Growth in the Cost of Health Care

The 80 – 20 Rule is not far off

10% of people70% of cost

10% of the Population Accounts for 69% of Health Care Expenses

Which Cost of Healthcare Matters? It Depends Whom You Ask. Premium only (insurance component) Payments to the health care sector

Third party payments Out of pocket expenses Forgone tax revenues

(estimated at $188 B per year by Lewin) Total Burden of Illness

Direct outlays for medical care Foregone output – absenteeism and

presenteeism

Health Premium Increases and Per Capita Health Cost Growth 1999-2003

Health Insurance Premium Increases vs. CPI and Wage Growth 1988-2004

Wage Share of Labor Compensation Has Declined Steadily Since 1968

Labor bears the burden of increased health care expenditures.

The Burden of Illness for Those with Chronic Disease – The Largest Opportunity

Working age pop. with chronic disease generates expenses 3 x non-chronic pop.

Those w/ chronic conditions account for 17% of population but 83% of health care $

Burden of illness includes both outlays for medical services and lost productivity

Ave. impairment 2 to 11 days / 30 workdays Total burden – over $1 trillion per year Sources: CDC and R. Kessler (Harvard)

The Burden of Unhealthy Workers Varies Greatly Across Employers

2 4 © 2 0 0 0

S u m o f m e d i a n 1 9 9 8 H P M c o s t s a c r o s s p r o g r a m s w a s$ 9 , 9 9 2 p e r e l i g i b l e e m p l o y e e

B e s t p r a c t i c e ( 2 5 t h p e r c e n t i l e ) – 2 6 % H P M c o s t s a v i n g s

W o r k e r s ’ C o m p

$ 3 1 03 %

G r o u p H e a l t h$ 4 , 6 6 6

4 7 %

N o n -O c c u p a t i o n

D i s a b i l i t y$ 5 1 3

5 %

T u r n o v e r$ 3 , 6 9 3

3 7 %U n s c h e d u l e d

A b s e n c e$ 8 1 0

8 %

T h e M E D S T A T G r o u p

It’s All About Contracts and Risk Sharing Decisions Labor/Management Contract: Firm manages health benefits or

shifts burden to employees Company/Health Plan Contracts: Health plan defines benefit

plan design/scope as well as provider network breadth

Provider/Health Plan Contracts: Prepaid (capitation or salary) or Fee-for-Service Fee schedules, discounts, and payment tiers are commonplace

RX/HealthPlan: tiers (typically 3), formularies, & discounts Few plans relate to value or benefit of intervention Variety of incentives for rebates and substitution

Direct Contract: Skip health plan but not risk bearing

Good Contracts Make Good Relationships You get what you pay for :

More choice of provider, costs more If procedures are rewarded, pay twice for errors

1/3 of Medicare expenditures are wastefully spent Louisiana ranks first in Medicare $, last in quality

Improved outcomes (pay for performance) Short term incentives differ from long term ones Coverage of primary and secondary prevention Payment related to place of service and access

ambulatory versus inpatient coverage ER coverage vs. clinic (timely access? 24/7)

What Role does Market Competition Play? It Depends on how Choices are Structured How frequently are choices made? Are long

term partnerships developed? How many health plans are offered?

How much do provider networks overlap? What incentives exist in the payment structure?

Are insurance brokers or benefit consultants used? How are they paid?

Is direct contracting with providers a constructive option? Who does the risk-bearing?

Health Plan Objectives and Tradeoffs

Market geographic scope and share Short run cash flow Long run profit Mission – varies with degree of integration

with health care provider Role of insurance cycle – bounce between

market share and profits as primary objective Before 1990 – alternate three years of loss

with three years of profit Since 1990 – now closer to six years

Health Care Provider (MDs and Hospitals) Objectives and Tradeoffs Target income or profit Desired effort level Reputation sought Market share desired Geographic influence sought Profit and other missions No margin, No mission yields “not only for

profit” business objective

Market Competition – Mid 1990sManaged Care’s Influence Peaks Strong cost containment incentives for

providers (but not for consumers) Narrow networks compete; reduced provider

market power results Competition among insurers – desire to

increase market share – constrains premia Optimism based on competing integrated

delivery systems and prepaid care (risks totally shifted to provider community)

Managed Care Unwinds 1997 - 2003

Health care inflation returns to double digits Financial incentives weaken for all Networks broaden in response to consumer

demand and tight labor markets Reversal of integration of delivery systems Specialists consolidate Hospitals consolidate Health plans consolidate Insurance profits rise to replenish coffers

Present Trends Increased patient cost sharing marketed as

consumer directed health care Initial coverage and large deductible Reduced dependent coverage

Tax incentives for high deductible policies Development of “pay for performance” schemes Tiered payment for providers and pharmaceuticals

(65% of workers - HRET Survey-2004) Improved information technology for health care

management & consumer purchasing – National Health Information Network Program (est. $200B)

Cost Containment: Purchaser Choices

Target/control specific health care components Seek increased efficiency of the delivery system

(supply management) Emphasize primary and secondary prevention Provide financial incentives for patients to reduce

their use of medical services (demand management) Implement administrative controls on the use of

services Increase bargaining power by joining purchasing

coalitions

Demographics Complicate Choices

Those aged 45 – 64 spend roughly twice the amount spent per person per year by those 18 - 44

Chronic Disease Prevalence Rises More than Proportionately with Age

Medical Expenditures Panel Survey 2001

Target Components: The Whack a Mole Response to Containing Costs Benefit redesign:

Target fastest growing component (e.g., ER , RX) Cost Accountant’s Revenge

If incentives slow the fastest growing component, a new fastest grower emerges

Substitution is inevitable & may be less efficient (i.e., more costly or less effective)

To avoid substitution, target total expenditures Beware direct and indirect long term consequences If total $ fixed, how are priorities set and resources

allocated?

Identify Efficient Use of Resources Identify and discourage high cost, low value services

– use evidence-based medicine (EBM) Decrease chance of expensive adverse events for

those with chronic illness – disease management Decrease the risk profile of population – primary

prevention Decrease bargaining power of healthcare providers –

anti-trust and purchasing coalitions Pay for good performance – compatible incentives All options require strong, committed leadership at

various levels since resources must be reallocated

Implement Primary and Secondary Prevention Strategies Screen enrollees to determine risk levels Offer incentives to sustain low risk Provide performance-based disease

management to contain moderate and high risk by reducing chance of adverse event

Educate enrollees to best manage chronic disease

Reduced Risk Means Reduced Cost

Dee Edington

Prevention Also Requires Sacrifice Payment comes before savings

Prevention not worthwhile w/ annual enrollment switching

Each program has a different payback period Serious wellness programs require 3-4 years

Each population faces a different set of risks Target prevalent risks in your population

Compliance (medical community and patient/consumers) requires both education and compatible incentives

Use Consumer Directed Health Care -Incentives for Patients to Economize Health Savings Accounts

Response to OPM disease Large deductible – low premium insurance Increased cost sharing – consumer’s decide Various amounts of information provided to

improve decision-making Tax subsidies with MMA 2003 High deductible plans offered by 10% of firms

(2004) - 27% of firms at least somewhat likely to offer by 2006 (HRET Survey)

Concerns about Consumer Directed Health Care (CDHC) Attractive to young & healthy thus potential

adverse selection if enrollees choose plans If one CDHC plan, tradeoffs worsen for those

w/ chronic disease until they reach deductible Focuses on 50% who spend 3% of total $ Money taken out of the general pool and

given to individuals (e.g., $500 per employee) Consumers don’t easily distinguish between

cost-effective and cost-ineffective services

Use Administrative Rules / Managed Care – “Divide and Contract” PPO, POS, and HMOs – Selectively contract

Deliver volume to a subset of providers in exchange for discounted price

Utilization controls of various sorts Various degrees of prevention offered Large number of structures – integrated or contracted Given variety, hard to generalize – read the fine print

HMOs often feature fixed payment to providers, limited choice of provider, and directed practice

Offered good coverage for prevention Kept $ growth low in the mid-1990s Wide variation in ability to deliver quality care

The Backlash Against Managed Care

Rejected by those who wanted more choice –if paid for by entire insurance pool (return to OPM)

Tight labor markets forced firms to weaken controls in order to attract and retain laborers

Increased purchaser bargaining power induced providers to consolidate Hospital systems evolved Physician group practice thrived – no longer a

cottage industry

Use Purchasing Coalitions to Increase Purchaser Bargaining Power Insurance load factor falls from 40% to 6% (10k covered lives) HIPCs – some state sanctioned

Problem: agreement on common benefit package & strategy Two key survivors:

Pacific Business Group on Health Patients’ Choice

Effects of ‘divide and contract’ Some providers lose (and rebel) Some players (providers and employers) drop out

Association Health Plans – Proposed current legislation Exemption from state mandates for cross state plans Problem: local delivery and variety of benefit preferences Potential administrative nightmare for medical practitioners

Other sessions focus on this topic

Seek Value – Quality/$ spentWide variation exists across markets NEJOM/Rand report indicates (2004)

Participants received only 55% of recommended care Both under-use and over-use are commonplace

IOM report on the Quality Chasm (2001) Between 44,000 and 98,000 die from mistakes in

hospitals Cost of preventable mistakes - up to $29B

MBGH report estimates the cost of poor quality as 30% of direct health care cost - $1,350 per person Indirect costs estimated at $350 per person

Ideally, reduce unnecessary hospital admissions Ambulatory Care Sensitive Conditions

Medicare Spending per Beneficiary vs. Quality of Care Ranking (2001)

CMS, Dartmouth College, and the Washington Post

Poor Care Coordination Leads to Unnecessary Hospitalizations

Johns Hopkins University, Partnership for Solutions

Value-Based Purchasing and Pay for Performance (P4P) Reward evidence-based “best practice”

–Caveat Emptor! Competing definitions (EBM) – See HA J/F 2005 –

guidelines or standards determination Process or outcome – which indicators are valid? Apples to apples requires risk adjustment “Your complications are my costs”

Numerous implementation barriers exist Funding required to construct IT infrastructure Key providers may not cooperate Employers may not back with appropriate incentives

Pay-for-Performance Demonstrations

Rewarding ResultsDemonstration Sites Unit of A/C Geographic

Region

BCBS of Michigan Hospitals Michigan

Blue Cross of California Individual MDs SF Bay Area

Bridges to Excellence Individual & Group MDs

Cincinnati, Louisville, Boston, Albany

Excellus/ Rochester IPA Individual MDs Rochester, NY

P4P - Integrated HC Association Group Practices California

Center for Health Care Strategies Individual & Group MDs California

Mass. Health Quality Partners Group Practices Massachusetts

Young et al., Overview of P4P, 2005

Four majors programs

Leapfrog – Targeted attempts to improve patient safety in the hospital (2000)

Medicare under Mark McClellan (MD, Ph.D)

Bridges to Excellence – a structured response to the Quality Chasm

Pennsylvania infection control initiative

The Leapfrog Initiative Purposes:

Consolidate purchaser voice Engage consumers and practitioners in QI –reduce preventable

hospital deaths Policy: Use EBM to identify 3 safety leaps

Computerized MD order entry (CPOE) ICU staffing with “MD intensivists” High volume hospital referrals

Implementation – incentive and reward toolkit Results:

Limited hospital participation so far Few purchasers make indicators part of P4P Business case for adaptation of 3 leaps not yet accepted Reward structure still modest Leapfrog has changed focus from employer to health plan

Leapfrog is catalyst, but employers must decide to take the “leap”

Medicare Variation in Cost and Quality Spending per beneficiary varies by a factor of 3 across counties,

even after adjusting for age, sex, practice costs, and case-mix Medicare spent more than twice as much per patient in Miami as in

Minneapolis yet risk adjusted quality better in MPLS

Quality of care, based on 24 measures established by CMS also shows significant variation

Dr. McClellan – strong advocate for P4P demonstrations Proposed 1 to 2% performance bonuses but will it withhold money from low

quality providers? Not likely, politics won’t allow it. Demonstration projects seek to change compensation system from one

based on services provided to one based on health outcomes

“Real markets have ‘losers.’ Without them, it is difficult to achieve much efficiency. In a political system,

losers, potential losers, and even those who fell that they might someday be losers, often seek redress from their elected officials.” – Cooper and Vladeck

Bridges to Excellence: Rewarding Quality Across the Healthcare System Seek STEEEP care – Safe, Timely, Effective,

Efficient, Equitable, and Patient-centered Care Group of stakeholders (including CMS, NCQA, large

firms, health insurers, PBGH, and Leapfrog) reached consensus on how incentives might be used to Reengineer care processes to reduce mistakes Reduce misuse, overuse, and under-use Increase accountability through release of comparative provider

performance data

Initial results for AMI, health failure, and pneumonia are encouraging

Pennsylvania Hospital Infection Reporting

Hospitals must report all infections to Pennsylvania Health Care Cost Containment Commission (PHC4) – starting in 2006

Vast under-reporting: Only 12,000 cases reported but 120,000 cases billed for

Estimated cost -$125M+ -Medicaid; $1B+ - private insurers (PA) Hospital responses:

Look at processes not outcomes Let providers fix it Don’t scare the public

PHC4 responses: “If you bill for it… you ought to be accountable for it.” Pittsburgh initiative – 84% reduction in infections from one

major source; 95% reduction in deaths from this source

Which Business Strategy for Employers? Health care – a component of the cost of

labor - manage it Health care – a consumer responsibility –

shift it Health and productivity management – treat it

as central to business mission Some combination

Suggested Guidelines for Purchasing Value Focus on the total burden of illness, not

component cost control

Develop and nurture long term coordination among patients, providers, and payers

Identify health risk factors and choose health programs and benefit designs to reduce them

Guidelines Continued Invest in the information (including evidence-

based guidelines) and communication infrastructure for prevention

Provide incentives for enrollees, providers, and payers to reward performance consistent with reduced risks and illness burdens

Choose persuasive leaders who seek value from health services & human capital

One Solution: Value + Choice Find value and support it. Make a fixed contribution to a flexible spending

account Provide at least 2 health plan options

A focused narrow network that encourages prevention and chronic disease management (Consistent with HPM focus)

Health savings account with high deductible and wide choice of health care provider

(Consistent with consumer responsibility approach)

Pacific Business Group on Health Begun in 1989 – 50 large purchasers with 3 million covered

lives Added CA legislated small employer purchasing pool (1999) Three targets

Value-Based Purchasing Quality Measurement and Improvement Consumer Engagement

Active participant in Consumer-Purchaser Disclosure Project –”sunlight is the best disinfectant” Existent report cards have flaws and limited use 2007 objective: publicly report, standardized comparative

information on providers www.healthscope.org – quality ratings for hospitals, medical

groups, and health plans

Business Health Care Action Group (BHCAG) and Patient Choice Components

Direct contracts with distinct, competing care systems Risk-adjusted provider bids to contracting authority Consumer incentives to make price and quality

conscious choices Result 1: In the Twin Cities, it is possible to use

competition to achieve pay for performance Result 2: Despite attempts to try elsewhere, Patient

Choice has been successfully transplanted to other MSAs (attempts in Boston, Des Moines, Denver, St. Louis, Portland, Milwaukee, and Sioux Falls SD)