What’s Next for Health Care? Understanding the current state to get to the future state Julie...
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Transcript of What’s Next for Health Care? Understanding the current state to get to the future state Julie...
What’s Next for Health Care? Understanding the current
state to get to the future state
Julie LewisDirector for Health Policy
The Dartmouth Institute for Health Policy & Clinical Practice
Presented to the Concord Coalition
May 28, 2009
What does health care in the US currently look like?
Healthcare is in Crisis Unsustainable Growth in Spending
Pay for Volume, not Value Little to No Accountability for Quality or Cost
Gaps & Variances in Care Poor Chronic Disease Management Lack of Care Coordination Disparities by Race and Ethnicity
Increasing Uninsured & Underinsured Lack of Information
Effectiveness of Treatments Comparative Effectiveness Public Information on Provider Cost and Quality
The Numbers US healthcare costs in excess of $2.5 trillion Recent CBO report suggests waste = $700B/year Patients, on average, receive recommended health
care only 55 percent of the time (McGlynn et al. 2003)
Per
cent
of G
DP
Cost: Over half of cost growth in federal spending will be attributed to per capita cost growth
Allocation of Projected Growth in Federal Spending on Medicare and Medicaid by SourceSource: Economic and Budget Issue Brief: Accounting for Sources of Projected Growth in Federal Spending on Medicare and Medicaid. A series of issue summaries from the Congressional Budget Office. May 28, 2008
Cost: U.S. Health Expenditures and Workers’ Earnings, 2000–2008
0
25
50
75
100
125
2000 2001 2002 2003 2004 2005 2006 2007* 2008*
Net cost of private health insurance administration
Private insurance net of administraion
Out-of-pocket spending
Workers’ earnings
106%
75%
29%
Per
cen
t
47%
Three fold variation in per capita spending
Peter Orszag, N Engl J Med, 2007
Spending and resource usechronically ill, last 6 months of life
Total Medicare spending 50,522 40,181 26,330
Physician visits 52.1 42.2 23.9
Hospital days 19.2 17.7 12.9
UCLA MedicalCenter
Massachusetts General Hospital
Mayo Clinic (St. Mary's Hospital)
End-of-Life SpendingVariation at Major US Medical Centers
Where is the variation?
More Care in High Spending Regions
Less Care in High Spending Regions
Examples:Mammogram, Women 65-69 Pap Smear, Women 65+Pneumococcal Immunization Aspirin at admission (Heart attack)
Evidence-Based Quality
Higher healthcare spending is not associated with better quality
Source: Baicker et al. Health Affairs web exclusives, October 7, 2004
Where is the variation?
More Care in High Spending Regions
Less Care in High Spending Regions
Examples:Total Hip Replacement Total Knee ReplacementBack Surgery CABG Following Heart Attack
Evidence-Based Quality
Preference Sensitive Care
Variation in preference sensitive care exists within ALL regions rather than between regions
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Q1 Q2 Q3 Q4 Q5
Rate of Coronary Artery Bypass
Graft SurgeryAge-sex-race adjusted, 2001
Rate
per
10
00
Enro
llees
HRRs by Spending Quintile
Each red dot represents a Hospital Referral Region (HRR)
Where is the variation?
More Care in High Spending Regions
Less Care in High Spending Regions
Examples:Total Inpatient Days/ICU Days Diagnostic TestsEvaluation and Management (visits) Imaging
Evidence-Based Quality
Preference Sensitive Care
Supply Sensitive Care
What do higher spending regions get?
(1) Fisher et al. Ann Intern Med: 2003; 138: 273-298 (2) Baicker et al. Health Affairs web exclusives, October 7, 2004(3) Fisher et al. Health Affairs, web exclusives, Nov 16, 2005(4) Skinner et al. Health Affairs web exclusives, Feb 7, 2006(5) Sirovich et al Ann Intern Med: 2006; 144: 641-649(6) Fowler et al. JAMA: 299: 2406-2412
What’s going on? Research on causes of regional variations
What might be going on?Research on causes of regional variations
Source: Sirovich et al. Health Affairs. May/June 2008
What about Iowa?
Per Capita Medicare Reimbursements(Part A & B, 2006)
Iowa$6,572/beneficiary
Dolla
rs
States
Per Capita Medicare Reimbursements(Part A & B, 2006)
Dubuque$7,859/beneficiary
Dolla
rs
Hospital Referral Region
Iowa City$6,045/beneficiary
Total Medicare reimbursements per enrollee (Part A and B)
Area Population RatesSurplus/Deficit
*Marshalltown , IA 7,611 4169 -
Dubuque , IA 11,082 7586 37,863,403
Mason City , IA 15,814 7495 52,587,171
Clinton , IA 8,196 7086 23,900,376
Davenport , IA 18,135 7041 52,070,779
Waterloo , IA 13,903 7031 39,787,086
Fort Dodge , IA 7,394 6913 20,285,509
Sioux City , IA 15,666 6796 41,150,195
Burlington , IA 8,470 6771 22,037,085
Des Moines , IA 52,517 6412 117,787,060
Ames , IA 7,653 6200 15,539,730
Cedar Rapids , IA 28,327 5999 51,834,360
Ottumwa , IA 5,094 5874 8,680,673
Council Bluffs , IA 9,919 5769 15,866,515
Iowa City , IA 14,041 5605 20,154,443
What if….If per capita Medicare spending in Iowa was at the Marshalltown level?
Saving for…- Just Medicare- Just for Part A & B- Just 2006
Would have been:
$520 Million
Standardized PricesTotal Medicare Expenditures (Part A & B)
National Average
Standardized Prices Inpatient Short Stays
National Average
Standardized Prices Hospice Services
National Average
Standardized Prices Outpatient Services
National Average
Annual Growth Rates of per Capita Medicare Spending
Source: Slowing the Growth of Health Care Spending: Lessons from Regional VariationFisher, Skinner, Bynum, New England Journal of Medicine, February 26, 2009
Dubuque……………..5.2%Sioux City……………4.9%Waterloo……………..4.2%Des Moines………….4.0%Davenport……………3.5%Cedar Rapids………..3.5%Iowa City……………..2.8%
Where are we trying to go?
Focus of Measurably Improving
Health
Better Evidence to
Reduce Gray Areas
Engaged Patients, Informed Choice
The Right Workforce to Lead the
Change
Organizational
Accountability for
Capacity, Cost, and Quality
Meaningful Measures of
System Performance
Rewarding Value, Not
Volume
Principles for
Reform
Focus of Measurably Improving
Health
Engaged Patients, Informed Choice
The Right Workforce to Lead the
Change
Organizational
Accountability for
Capacity, Cost, and Quality
Meaningful Measures of
System Performance
Rewarding Value, Not
Volume