Making Cent$ of Health Care Costs

Transcription

1 Making Cent$ of Health Care Costs Bob Morrow, MD, MBA Market President, Houston & Southeast Texas Blue Cross and Blue Shield of Texas A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

2 INTEGRITY RESPECT COMMITMENT CARING OUR PURPOSE To do everything in our power to stand with our members in sickness and in health

3 Agenda - Growing health care costs - Challenges for members and employers - Creating solutions 3

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5 State of U.S. Health Care Average: 10.4% Percentage of GDP Spent on Health Care Source: 2014 International Profiles of Health Care Systems. The Commonwealth Fund. January

6 Health Care Spending

7 After Adjusting for Wealth

8 The Premium Dollar 8

9 U.S. Health Care expenses 50% 45% Personal Health Care by Category (Source of Expense) % 35% 30% 25% 20% 15% 10% 5% 0% Hospital Care Physician and Clinical Services Prescription Drugs Other Health Care Source: Centers for Medicare & Medicaid Services, National Health Expenditures, 2014 release. CCF InfoGraphic Data 9

10 Factors Impacting Cost of Care 10

11 Source: Center for Managing Chronic Disease, University of Michigan

12 Many costs are driven by behavior Obesity 25% of all Americans got NO exercise in the last month Diabetes A non compliant diabetic costs $11,000 more per year than a compliant one Smoking $170 Billion per year 12

13 But the US is not as sick as Europe

14 Drug picture

15 Source: PwC Health Research Institute, Medical cost trend: Behind the numbers 2015, June 2014, analysis based on data from CVS Caremark

16 OECD Expenditure on Pharmaceuticals

17 Specialty vs. Traditional Drug Spend

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19 The Impact of Hospital Consolidation Robert Wood Johnson Foundation Study Key Findings: Hospital consolidation generally results in higher prices Hospital competition improves quality of care Physician-hospital consolidation has not led to either improved quality or reduced costs

20 Are these ERs or Urgent Care Centers? The answer matters. 20

21 Explosion of Free-Standing ERs 50% 75% 10X of the USA s Free-standing ERs are in Texas Overlap in services between FSEDs and UCC Service Costs are 10X that of Urgent Care

22 Where You Go Matters Top 10 Dx Average Cost to Treat (per claim) Diagnosis Hospital ER Freestanding ER Urgent Care Clinic Retail Clinic Headache $2,214 $2,472 $170 $80 Urinary Tract Infection, Site $1,987 $1,579 $151 $66 Other and unspecified, Site $2,527 $2,729 $158 $77 Acute Bronchitis $1,298 $1,611 $175 $77 Acute Upper Respiratory Infection $872 $1,127 $162 $82 Dizziness and Giddiness $2,696 $3,026 $167 $70 Acute Pharyngitis $888 $1,331 $166 $86 Nausea with Vomiting $2,257 $2,126 $169 $77 Unspecified Essential Hypertension $1,872 $2,024 $142 $63 Lumbago $1,482 $1,814 $159 $66 22

23 Increase in Free-Standing ERs Data shows

24 FSERs are Located in Affluent Areas 24

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27 Shopping for Health Care Source: Blue Cross and Blue Shield Association 27

28 Transparency Tools: Cost Estimator 29

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30 Patient Engagement is Necessary 31

31 Incentives are necessary 32

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33 Redefining Value in Health Care QUALITY VALUE Achieve better outcomes Increase safety Improve satisfaction COST Reduce avoidable medical spending Decrease total cost of care 34

34 Value Creation in New Models Continuum of Payment Models Fee-for- Service Pay for Performance Bridges to Excellence Our Medical Home Approaches: EMH & IMH Episodes of Care Accountable Care Organization HMO Global Payment Provider Accountability (cost & quality) 35

35 ACOINO 36

36 Beware of ACOs in Name Only Hospital A $2,000 per member per year; Attracts 500 XYZ employees Total costs = $2,000 x 500 = $1 M Hospital B $1,000 per member per year; Attracts 500 XYZ employees Total costs = $1,000 x 500 = $0.5 M New ACO to cut 10% costs Total Cost $1.5M $1,800 per member per year; Attracts 800 members $1.64M $1,000 per member per year; Attracts 200 XYZ employees Total costs = $1,800 x 800 = $1.44 M Total costs = $1,000 x 200 = $0.2 M

37 Zooming in on an individual physician provides insight into who that physician connects with and how the efficiency of their connections impacts their efficiency Node Color Efficiency Percentile High 75% - 100% Med-High 50% - 75% Med-Low 25% - 50% Low 0% - 25% 38

38 Our Accountable Care Organizations Midland Integrated ACO* El Paso National ICN, Inc. (Tenet) Lubbock Covenant Health Partners* Dallas/Ft. Worth Catalyst Health Network National ICN, Inc. (Tenet) Patient Physician Network Holding Company LLC.* Premier PHC Physician Group, Inc.* Texas Health Resources (THR) TXCIN USMD Physician Services* Kerrville Hill Country Accountable Care Organization, LLC* San Antonio Christus Connected Care Network* Integrated ACO* National ICN, Inc. (Tenet) RGV ACO Health Providers, LLC* UPSA ACO, LLC Laredo Seven Flags ACO LLC* Rio Grande Valley Austin Austin ARIA Integrated ACO* Southwest Provider Accountable Care National ICN, Inc. (Tenet) Osler Medical Group ACO, LLC* RGV ACO Health Providers, LLC* Valley Organized Physicians, LLC* East Texas Christus Connected Care Network* East Texas Regional Accountable Care Collaborative, LLC Houston Houston Regional Accountable Care Organization, LLC Memorial Hermann Accountable Care Organization National ICN, Inc. (Tenet) Platinum Physician Associates PracticeEdge Alliance ACO LLC. Renaissance Physician Organization Village Practice Management The University of Texas Medical Branch at Galveston* * Denotes new ACOs 39

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40 Key Takeaways Health care costs are growing, and we must work together to keep health care affordable. Employers and consumers carry the weight of a heavy portion of health care costs. Creative solutions include increasing cost transparency and moving toward fee-forvalue reimbursement. 41

41 Thank You 43