THE PATH TO AFFORDABLE HEALTHCARE MYLIA CHRISTENSEN CHIEF OPERATING OFFICER HEALTHINSIGHT AffordHC18 AffordableCareTogether 1
The path to affordable healthcare Role of regional collaboration Mylia Christensen Chief Operating Officer HealthInsight Chair of NRHI Affordability Committee 2 2018
Affordability Advisory Group Members Ana English Cindy Munn Jerry Reeves Julie Sonier Karen Feinstein Louise Probst Nancy Giunto Sara Medley Chris Queram Robert Ferguson Sara Bolton Meredith Roberts Tomasi David Puelle (Puelle Design) Ellen Gagnon Jolie Ritzo 3
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We have an unsustainable problem. Harder choices are coming. Health spending as a share of U.S. GDP, 1963 to 2023 - selected years 13.4% 15.4% 17.4% 19.3% 10.1% 5.4% 7.2% 1963 1973 1983 1993 2003 2013* 2023P *2013 figure reflects a 3.1% increase in gross domestic product (GDP) and a 3.6% increase in national health spending over the prior year. See page 27 for a comparison of economic growth and health spending growth. Notes: Health spending refers to national health expenditures. Projections shown as P. Source: National Health Expenditure Data, Centers for Medicare & Medicaid Services (CMS), 2014 (historical) and 2015 (projections), www.cms.gov. 2015 CALIFORNIA HEALTHCARE FOUNDATION 5
We have an unsustainable problem. Harder choices are coming. Between 2006 to 2016 premiums are up 77% 2006 2016 Healthcare costs will consume half of household income by 2021 2021 Premiums and out-of-pocket expenses Household income Source: Henry J Kaiser Family Foundation, September 19, 2017. Premiums and Worker Contributions Among Workers Covered by Employer Sponsored Coverage. https://www.kff.org/interactive/premiums-and-worker-contributions/ Source: Young RA, DeVoe JE. Who Will Have Health Insurance in the Future? An Updated Projection. Am Fam Med 2012; 10(2): 156-162. PMCID: PMC3315130. 6
Percent change in middle income households spending on basic needs (2007-2014). Healthcare 24.8% -3.6-6.0-6.3-6.4-7.6 Food at home Housing Total Transportation Total food -13.4 Food away from home -18.8 Clothing -20-15 -10-5 0 5 10 15 20 25 Source: Brookings Institution, Wall Street Journal 7
Medicaid crowds out education. Source: National Association of State Budgets Officers 8
Understanding the problem
We ALL created this problem. We ALL need to be part of the solution. Patients Payers Providers Purchasers Policymakers 10
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The major drivers of affordability. Solving one issue in isolation does not achieve the goal. 12
Addressing the drivers of affordability has systemic benefits in addition to the positive economic impact. + HEALTH Healthier populations: use fewer resources increase productivity enhance communities - WASTE Unnecessary clinical procedures: increase clinical harm cause emotional distress incur financial harm Administrative burden: increases cost is burning out providers - PRICE High prices: don t correlate with quality incentivize waste misallocate resources 13
What would it take to fix all this? Transparency Data & Information Aligning Incentives Community Engagement Collaboration Across Sectors New Payment Models Informed Consumers Who could do all this? 14
There is hope. Patients Payers Providers Purchasers Policymakers In many regions across the country we are coming together to untangle complexities and find a path to affordability. 15
So, what are we doing about it?
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Health Summary Using SDoH data to reduce ambulatory caresensitive hospitalizations Combined SDoH (e.g., insurance type, race/ethnicity, language preference, education, household income) with clinical data for increased care coordination and improved primary care. Linking social determinants of health and utilization Outcomes: Hospitalization rates decreased by 106 more per 100,000 adults than they did in comparative counties 5,764 hospitalizations for ambulatory care-sensitive conditions were averted between 2009-2014 Graph source: Health Affairs, Association Of A Regional Health Improvement Collaborative With Ambulatory Care Sensitive Hospitalizations, February 2018 18
Health Summary Route 66 Accountable Health Community Leverages technology to address gaps in clinical services and health-related social needs of Medicare and Medicaid beneficiaries. Program screens for five SDoH with patients - food, shelter, transportation, domestic violence, & public utility access Power of interoperability Program documents measures and integrates information into HIE and provider EHRs Testing positive for SDoH measures triggers program to coordinate services and inform clinical sites as to whether those services were delivered Program went live May 1, 2018 outcomes to be determined 19
Health Summary Care coordination/medical Neighborhoods Creating medical neighborhoods for increased care coordination lead to improved health. Data sharing to improve whole person health Improved referral pattern allowed for EDs to identify primary care providers for highutilizers Reduced variation across systems; enabled adopting/spreading best practices Tracked patient history to avoid duplication of services and error 20
Health Summary Improving end-of-life care NJHCQI developed a plan that shares tactical solutions to improve end-of-life care for New Jersey adults. This plan was developed in response to a poll: 60% of New Jersey adults had no written documents expressing their wishes for care at the end of their lives. Finding solutions to respect patient wishes The plan calls for improved: Technology Payment reform Education Culture 21
Health Summary Supporting providers in Caring for ME 2016: Maine passed legislation enacting comprehensive and aggressive limits on opioid prescribing. MQC partnered with Maine Medical Association to create: Caring for ME an effort to bring together a wide set of partners to promote shared messages, educational resources, and practical tools for healthcare providers Addressing Maine s opioid epidemic Goals: Support prevention efforts Maintain compassionate/trauma-informed approach to chronic pain management Improve safety of opioid prescribing Appropriately diagnose addiction Improve access to effective treatments Maine has seen the largest decrease (25%) in the country in opioid prescribing between 2016-2017 22
Outcomes Health Maine has seen the largest decrease in the country in opioid prescribing over the year. Addressing Maine s opioid epidemic 23
Price Summary Untangling the Cost Drivers: A Comparison of Total Cost Between Five States Measuring and comparing total cost of care It s not just price or just waste in the system In-depth analyses make it possible to identify important differences in regional cost drivers. It s not just care patterns and delivery systems It s different state-to-state (sometimes within a state) 24
Price Background Relative cost of care Measuring and comparing total cost of care Bringing the higher than average cost states highlighted above down to the average of the participating states could potentially save over $1 billion. 25
Price Outcomes Where are we headed? America s healthcare cost crisis will not be solved by data alone, and it cannot be solved without it The Total Cost of Care measure set provides a high-level framework to learn about cost; this framework combined with quality reporting completes the value equation Expanding to include Medicare and Medicaid reporting provides a comprehensive view of the market Measuring and comparing total cost of care Regional Health Improvement Collaboratives (RHICs ) extensive local networks provide a natural highway for sharing this data and coordinating action 26
Price Index Background Price Detailed insight High Price 1.15 High Price Low Use High Price High Use 1.05 0.85, 1.05 0.95 Translating information into action Low Price Low Price Low Use 0.85 0.65 0.75 0.85 0.95 1.05 1.15 1.25 1.35 Low High Use Use Resource Use Index (RUI) Other Oregon Clinics Clinic Low Price High Use Individual patient data is attributed to primary care providers and includes: Risk adjusted for fair comparison Total Cost of Care and Resource Use Indices, with breakouts of inpatient & outpatient usage, professional & pharmacy claims, and inpatient admissions & emergency 27
Price Summary Making cost and quality information public Wear the Cost campaign provides cost and quality information for consumers. Empowering consumers Goals: Patients/providers become more aware of variation among hospitals statewide reduce costs help patients make high-value choices. Empowering consumers to get involved in their own healthcare, with numerous ways to take action. 28
Price Summary Benchmarking & hot-spotting to improve care Created second version of California Regional Health Care Cost & Quality Atlas state s largest improvement measurement tool that tracks: Clinical quality Hospital utilization Cost of care Roadmap to cost and quality improvement Data gathered from 29M insured Californians showed wide variation of costs and quality across state (2013 & 2015). Outcomes: Clinical quality varied by average of 25% across 19 areas in 2015 Clinical quality improved modestly from 2013-2015, while costs increased 3.85% annually IHA plans to update Atlas with 2017 data by end of 2018. 29
Waste Understanding clinical waste Summary Shining a light on waste in Washington state Overuse of low-value services introduces the unnecessary risk of adverse physical and financial harm for patients, drives up costs for purchasers and insurers, and strains the system. Outcomes: This report examined 47 common treatment approaches known by the medical community to be overused More than 45% of the healthcare services examined were determined to be low value Approximately 1.3 million individuals received one of these 47 services; among these individuals, almost one-half (47.9%) received a low value service 36% of spending on the healthcare services examined went to low value treatments and procedures - this amounts to an estimated $282 million in wasteful spending 30
Waste Summary Controlling administrative waste Of 89 measures across 9 programs sets, only 4 were in all sets, while 60 were in only 1 or 2 sets. Outcomes: Common Standard Measure Set used for P4P Reducing measurement burden Single set of results used by health plans for rewarding healthcare systems and provider for delivering high value care Healthcare providers benefit from reduced administrative waste and can apply comprehensive interventions across all patients 31
Waste Background Controlling administrative waste Reducing measurement burden IHA stakeholders identified 9 key measurement programs particularly relevant for ACO alignment considerations. 32
Waste Summary Removing unnecessary services PRHI aims to remove unnecessary services and pay for what matters, with a focus on perinatal care. The maternal mortality rate in the U.S. is 3x higher than any other developed country. Paying for what matters 33
Waste Summary Reducing unnecessary Medicare patient readmissions Established a standard set of quality measures to improve rural hospital care and reduce unnecessary admissions. Goal: identify and field test measures for rural, community-based programs that reflect clinical quality, patient and family experience, and resource utilization as a metric of financial impact. Improving rural care coordination Data used to standardize and coordinate processes in providing palliative care Emphasized important role standard measures play in supporting integration and communication Worked to connect patients with community resources Resulted in 7,168 fewer unnecessary hospital readmissions. 34
Waste Summary Building a common measure set Led a committee that researched and selected 32 unique comparative measures. Chose measures that were aligned across payers and could be reported reliably. Improving health & minimizing burden Goals: Improve quality/value of care Reduce provider reporting complexity Align healthcare organizations 35
What do all these initiatives have in common?
They re bringing together all parties for safer, higher quality, more affordable care that works better for everyone. 37
Regional Health Improvement Collaboratives (RHICs) Regional Focus Neutral Conveners Non-Profit 38
The Role of RHICs Patient Education Analysis & Reporting Regional Focus Neutral Conveners Non-Profit Paying for What Matters Quality Improvement 39
RHICs currently work in many regions across the U.S. 40
Multiple Stakeholders, Varied Tactics One Goal Health Members engage from positions of particular knowledge, experience and strengths: RHIC RHIC Population Health Payment Reform Quality Improvement Data Analysis Affordability Price RHIC Waste Cross pollinate best practices Disseminate educational materials Lead community dialogue 41
Partnering for greater reach NRHI is recruiting national partners to join forces and reach a broader public audience with the message of why affordability matters and what we can do about it. Regional Efforts Health National Partner Regional Efforts Price NRHI Regional Efforts Waste National Partner 42
JAN 25, 2017 Health Plans Spend $1,000 More Per Patient Depending On Region Bruce Japsen, CONTRIBUTOR The Road To Affordability: How Collaborating At The Community Level Can Reduce Costs, Improve Care, And Spread Best Practices Elizabeth Mitchell NOVEMBER 14, 2017 While practices struggle with MACRA, value-based payment systems past due, expert says by Joanne Finnegan Dec 4, 2017 12:30pm Although many physician practices struggle to get on board with the new Medicare payment system implemented by MACRA, 43
Rational common interests and rational individual interests are in conflict. Our failure as a nation to pursue the Triple Aim meets the criteria for what Garrett Harden called a tragedy of the commons. As in all tragedies of the commons, the great task in policy is not to claim that stakeholders are acting irrationally, but rather to change what is rational for them to do. - Don Berwick, Health Affairs, May/June 2008 44
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Do your part to make healthcare more affordable 47
Thank you. Questions?