SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2013. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2013; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999-2013 (April to April).
Percentage of All Firms Offering Health Benefits, 1999-2013 *Estimate is statistically different from estimate for the previous year shown (p<.05). NOTE: Estimates presented in this exhibit are based on the sample of both firms that completed the entire survey and those that answered just one question about whether they offer health benefits. The percentage of firms offering health benefits is largely driven by small firms. The large increase in 2010 was primarily driven by a 12 percentage point increase in offering among firms with 3 to 9 workers. In 2011, 48% of firms with 3 to 9 employees offer health benefits, a level more consistent with levels from recent years other than 2010. The overall 2011 offer rate is consistent with the long term trend, indicating that the high 2010 offer rate may be an aberration. SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2013.
Fast-Changing Relationships: The Road Ahead for Employers
Moderator: Kathleen S. Neal, Director of Integrated Health Care & Disability, Chrysler Group, LLC Former Executive Director Deloitte Center for Health Solutions Panelists: John Neuberger, Director of Client Partnerships, Quad/Graphics Randy Vogenberg, Principal, Institute for Integrated Healthcare
Impacts of Response: The Changing Landscape for Providers
Carlos Jackson Senior Associate Director, Federal Relations American Hospital Association
The Changing Landscape for Providers Carlos Jackson American Hospital Association March 12, 2014
ACA implementation Wednesday, February 15 Naval Heritage Center 9:30 AM
Implementing reform Insurance reforms −High risk pools −Medical loss ratios −Mandates −Insurance exchanges Integrated care options − Bundling − Accountable care organizations − Medical homes −Center for Medicare and Medicaid Innovation Value-based purchasing Readmissions Regulatory Design
Research and analysis by Avalere Health CMS quality and accountability initiatives provide additional impetus to hospitals’ integration efforts. Chart 3: Timeline of CMS Value-Driven Payment Initiatives Incentive Payments Only Upside/Downside Risk Penalties Only Nonpayment Hospital Inpatient Quality Reporting Program (P4R) Accountable Care Organizations * Readmission Penalties for Low Performers 20082009201120132017201520182016201420102012 Bundled Payments for Care Improvement * Hospital Outpatient Quality Reporting Program (P4R) Hospital Value-Based Purchasing Program Meaningful Use (HITECH Act) Hospital-Acquired Conditions** P4R: Pay-for-reporting HITECH: Health Information Technology for Economic and Clinical Health *Program is voluntary **In 2008, Medicare stopped paying for select hospital-acquired conditions (HAC). In FY 2015, Medicare will begin penalizing hospitals in the top quartile of Medicare HACs. Source: Centers for Medicare & Medicaid Services
Research and analysis by Avalere Health Physicians widely anticipate increased levels of integration with partner hospitals. Chart 5: Percent of Physicians that Believe Physicians and Hospitals are Likely or Very Likely to become More Integrated in the Next 3 Years, by Medical Specialty, 2013 Source: Deloitte Center for Health Solutions (2013). Deloitte 2013 Survey of U.S. Physicians.
Research and analysis by Avalere Health Integration helps hospitals gain efficiencies through economies of scale. Chart 6: Economies of Scale with Increasing Patient Population Fixed costs, such as medical technologies, are spread across each patient. The more patients that need the technology, the lower the cost per patient. Variable costs, such as labor costs, scale with the number of patients. As the number of patients increases, variable labor costs can decrease over time due to new efficiencies. 1 patient 2 patients4 patients Variabl e Costs* Fixed Costs Source: Bond, R. (2012). American Healthcare Industrial Revolution: Economies of Scale and the Accountable Care Organization (ACO). ACODatabase.com.
Research and analysis by Avalere Health Current legal and regulatory barriers are a deterrent to innovative clinical integration efforts. Chart 7: Legal Barriers to Integrated Care Delivery LawWhat is Prohibited?The Concern Behind the LawUnintended ConsequencesHow to Address? Antitrust (Sherman Act)Joint negotiations by providers unless ancillary to financial or clinical integration; agreements that give health care provider market power Providers may enter into agreements that either are nothing more than price-fixing, or which give them market power so they can raise prices above competitive levels Deters providers from entering into procompetititve, innovative arrangements because they are uncertain about antitrust consequences Additional guidance from antitrust enforcers to clarify when arrangements will raise serious issues; guidance is currently available for federally-designated accountable care organizations (ACOs) Ethics in Patient Referral Act (“Stark Law”) Referrals of Medicare patients by physicians for certain designated health services to entities with which the physician has a financial relationship (ownership or compensation) Physicians may have financial incentive to refer patients for unnecessary services or to choose providers based on financial reward and not the patient’s best interest Arrangements to improve patient care are banned when payments tied to achievements in quality and efficiency vary based on services ordered instead of tied to hours worked Congress should remove compensation arrangements from the definition of “financial relationships” subject to the law. Arrangement would continue to be regulated by other laws. Anti-kickback LawPayments to induce Medicare or Medicaid patient referrals or ordering covered goods or services Physicians may have financial incentive to refer patients for unnecessary services or to choose providers based on financial reward and not the patient’s best interest Creates uncertainty concerning arrangements where physicians are rewarded for treating patients using evidence-based clinical protocols Congress should create a safe harbor for clinical integration programs Civil Monetary Penalty (CMP) Payments from a hospital that directly or indirectly induce a physician to reduce or limit services to Medicare or Medicaid patients Physician may have incentive to reduce the provision of necessary medical services As interpreted by the Office of the Inspector General (OIG), the law prohibits any incentive that may result in a reduction of care, even if the result is an improvement in the quality of care The CMP law should be changed to make clear it applies only to the reduction or withholding of medically necessary services IRS Tax-exempt LawsUse of charitable assets for the private benefit of any individual or entity Assets that are intended for the public benefit are used to benefit any private individual (e.g., a physician) Uncertainty about how IRS will view payments to physicians in a clinical integration program is a significant deterrent to the teamwork needed for clinical integration IRS should issue guidance providing explicit examples of how it would apply the rules to physician payments in clinical integration programs
Hospital Squeeze Labor Life-saving technology/Rx Older, sicker patients Redundant regulation Liability insurance Info technology Emergency readiness Government payment Private payor pressure New care delivery models Rising uninsured
Prospective coding offsets ($8 billion) Site neutral payment policies E&M code/HOPD ($10 billion) 66 additional APCs procedures ($9 billion) 12 procedures performed in ASCs ($6 billion) Hospital bad-debt reductions ($20 billion) GME reductions ($10 billion) CAH: payment reductions and qualification criteria ($2 billion) Post acute care ($70 billion) IPAB expansion ($4.1+ billion) Medicaid: State provider assessments ($22 billion) Medicaid DSH “rebasing” Hospital Vulnerability List Options for offsets and deficit reduction
Impact of site neutral payment options Medicare Margins for Hospital Outpatient Department Services 2007-2011 and Projected with MedPAC Proposed Cuts Source: Medicare Payment Advisory Commission, December 2012 meeting materials and June Report to Congress. E&M Only E&M and 66 E&M, 66 and 12
President’s FY 2015 Budget Key hospital provisions Replace remaining sequestration with other savings Reduce GME by $14.6 billion (proposes $5.23 billion for 13,000 new residency slots through a new competitive GME program) Strengthen IPAB ($12.9 billion) $112 billion in post-acute cuts (site-neutral SNF/IRF, 60% rule, reduces updates) Phase out Medicare bad-debt payments by $30.8 billion Rebase Medicaid disproportionate share hospitals in FY 2024 for savings of $3.26 billion Critical Access Hospitals: 101% to 100% and 10 mile designation ($2.4 billion reduction) $414 Billion in Medicare and Medicaid Cuts
The Two-Midnight Rule CMS will generally consider hospital admissions spanning two midnights as appropriate for payment under the inpatient prospective payment system (PPS). In contrast, hospital stays of less than two midnights will generally be considered outpatient cases, regardless of clinical severity. 1
On the Horizon: What’s Around the Corner for Providers?
Moderator: Laura Appel, Vice President of Federal Policy and Advocacy, Michigan Health & Hospital Association Panelists: Gina Buccalo, MD, Chief Medical Officer, Partners in Care Carlos Jackson, Senior Associate Director, Federal Relations, American Hospital Association Michael Madden, President and CEO, The Physician Alliance
Challenges for the Government – The Federal Response
Tevi Troy President The American Health Policy Institute
Tevi Troy, President The American Health Policy Institute
Perspectives of an insider Policy makers inside government have different perspectives from those in the private sector. They are often equally competent but they're looking at things from a different angle have different bosses and different constituencies to satisfy. In addition they are subject to different rules. The APA governs how regulations are determined and puts the development of regulations in a very tight stricture.
Perspectives of an insider One of the challenges in developing the website was that policymakers had to use federal contractors, a universe with a high bar to entry, using "cost-plus" reimbursement, and requiring certifications of compliance with OFCCP, acquisition requirements, and other federal standards. It is true that policymakers come with results that differ from one of those in the private sector would have come up with, but much of this stems from the different perspective and the different rules the government imposes, as well as their lack of private sector experience.
Coping with a Challenging and Uncertain Regulatory Environment Health care faces significant policy challenges. Health care environment rife with regulatory uncertainty. Post-elections/Supreme Court/mandate delay/Shutdown fight, regulatory landscape and employer responses will determine the disposition of the ACA more than Congress in the short term.
51 OBAMA ADMINISTRATION’S TOP ISSUES Economic Recovery Foreign Policy & Defense Energy & Environment Healthcare Reform Immigration Education Veterans Taxes Civil Rights Disabilities Rural Family Ethics Poverty Social Security Women Science Oceanic Policy Transportation Seniors Faith-Based Initiatives Arts Urban Policy Science Child Advocacy HIV/AIDS Service Technology Sportsmen
OBAMA ADMINISTRATION’S TOP ISSUES: Healthcare Reform Increasing costs 1960: healthcare 5% of GDP 2011: healthcare 17.9% of GDP - $2.7 trillion 2021 (projected), $4.8 trillion - 19.6% of GDP Government expected to spend $2.4 trillion (50% of healthcare spending) 52
US Health Care Costs US Average annual cost of health care was $8,233 per capita -- 2.7x Japan’s in 2010 U.S. households spent 6% of their annual incomes on health costs U.S. performs more expensive diagnostic tests, such as MRI’s and CT’s On the other hand, the U.S. does not have an excessive number of doctors or hospital beds relative to its population Similarly, duration of hospital stays is not above average 53 http://www.pbs.org/newshour/rundown/2011/11/why-does-healthcare-cost-so-much.html
2030 Baby Boomer Projections In 2030: The over 65 population will be at 72,091,915 (19% of the overall U.S. population) - 40,228,712 million in 2010 (13% of overall U.S. population) Over 21 million will be considered obese Approx. 14 million will be living with diabetes http://www.census.gov/prod/2010pubs/p25-1138.pdf http://www.aoa.gov/aoaroot/aging_statistics/future_growth/future_growth.aspx#age www.aha.org/content/00-10/070508-boomerreport.pdf
Breakdown of National Health Care Expenditures: 1965-2010 Source: Office of the Actuary of the Center for Medicare and Medicaid Services
Before Reform Became Law… 5 different committees 3 House 2 in Senate Two Houses of Congress House Floor Senate Floor Conference In Senate Reconciliation (51 votes) or Regular Order (60) Presidential Signature 56
TypePre- enactment Upon enact- ment 6 month s post enact- ment By Jan 1, 2011 1 year post enact- ment 1 year post enactment to Jan 31, 2011 Jan1, 2012-Dec 31, 2013 2014- 2020 TotalPercent of total Medicare 729744711342416335 Medicaid 533742317449 CHIP 0011102051 Public health 1446554957917 HHS 0020101041 Taxes 3316001012357 Insurance 03122319215111 Long-term care 000000202<1 IHS 1681074508618 Total 17150336528227579469100 Percent of total 432714651617100 Analysis of CHT Timeline 60
How did we get here? Intense effort to micromanage The Affordable Care Act (ACA) has required almost 20,000 pages of regulations, elaborating on the original 2,700 page law. Can be very specific. Consider Section 4102 of the ACA, which states: "The secretary shall develop oral healthcare components that shall include tooth-level surveillance.” Not necessarily welcome: 51% of doctors percent felt that the law would have a negative impact on their relationships with their patients 61
Outlook of the next four years ACA will not be overturned before 2017 Implementation challenges greater than expected, but do not change the central dynamic: Democrats will never admit full extent of the law’s shortcomings Republicans will never call the law a success even if it works as promised How should people judge the law?
Judging the Law Evaluate the law based on its 3 main goals Universal coverage “Bending the cost curve” The guarantee of the ability to keep current plan
Promise: Universal Coverage Ranging number of uninsured, between 30 – 47 million people Moral imperative to cover people Most expansive definitions of the uninsured that President Obama used included both illegal immigrants, as well as individuals, who were already eligible for public assistance, but not partaking in it
Promise: “Bending the cost curve” President Obama claimed he would reduce premium costs by $2,500 for a family of four There is tension between the goal of universal coverage and the effort to bend the cost curve
Promise: “If you like your health care you can keep it.” Became standard response to the public’s skepticism of the ACA President Obama mentioned it nearly every time he spoke of the law Some sources say he said it hundreds of times The promise was to ensure Americans that the law would not affect 85% of Americans that already had health insurance
Other metrics to evaluate ACA imposes $1.1 trillion in new taxes over the first 10 years Employers are trying to stay under 50 employees, or 30 hr threshold Health care market has been one of the only sectors continuing to hire during the recession In September 2013 there were more layoffs among health-care providers than in any other industry
Legislation - GOP Alternative Senate Republican Proposal Keeps most popular provisions of the ACA o Guaranteed issue, coverage of dependents to age 26, no lifetime limits Repeals more than a dozen ACA taxes and the employer mandate Provides continuous coverage protection for pre-existing conditions Gives tax credits to people who are not employed at large companies Limits tax exclusion of employer provided health benefits to 65 percent of plan costs. 68
American Health Policy Institute AHPI is a non-partisan 501 (c)(3) think tank focused on health care policy and the employer-based system. AHPI will be looking at: how the ACA affects employers; what employers are doing about ACA; and policy recommendations. o The first study from AHPI will be on employers costs under ACA 69
Going forward? Democrats are adamant the law stay in place. Republicans are adamant the law goes. This dynamic means there is no pathway for real improvement of changes during the remainder of the Obama administration Employers need to chart a path forward, recognizing that they will get little help from Washington. This requires two steps: Creating health care plans that work for employers and employees within the current structure Laying the groundwork now that will have to come in the future administration
Units X Price = Cost, right? Quick Quiz: What causes American Health Care to be more expensive than HC in other countries? We uses more stuff, i.e., it’s a units problem, mostly. The stuff we use is higher priced, i.e., it’s a price problem, mostly. Both in roughly equal measure.
How did it get this way? Fee for service= accountability for activity, not for outcomes Industry consolidation for two decades = oligopoly formation Third party payer system: those who use the service and provide the service don’t pay for the service = moral hazard
Where current reform schemes work Units –Pay for performance –Nonpayment for readmissions –Bundles –Capitation Prices –Benefit design, e.g. reference pricing –Price transparency
Providing Answers to: Consumers… “How much will my knee MRI cost and what are my best options?” 83 Businesses… “Which health plan provides the best value providers for our premium?” “How does cost, utilization and quality compare between public and private payers?” Providers and Facilities… “How do I compare to my peers and demonstrate value?” Legislators and Policy Experts…
StateStatewide or partial geographi c area Statutory or voluntary Provides consumer focused reporting Currently collecting data? Currently doing any kind of public reporting? 1. MaineStatewideStatutoryYes 2. NHStatewideStatutoryYes 3. VTStatewideStatutory Yes 4. MAStatewideStatutoryYes 5. MDStatewideStatutory Yes 6. KSStatewideStatutory No 7. UTStatewideStatutory No 8. TNStatewideStatutory No 9. MNStatewideStatutory YesNo (reports are not public) 10. ColoradoStatewideStatutory Yes 11. OregonStatewideStatutoryNoYesNo 12. WisconsinPartialVoluntary YesNo 13. Washington State PartialVoluntary YesNo
Status of state APCDs 11 statewide, statutory APCDs, including Colorado, that have collected data. There are two states that have voluntary data for part of the state (WI, WA). Oregon has not issued any reports yet, so that is why the count is often “10 APCDs.” Seven states have issued reports at one time or another. (ME, NH, VT, MA, MD, KS, UT). Five states allow data release: ME, NH, VT, MA, CO Three states do consumer focused reporting: ME, NH, MA and soon CO
Will market forces regulate prices? Motivated purchasers/consumers –Benefit design, high deductible –Reference pricing strategies Transparent pricing Transparent and relevant quality Willing competitors –Centers of excellence strategies
CMS moving toward greater transparency CMS NEWS Feb. 21, 2014 Quality Data Added to Physician Compare WebsitePatients Get More Information to Help Find a Doctor Today, the Centers for Medicare & Medicaid Services (CMS) announced that for the first time, quality measures have been added to Physician Compare, a website that helps consumers search for information about hundreds of thousands of physicians and other health care professionals. The site helps consumers make informed choices about their care.
What you’d want to make prices real and accurate Paid amounts, not charges Large database so results are statistically significant Acuity adjustment methodology that doesn’t penalize providers who take care of sicker patients
Take Homes While we have room to improve on how much HC we use, we’re not that different from others in this regard Where we do differ is that our prices are much higher for the same services While much of HC cost containment to date has been focused on lowering utilization (units used), we must focus attention on prices as well
Take Homes One of the ways we might get better pricing is more transparency APCDs offer the chance to get the biggest datasets available Oligopolies generally oppose transparency, as they are designed to maintain higher prices and to avoid price competition
Ed Wolking Executive Vice President Detroit Regional Chamber
L EAPFROG H OSPITAL R ECOGNITION P ROGRAM (LHRP)
T OP H OSPITALS IN MICHIGAN - 2013 Recognition for top performing hospitals - Leapfrog Hospital Survey Top Hospital (hospitals coded as Urban) DMC Detroit Receiving Hospital and University Health Center Mercy Health Saint Mary's Top Children’s Hospital DMC Children's Hospital Of Michigan Top Rural Hospital (includes Critical Access Hospitals) OSF St. Francis Hospital & Medical Group Spectrum Health Kelsey Hospital
Regional Initiatives: Detroit and Michigan-Miles to Go Before We Sleep?
Moderator: Kirk Roy, Vice President, Office of National Health Reform, Blue Cross Blue Shield of Michigan Panelists: Kate Kohn-Parrott, President and CEO, Greater Detroit Area Health Council Christopher Priest, Senior Strategy Advisor, Office of the Governor