1. Paying for Care Coordination Gerard Anderson, PhD Johns Hopkins University

2. Who Should Pay For Care Coordination? Providers? Patients? Insurers?

3. Perhaps A More Appropriate Question Is Who actually benefits from care coordination ?

4. Current Practice Providers pay while patients and insurers benefit

5. Example – Medicare Program Medicare beneficiaries with 5+ chronic conditions –23% of beneficiaries, but 68% of spending –13 different physicians –50 prescriptions

6. Preventable Hospitalizations Among Medicare Beneficiaries Source: Prevalence, Expenditures, and Complications of Multiple Chronic Conditions in the Elderly, Archives of Internal Medicine, 2002

7. Annual Out-of Pocket Spending by Medicare Beneficiaries Source: Medicare and Chronic Conditions, NEJM, 2005

8. Medicare Does Not Pay for Care Coordination No care coordination payment No electronic medical record payment No disease management

9. Medicare is a program for people with chronic conditions… And is beginning to learn

10. Medicare Modernization Act of 2003 First steps in promoting care coordination Several care coordination provisions

11. National Standards for Electronic Prescriptions Purpose – to develop national standards for electronic prescriptions

12. Electronic Prescriptions Grants Purpose – Provide grants to MDs for purchase of computers

13. Specialized Plans for Patients with Special Needs Purpose – To provide incentives for managed care plans to enroll patients with complex chronic conditions

14. Chronic Care Improvement Purpose – Disease management companies were given contracts to improve adherence to evidence based medicine

15. Care Management for High Cost Beneficiaries Purpose- To involve clinicians in care management in fee-for- service Medicare

16. Beneficiaries With 5 or More Chronic Conditions Account for Two-Thirds of Medicare Spending Source: Medicare 5% Sample, 1999

17. Beneficiaries With Multiple Chronic Conditions Are Over Half of Medicaid Spending Source: Medical Care Expenditure Panel Survey, 2000

18. Subscribers with Multiple Chronic Conditions Account for Three Quarters of Private Health Insurance Spending Source: Medical Care Expenditure Panel Survey, 2000

19. Two Ways that Insurers Could Foster Care Coordination Electronic Medical Record Pay for Care Coordination

20. Electronic Medical Records – U.S. in Dark Ages Other countries have substantial head start Other countries have substantial governmental leadership

21. United States Office of the National Coordinator for HIT Initiated 2006?, expected to be completed 2016 $125 million US invested as of 2005 ($0.43 per capita) Uses EHRs, PHRs, telehealth, health information network

22. Australia HealthConnect formed by the National Health Information Group Initiated IT efforts in 2000 $97.9 million US invested as of 2005 ($4.93 per capita) Uses EHRs, point-to-point messaging

23. United Kingdom Established the National Programme for IT (NPfIT) –Anticipates creating an integrated care record service, an electronic appointment system, and an electronic prescription transmission system and will build infrastructure and networks that will be accessible to all of the major health care providers by 2014 $11.5 billion US invested as of 2005 ($192.79 per capita)

24. Canada Office of Health and the Information Highway launched Canada Health Infoway (2001), a nonprofit organization Initial efforts began in 1997 –Expects to have EHRs for half of the population by the end of 2009 $1.0 billion US invested as of 2005 ($31.85 per capita)

25. Germany Better IT for Better Health First country to start developing a national HIT network (1993) and first expected completion date (2006) $1.8 billion US invested as of 2005 ($21.20 per capita) Updating its smart-card technology to use advanced security features to protect the stored personal medical data.

26. Norway Say @h!; Te@mwork 2007 Initiated IT efforts in 1997; expected completion in 2007 $52.2 million US invested as of 2005 ($11.43 per capita) Uses EHRs, Norwegian Health Net

27. One Policy Option for U.S. Pay $5 for providers to submit an electronic medical record Cost - $10 billion annually - $ 4 billion Medicare Possible Savings to Insurers - $25 billion (full participation )

28. Pay for Care Coordination Allow each person with 5+ chronic conditions to designate a care coordinator Care coordinators responsibilities : –Serve as main contact person for patients –Maintain contact with all other clinicians –Resolve treatment issues

29. Additional Issues Cost Sharing Paying Managed Care plans

30. Cost Sharing Out-of-pocket spending nearly doubles with each chronic condition Create out-of-pocket maximum

31. Managed Care Plans Better risk adjusters needed –Need to reflect number of chronic conditions

32. Vision for Future Because insurers benefit from care coordination, insurers will pay for care coordination