1. Speeding up Improvement in Chronic Care: What should be the Federal Role?
Sandra M. Foote
Senior Vice President, Capitol Health
January 29, 2009

2. 9 Days Ago, We Inaugurated a New President2

3. Both Candidates Promised to Reform Health Care3

4. Pressures for Health Reform
47 million uninsured
Coverage eroding
Unemployment increasing
$2+ trillion and rising
Premiums up 80%,
Competitiveness
Medical errors
Average premiums for employee-only coverage increased from $28 to $52 per month from 2000 to 2006, an 86% increase. Average family-coverage premiums increased from $138 to $248 per month from 2000 to 2006, an 80% increase. In contrast, the consumer price index (CPI) increased by 17% from 2000
to 2006.
Quality gaps
Variations
in care 4

5. 82% of Americans Say the Health Care System Needs Fundamental Change
Only minor changes: 16%
Rebuild completely: 32%
Fundamental changes: 50%
Source: Commonwealth Fund Survey of Public Views of the U.S. Health System, 2008 5

6. RECOMMENDED REFORM STRATEGIES
If the political will exists, what fundamental changes are needed?
Policy compass, not Rx for change 6

7. Key Message:
To be successful, reforms aimed at expanding access must also address the underlying problems of quality and cost.
Structure reforms to include the building blocks of a high performance health system.
Source: M. O’Kane et al. “Crossroads in Quality,” Health Affairs 27, no. 3 (2008): 7

8. Obama Health Reform Plan
Building Blocks
Plan Features
Evidence base
Independent institute for comparative effectiveness research
New models of care
Federal investment in HIT
Support providers in developing care management, medical home, care integration & coordination programs
Disease management and prevention programs included in federal programs
Payment for High-Value Care
Align incentives for excellence
National Performance
Measurement Strategy
Full transparency on quality and costs
Report preventable errors
Support practice improvement
Use validated performance measures
Multi-stakeholder Approach to Improving Population Health
Develop regional and national public health strategy and align funding to support
Tackle disparities
Develop public health infrastructure 8

9. Medicare Reform : A Major Opportunity
Sustainable Growth Rate formula resulted from urgent need to reduce rate of growth
Source: The Congressional Budget Office, Social Security and the Federal Budget: The Necessity of Maintaining a Comprehensive Long-Range Perspective August 1, 2002 9

10. Medicare Growth Projections
SOCIAL
SECURITY
Medicare's cost in 2007—3.2 percent of GDP— is projected to surpass the cost of Social Security in 2028
HI= Hospital Trust Fund SMI=Supplementary Medical Insurance Trust Fund
OASI=Old Age Survivors Insurance DI=Disability Insurance
Source: Summary of the 2008 Annual Social Security and Medicare Trust Fund Report 10

11. Medicare Shapes Chronic Care
Dominant payer nationally – by far
$500 billion projected expenditures 2009
45 million beneficiaries, most with multiple chronic conditions
Fee For Service policies reinforce status quo
Poor coordination of care
Lack of self-care support
Uneven adherence to evidence-based medicine
Demonstrations not producing rapid progress 11

12. Medicare Leadership Needed: Change Agent for Chronic Care
Time to move beyond research paradigm
Make Population Health Improvement a core component of the CMS’ mission
Draw on lessons from the quality improvement field 12

13. Many QI examples nationally
Towers Perrin 2008 Health Care Cost Survey – comparison of high and low performance employers:
72% of high performing companies say they play a significant role in employee health management (e.g., identifying and managing health risks in the population and managing disease, chronic conditions and high cost patients). 13

14. Critical Success Factors
Impassioned leadership commitment
Explicit goals & performance metrics
Organizational structure
Authority and resources for innovation
Incentives
Processes to drive rapid innovation with partners
Tolerance of mistakes
Review and action based on findings
“Continuous Innovation In Health Care: Implications of the Geisinger Experience” (Health Affairs 27:5, 2008) 14

15. Build on CMS experience
Large population-based programs
Public-private partnerships
Pay for performance structures
Beneficiary and caregiver engagement
Provider support and incentives
Broad multi-stakeholder collaboration
New data flows
Rich data bases for learning about chronically ill subpopulations 15