1. Global Healthcare Trends
Byron C. Scott, MD, MBA
Associate Chief Medical Officer—Truven Health Analytics

2. Agenda Puerto Rico Healthcare Trends Performance Improvement
Population Health Management
Consumerism
Payers: Employers & Health Plans

3. Healthcare Reform!

4. Puerto Rico Healthcare Trends

5. Puerto Rico Healthcare Trends
Puerto Rico Bond Debt Crisis
Healthcare is 20% of Puerto Rico’s Economy
60% of the Population rely on Medicare, Medicare Advantage, or Medicaid
Disparate reimbursements rates compared to mainland states
Medicaid—70% lower than states
Medicare Advantage--60% of states
Lack of individual mandate
Risk of future cuts to programs
Puerto Rico Adopted via bills many of the ACA rules unlike other territories---except for individual mandate (everyone must have health insurance)
Bond debt around $73 Billion
Healthcare facilities everywhere will have to become more efficient with limited resources---Some more than others(Puerto Rico)

6. Performance Improvement

7. Performance Improvement
Institute of Healthcare Improvement Triple Aim
Improve the experience of care
Improve the health of populations
Reduce the per capita costs of healthcare
Population Health and IHI Triple Aim-----guideline for really what most of us are in this for.

8. Aging Population Worldwide
Japan—interest in nursing homes and assisted living because of aging population

9. U.S. Healthcare Spend Today
US Total Cost in 2013
$2.9 Trillion
Federal Spend in 2013
Medicare $586 Billion
Medicaid $450 Billion

10. Center for Medicare & Medicaid Services Projects Spend by 2023
U.S. Total Cost $5.2 Trillion
Continued Government Spend
CMS will be ~33% of this!
GDP on healthcare over 20%

11. Global Medical Cost
Americans spend over twice as much per capita as any other developed country… approaching 18% of GDP
Americans spend over twice as much per capita as any other developed country…approaching 18% of GDP
*Peter G. Peterson Foundation Study

12. Performance Improvement Targets
Readmissions
Medicare 30 Day Readmissions
20% Medicare Patients
2 million patients per year
$26 Billion per year
Quality and Patient Safety
Mortality
Hospital Acquired Conditions
Sepsis
Healthcare reform going on in Europe---Cost containment is a major theme
Drug Pricing
Declining reimbursements for knee implants

13. Performance Improvement Targets
Efficiency
Length of Stay
Throughput
Operating Room
Emergency Department
Cost/Spend
Supply Chain—Pharmaceuticals, Medical Device, Joint Implants
Medicare Spend Per Beneficiary (MSPB)
Patient Engagement
Patient Satisfaction
Compliance

14. Performance Improvement Tools
Team Based Care
Process Improvement tools like LEAN
Electronic Health Records with Population Health Focus
Outpatient areas connected to Inpatient
Analytics
Data

15. Population Health Management

16. Population Health Management
Ability to view and manage patients/groups of patients across a continuum of time and location
Retrospective, Real Time, and Predictive
Population Health Management: More than collecting clinical information/data and performing analytics
IHI—these groups are often geographic populations such as nations or communities, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group.
Theme: Structure, Organization, Leadership, Physicians
Population Health Strategies for Success:
Health Promotion
Prevention
Screening
Behavioral Change
Consumer Education-----Self Management
Disease Management
Chronic Care Management

17. Population Health Management
Hospital
Home Health
Skilled Nursing
Rehab
Hospital
Physician Office
A patient can be in anyone of these places along the time continuum—past, present, future---Location Continuum—Not just inpatient anymore
Goal: being able to view information from any of these location systems at any time with immediate access
Imagine: all may have separate EMR----interoperability
Hospice
Nursing
Home
Other Outpatient

18. Population Health Management
Strategy
Socioeconomic determinates impact on health in the community
Care Coordination between Inpatient and Outpatient
Skilled Nursing, Home Health, Nursing Home, Rehab, etc.
Care Management
Physician Engagement and Alignment
Structure, Organization, Leadership, Physicians

19. Population Health Management
Strategy
Patient Engagement
Behavioral Changes
Wellness
Prevention
Information Technology
Electronic Medical Records
Health Analytics Capabilities
Interoperability
EMR’s—types, capabilities, and EMR’s

20. Population Health Management
“The Nirvana of Population Health”
Achieve both Cost & Quality Improvement by leveraging
Predictive Analytics
Target Patients at risk for admissions, readmissions, and chronic disease

21. Population Health Management—Global Issues
Globalization
Increased International Travel
Need for Improved Real Time Surveillance Tools
Malaria—Puerto Rico
Ebola---Mainland U.S.
MERS—outbreak in Korea outside the Middle East
Influenza—when is the next pandemic?

22. Consumerism

23. Consumerism Patient Engagement
Patient Satisfaction—improved satisfaction fosters better compliance
Transparency
Cost/Price
Access to Health Information
Make informed decisions on providers and quality

24. Payers: Employers & Health Plans

25. Payer Trends Key Issues
Align higher reimbursement percentages tied to:
Performance
Value Based
Readmissions
Hospital Acquired Conditions
Alternative Payment Models
Accountable Care Organizations (ACOs)
Medicare Shared Savings Program (MSSP)
Bundled Payments
Key Issues
End 2016
30% of traditional Medicare FFS to quality or value through alternative payment models(ACOs, Bundles)
50 % by end of 2018
Moving toward Risk Contracts & Capitation Models

26. Payers Efforts to Control Cost
Benefit Redesign
Increase Employee Cost Share
Higher Co-Pays and Deductibles
Narrow Networks and Centers of Excellence
Very Interested in Hospital and Physician Quality Metrics
Employers
Employers

27. Payers Efforts to Control Cost
Plans to expand provider value based reimbursement
Narrow Networks and Centers of Excellence
Health Plans
NEBGH conference end of April on provider quality—CMO/Medical Directors from health plans

28. Data Releases Driving New Reimbursement Models
Release of hospital charge and reimbursement data on 2013 Hospital Medicare patients on June 1, 2015 by CMS
Joint Replacement Surgery was most common Medicare Inpatient Surgery in with cost of $6.6 Billion
Commercial Payers reviewing closely and could influence decisions about narrow networks & bundled payments
Blue Cross Blue Shield Association released cost variation of hip/knee surgery in January 2015
CMS announces on July 9, 2015 that 800 hospitals in 75 geographic areas will have to participate in test of bundled payments for hip/knee replacement starting January 1, 2016
Huge variances within cities on charges

29. Bundled Payments
A single payment for “bundles” of related services during an episode of care, rather than separate payments for each service
CMS, Health Plans, and Employers interested in model
Improve quality and reduce cost—more efficient
Center for Medicare & Medicaid Innovation (CMMI) launched Bundled Payments for Care Improvement program (BPCI)
Pays hospitals a bundled rate for certain hospital-based and outpatient services associated with select DRGs
4 Different Payment Models
Over 2400 Providers participating

30. Bundled Payments Focus Areas for Success
Post Acute Care Facilities and Physicians
Reduce Physician Practice Variation
Reduce Readmissions

31. Ortho Anchor Procedure
Bundled Payments
Timeframe Length of bundle varies
Default is 30/60/90 days post-discharge
90 days is the typical market expected maximum length
Inpatient Admission
Ortho Anchor Procedure
Post-Discharge Care
Acute Discharge
Readmission(s)
30 Days Post- Discharge
90 Days Post- Discharge
Pre-Op Testing
60 Days Post- Discharge