national commission for quality long term care testimony of george taler, md director, long term...
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National Commission for Quality Long Term Care
Testimony ofGeorge Taler, MD
Director, Long Term CareWashington Hospital Center
Washington, DC
Past President, American Academy of Home Care Physicians
Summary
• Primary Care & Geriatric Medicine
• A different approach to the health care challenges of an aging population
• Restructuring health care delivery and health care financing
Woo B. N Engl J Med 2006;355:864-866
Median Compensation for Selected Medical Specialties
Bodenheimer T. N Engl J Med 2006;355:861-864
Bodenheimer T. N Engl J Med 2006;355:861-864
Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates
Bodenheimer T. N Engl J Med 2006;355:861-864
Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists
National Medical AssociationGallup Poll of Membership, 2003
Maryland Academy of Family Physicians2005 Practice and Income Survey
• 663 Active Members (private practice: 66%)
• Median annual income: $103,400– 37% no change since 2001– 41% decrease since 2001
• In response:– 16% have increased hours or # of patients/wk– 44% have decreased hours in clinical practice– 35% plan to retire, relocate or change careers
Geriatricians Have GreatestCareer Satisfaction
Changes in Medicare Payments to Physicians 1999-2012
Concentration of Total Annual Medicare Expenditures Among Beneficiaries, 2001
Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.
Perc
ent
High-Cost Medicare Beneficiary Spending
Medicare Spending
% of Total
Mean
Top Quartile
85% $24,800
Second Quartile
11% $3,290
Bottom Half
4% $550
Total 100% $7,310
Medicare Spending
% of Total
Mean
Top 5 % 43.1% $63,030
Top 6-10 % 18.4% $26,900
Top 11-25% 23.5% $11,430
Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.
Note: Spending reported in 2005 dollars
Yes, but…
Just because you have a bad year, does your bad luck persist and for how long?
Expenditure History of the Top 25% of Medicare Beneficiaries, 1997
Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.
Distribution of High-Cost Months, 1997-2001
Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.
Concentration of Total Cumulative Medicare Expenditures Among Beneficiaries, 1997-2001
Targeting the High-Cost User
• Diagnostic characteristics
• Functional characteristics
• Resource utilization history
Prevalence of Chronic Conditions
Beneficiary Group(Spending pattern)
All Low Cost High Cost(Non-persistent) (Persistent)
Coronary Artery Disease 28.2% 19.1% 50.0% 53.7%
COPD 19.6% 13.9% 28.9% 37.5%
Congestive Heart Failure 18.5% 10.1% 33.0% 44.3%
Diabetes 16.7% 12.6% 23.5% 29.5%
Cognitive Impariment 8.8% 5.7% 13.9% 18.7%
Asthma 3.9% 2.9% 4.5% 7.3%
ESRD 2.3% 0.7% 4.2% 7.9%
Mean number of conditions 1.0 0.7 1.6 2.0
Notes: COPD=Chronic Obstructive Pulmonary Disease, ESRD=End Stage Renal Disease. Data from a 5 percent random sample of fee-for-service (FFS) beneficiaries between 1989 and 1997. Source: CBO preliminary analysis.
Number of Chronic Conditions Predicts High-Cost Status
Notes: The 7 conditions considered were: CHF, CAD, COPD, ESRD, Asthma, Diabetes, and Cognitive impairment. Source: CBO preliminary analysis.
Beneficiary Group(Spending pattern)
Low Cost High Cost(Non-persistent) (Persistent)
0 of the 7 conditions 89.5% 4.4% 6.1%
1 condition 71.5% 11.1% 17.3%
2 conditions 53.3% 15.0% 31.7%
3 conditions 34.5% 16.1% 49.4%
4 conditions 20.2% 13.8% 66.0%
5 conditions 10.8% 9.9% 79.3%
6 conditions 5.4% 6.0% 88.7%
7 conditions 0.0% 0.0% 100.0%
Spending for People with Chronic Illnesses and Activity Limitations
$2,890$3,830
$5,650
$7,800
$11,890
$13,420
$7,560
$5,650
$4,060
$2,550$1,500
$680
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
0 1 2 3 4 5+
Number of Chronic Conditions
Avg
. An
nu
al H
ealt
h C
are
Exp
ense
s P
er
Per
son
No Activity Limitation
With Activity Limitation
Sources: Partnership For Solutions, “Chronic Conditions: Making the Case for Ongoing Care,” December 2002; MEPS, 1998.
Service Organization Structure & Process Criteria
• Make the HOME the center of health care delivery and social supports
• Re-establish the Doctor-Patient relationship
• Continuity of care across all settings and over the natural history of illness
• Coordinate Medical, Social and Housing services
• Match patient goals and processes of care
Life Care Coordination Fees• Layered fee for non-covered services
– Comprehensive Geriatric Assessment– Team meetings– Care coordination– Enhanced urgent care services– On-call services– Gap-filling fund
• Renewable contingent on performance– Adherence to evidence-based guideline targets– Patient and caregiver satisfaction targets– Reduced costs
“Whose Ox Gets Gored?”
• Sponsoring Hospitals– Cover “margin” expectations– Rate incentives for supporting innovation
• SNF/ICF– Escalated payments for greater complexity– Decreased payments for custodial care– Incentives for community-based referrals
The “Ask”: How You Can Help
• Advocacy for a focused, population-based health care delivery system transformation
• Development of population target criteria
• Development of new financing mechanisms
• Special interdisciplinary training programs
• Development of a public-private partnership towards common goals and incentives
“You can judge a civilizationby the care it takes of its oldand sick people. I wantAmerica to pass this test well.”
Rep Claude D. Pepper
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