becker_options wv
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TRANSCRIPT
Health Care Challenges and
Opportunities for Primary Care
in West Virginia
James Becker, MD
Medical Director
WV DHHR, Bureau for Medical
Services
“We are all faced with a series of
great opportunities – brilliantly
disguised as insoluble problems.”
-- John W. Gardner
The evolution of systems
Investment
Growth
Plateau
Decline
Excerpt from “The Age of Paradox,” Charles Handy, 1994
National Health Expenditures per Capita, 1960-
2009
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; file nhegdp09.zip).
National Health Expenditures and Their Share of
Gross Domestic Product, 1960-2009
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; file nhegdp09.zip).
Dollars in Billions:
5.2% 7.2% 9.2% 12.5% 13.8% 14.5% 15.4% 15.9% 16.0% 16.0% 16.1% 16.2% 16.6% 17.6%
Projected National Health Expenditures: In Billions and as Percent of GDP
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
$4,500
16.0%
16.5%
17.0%
17.5%
18.0%
18.5%
19.0%
19.5%
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Bill
ion
s % G
DP
$2.57 Trillion 17.3% GDP
$4.48 Trillion 19.3% GDP
2008 version of the National Health Expenditures (NHE) released in January 2010
Average Annual Health Insurance Premiums and Worker
Contributions for Family Coverage, 2001–2011
43 49
3958
4120
1526
3226
126127
2010 Population 2015 Population
Large Group Risk & ASO
Small Group
Individual
Uninsured
Medicaid
Medicare
Medicare, Medicaid, individual and small group markets
% of
Total
58%
42%
% of
Total
41%
296M 306M
59%
Segments impacted
by Exchange/Other
Government
Subsidies by 2015
Source: Booz & Co. research (Total Population,
Commercial & Individual); Cowen & Goldman
Sachs estimates (Government splits)
Market Shifts to Greater
Government Subsidization
*Manufacturer price; ** Assumes 15% rebates from manufacturers to payors and PBMs; *** Average of U.K., Germany, Italy, France, and Spain
Source: IMS Health; McKinsey Global Institute analysis
U.S. vs. OECD: U.S. Higher
Drug Costs
US vs. OECD:
Hospital Stays / Costs Fewer and shorter hospital stays are offset by higher unit cost
Source: OECD, McKinsey
Global Institute Analysis
AGING OF THE BABY BOOM
GENERATION
78 million people
30 percent of U.S. population
Unfunded liability in Medicare = $70 Trillion
System Objectives
The Triple Aim
(Institute for Healthcare Improvement)
1. Improve population health
2. Reduce per capita cost
3. Improve patient experience
Outcome
Safety
Satisfaction
Chronic Disease*
People with chronic diseases → 70% HC spending
Diabetes
Coronary Artery Disease
Congestive Heart Failure
Asthma
Mental health / chemical dependency
*George Halvorson Health Care Reform Now
Distribution of Health Care Expenditures*
1% of population → 35% of HC spending
5% of population → 60% of HC spending
10% of population → 70% of HC spending
*George Halvorson Health Care Reform Now
Health Field Model
Influence Factors on Health Status
Source: McGinnis J.M., Williams-Russo, P., Knickman, J.R. (2002). Health Affairs, 21(2), 83
Lifestyle & Behavior 40%
Human Biology 30%
Medical Care 10%
Environmental 5% Social 15%
The Second Curve
Scenario B
B
WHERE THE RUBBER
MEETS THE ROAD
Cost continues to escalate Acute care system lacks capacity to absorb
2011 Baby Boomers Eligible for Medicare
Increase national debt
Increasing access problem for the elderly
Public dissatisfaction with care quality and
coordination
Where are the solutions?
• Development of a model that creates a Health Community.
• Improved data collection systems that allow analysis of
outcomes rather than just collecting process measures
• Prevention, wellness and medical care that are integrated to
create a true health system.
• A reimbursement model that rewards healthy outcomes
• Integration of behavioral and physical health
Profile of WV Medicaid
400,000 Medicaid member
We will expand by 170,000 new members
Medical costs in 2010 were $2.5 billion
We have had several years of surplus
We face a short fall in 2013
Reimbursement for most services is at 72-
75% of Medicare
50% of members are in managed care
Major Challenges
Expanded population
Higher cost for services
New therapies
Requirement to cover more conditions
Mental health parity
Risky lifestyle issues (substance abuse)
Readmissions, HCACs, Never events
Facts about our duals..
There are just under 50,000 West Virginia dual eligible members. That’s 12% of Medicaid eligibles.
Of the $2.5 billion in SFY 2010 medical expenditures $420 million Medicaid dollars are attached to the care of duals.
71% of that amount is spent caring for those over 65 years of age.
Facts about duals..
40% of the duals had a hospital admission in
2010.
28% had more than one admission.
32,000 dual eligible members (66%) had care
from a specialist in 2010 but no care claim by
a PCP.
20% of the dual population had at least one
nursing home stay in 2010.
West Virginia’s foster care
children….
Medicaid covers 8,500 children in foster
care.
600 of those children have asthma.
Many have behavioral, developmental or
psychiatric diagnoses. 60% are labeled as
“oppositional defiant disorder”
Medication profile: stimulants, AAPs,
mood meds
What are we doing in WV?
Data to guide decisions
Data warehouse, APCD, benchmarks
Many care coordination efforts
Health homes, PCMH, care integration
Using evidence to guide decisions
Working with stakeholders
FQHCs, comprehensives, private payers
The importance of coordinated
effort!
What else?
Major pharmacy efforts on opiates, psych
meds, high dollar oncology products
EHR, incentives, ePrescribing, meaningfull
use, Health Information Technology
WV is creating a Health Insurance
Exchange
This is clearly a time of challenge
and opportunity for primary care
physicians as we move forward
improving health and the health
care system. Primary care needs
to lead the way.