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June 11, 2008
Patrick Miller, MPH, Research Associate Professor, UNH NHIHPP &Senior Staff, Citizens Health Initiative
NH Citizens Health Initiative:
Healthcare Issues, Challenges, and Initiatives
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National Trends
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U.S. Health Care Spending Reaches $2.1T in 2006,
Increasing 6.7%
Source: Kaiser Family Foundation
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Chronic illness costs the economy more than $1 trillion a year
35.7 billion22.1 billion13.6 billion2.4 millionStroke
131.8 billion104.7 billion27.1 billion13.7 millionDiabetes
138.9 billion93.7 billion45.2 billion49.2 millionPulmonary conditions
169.3 billion104.6 billion64.7 billion19.1 millionHeart disease
216.7 billion170.9 billion45.8 billion30.3 millionMental disorders
312 billion279.5 billion32.5 billion36.8 millionHypertension
$319.3 billion$271.2 billion$48.1 billion10.6 millionCancer
Total economic expense
Value of lost productivity
Treatment cost
Reported cases*Disease
Source: The Milken Institute's "Unhealthy America: The Economic Burden of Chronic Disease" relied on data from the Medical Expenditure Panel Survey (2003), U.S. Census Bureau, the Behavioral Risk Factor
Surveillance System and the National Health Interview Survey.
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5
Estimated Source of Funds Personal Health Care in US, 2006
Other Public8%
Medicaid16%
Other Private4%
Medicare22%
Insurance36%
Out-of-Pocket14%
Public Sources
46%
Private Sources
54%
Note: Some of the spending that is categorized as private insurance actually originates from public funds: insurance for teachers, postal employees, and other government workers.
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Source: CDC, UCSF, IFTF
10%
20%
20%
50%
Factors that influence our health
Medical Care
Environment
Genetics
Healthy Behaviors
Healthy Behaviors A Case of Misaligned Resources
88%
$2.1 Trillion
Medical Care
4 %8 %
Healthy BehaviorsOther
Where we’re spending our money
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We Get What We Pay For …
Products Paid For:TestsVisitsProceduresPrescriptionsErrors
Results Wanted: Improved HealthBetter Outcomes
Return to WorkInformed
EmployeesEfficiency
Safety
“Tell me how you measure
me, and I will tell youhow I will behave. If you
measure me in an illogicalway … do not complain about
illogical behavior.”
– Eli Goldratt, author of “The Goal”
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Need to create a healthcare market with the following characteristics:
Informed and Engaged Consumers
Market Transparency• Treatment Options• Outcome and Quality Metrics• Cost
Aligned Incentives
Leverage National and Community Partnerships (medical, education, coalitions, public policy)
Start of a Solution
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NH Marketplace
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12
NH Health Expenditure as % of Gross State Product (GSP)
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Year
Projected
Source: Calculations by Douglas E. Hall, NH Center for Public Policy Studies, based on national projections made by Office of the Actuary, Center for Medicare and Medicaid Services, Washington DC.
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13
NH Personal Health Care Spending, 1990-2005
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,00019
90
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Year
Expe
nditu
re ($
mill
ions
)
Hospital CarePhysician ServicesOther Professional ServicesDental ServicesHome Health CarePrescription DrugsOther Non-Durable Medical ProductsDurable Medical ProductsNursing Home CareOther Personal Health Care
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Most costs are for those over 40.
Distribution of Total Private Insurance Payments by Age <= 65CHIS Data, NH Residents Only, 2005
$0
$10,000,000
$20,000,000
$30,000,000
$40,000,000
$50,000,000
$60,000,000
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64Age
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U.S. Life Expectancy at Birth (1900-2000)
47.3
51.5
55.7
59.9
64
68.2 69.7 70.873.7 75.4 77
30
35
40
45
50
55
60
65
70
75
80
Year
s
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
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16
Grand Total Approved CON Applications~ $63 million per year
$0
$50,000,000
$100,000,000
$150,000,000
$200,000,000
$250,000,000
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
~ $700 Million
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Hospital OwnershipCritical Access Designation?
Operating Margin After Tax
Parkland Medical For Profit 11.9%Portsmouth Regional For Profit 10.4%Exeter Not-For-Profit 10.3%So. NH Regional Not-For-Profit 10.0%Elliot Not-For-Profit 8.8%Memorial Not-For-Profit Yes 8.7%Catholic Med Ctr Not-For-Profit 7.3%Wentworth-Douglass Not-For-Profit 7.0%Littleton Not-For-Profit Yes 6.8%Frisbie Memorial Not-For-Profit 6.6%Lakes Region Not-For-Profit 5.8%St. Joseph Not-For-Profit 5.4%Concord Not-For-Profit 3.9%Cheshire Not-For-Profit 3.3%Upper Conn Valley Not-For-Profit Yes 3.3%Mary Hitchcock Not-For-Profit 3.2%Speare Memorial Not-For-Profit Yes 3.2%Androscoggin Not-For-Profit Yes 2.7%Valley Regional Not-For-Profit Yes 1.7%Weeks Memorial Not-For-Profit Yes 1.4%Huggins Not-For-Profit Yes 1.0%New London Not-For-Profit Yes 0.5%Franklin Regional Not-For-Profit Yes 0.3%Monadnock Not-For-Profit Yes 0.3%Cottage Not-For-Profit Yes 0.2%Alice Peck Day Not-For-Profit Yes -2.1%
NH Post-Tax Operating Margins (2005)
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Use of Premiums by 5 NH Health Insurers, 2005
Medical/Hospital64%
Pharmacy12%
Other Professional Services
2%
ERs & Out of Area3%
Outside Referrals1%
General Administration7%
Net Underwriting Gain (Loss)
8%Claims Adjustment
3%82% of premiums paid for
claims while 18% was administration and profit
Total spending:$1,263,919,626
Based on annual financial reports filed with NH Department of Insurance
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2006 Net Underwriting Profit (Loss)
$32,076,297
$62,431,535
-$7,496,736
-$938,436-$2,340,652
-$20,000,000
-$10,000,000
$0
$10,000,000
$20,000,000
$30,000,000
$40,000,000
$50,000,000
$60,000,000
$70,000,000
Anthem Mathew Thorton Cigna Patriot Harvard Pilgrim
Anthem combined = $95.5M
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Over the last 30 years, after adjusting for inflation, healthcare premiums have increased more than 300%, yet average hourly wages for private employees have actually decreased by 4%.(2008, JAMA, Emmanuel and Fuchs)
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Plans Cost by StateAnnual Medical/RX Costs Per Associate 2006 Estimate – Hannaford’s Plan
$4,100 $4,300$4,900
$6,400 $6,500
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
Ann
ual C
ost P
er A
ssoc
iate
(200
6 Pr
ojec
ted
Cos
t)
New York Mass Vermont Maine New Hampshire
Hannaford Average $5600
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The Initiative
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Committee Definition ofHealth:
“Health is a state of well-being and the capability to function in the face of
changing circumstances”
Definition, Institute of Medicine Committee
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The Institute of Medicine, 1997
Improving Health in the Community
“For too long, the personal health care and public health systems have shouldered their respective roles and responsibilities separately from each other…we need to invest in a process that mobilizes expertise and action…if we are to substantially improve community and population health.”
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CommunityHealth
Population (public) Health
(Social Justice)
Personal (medical) Care
(Market Justice)
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Initiative Goal
Our long term goal is to create and sustain a public dialogue that will measurably improve the “systems” that finance and provide health care in New Hampshire in order to accomplish two fundamental objectives:
1. Assure a healthy population
2. Create an effective system of care
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Policy Teams Management &Operations
•Administration
•Bd. Of Advisors
•Communications
•Reporting
•Finance
•Policy
NH CHI Structure
Integration and EvaluationProjects:
HEAL Home, RAPHIC, Reimbursement Pilot,
Transparency Web Tools
Partners:NHPGH, Foundations, NH DHHS, NH DOI, Providers,
Payers, WebSolutions
Intake and Release
Management
Health Promotion &Disease Prevention
Finance, Transparency, & TechnologyQuality & Efficiency
•Physical Activity / Nutrition
•Tobacco
•Alcohol
•HIT/E Strategic Plan
•Transparency
•Engagement
•Reimbursement
•ePrescribing
•Primary Care Workforce
•Medical Home
•Reimbursement
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Health Promotion & Disease Prevention (HPDP) Team
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The leading underlying causes of death in New Hampshire are similar to the rest of the U.S.
Tobacco usePoor diet and physical inactivityAlcohol consumption Microbial agentsToxic agents
Pound of Prevention - 2006
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Primary Care Workforce
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Access to Primary Care Services
Which Physicians are Primary Care?F.P., I.M., Peds., Ob-Gyn, Behavioral Health, Oral Health
What is Primary Care?Access to acute illness care, preventative services, chronic care and coordinate/navigate a complex healthcare system.
Why the "risk of collapse"?Rapidly decreasing supply, while demand for services is increasing. Decreased access to timely primary care services will Increase health care costs and Decrease the quality of care (Rand, IOM ,ACP, AMA)
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Recruit/retain the primary care workforce for NH by “competitive” incentives (e.g., loan forgiveness programs)
Expand "dedicated" positions at professional schools for qualified NH students
Expand NH health careers programs –"grow your own"
Develop mechanism for statewide primary care workforce planning and development
Recommendations
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Reimbursement and Medical Home Team
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Reimbursement
Goal of redesigning reimbursement in NH to:
• Align reimbursement to promote comprehensive primary care
• Reward explicitly defined quality care • Slow the rate of growth in healthcare expenditures • Reward excellence in the delivery of evidence-based
clinical practices • Incent the use health information technology • Recognize administrative best practices.
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Medical Home Pilot
Target 1/1/2009Multi-payerMultiple provider types/settingsIn process of developing work plan and
funding plan
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NH Purchasers Group on Health
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MaineGeneral Medical Center
4% more
0% at state avg762.5
Miles Memorial Hospital
33% more
28% more61.1 7
Too Few Cases
Mercy Hospital 24% less
9% more562.5
St. Mary’s Regional Medical Center
13% more
8% less557.5
Penobscot Bay 18% more
10% lessNA45.0
Maine Medical Center
5% less
14% less67.5 1
Mid Coast Hospital 2% less
5% less465.0
Central Maine Medical Center
15% more
1% more57.5 3
PatientSatisfaction°
Patient Safety MeasuresMedication(MHMC)
Overall(Leapfrog)
Cost (Compared to State Average)Inpatient Outpatient
Why create this report card? • In 2005, BIW employees and their families received $24 million in services from Maine hospitals.• In 2004 and 2005, Maine hospitals reported 35 deaths due to Medical errors, 10 instances where a patient
permanently lost some form of body function, and 6 cases where surgery was done on the wrong person or body part.
Parkview Hospital 12% less
2% less260.0
Commitment To Safety
Selected Clinical Quality MeasuresHeart Attack
Heart Failure Pneumonia
Surgical Infection
Overall Score
Report Card #3:Report Card #3:MAINEMAINEHOSPITALSHOSPITALS
Excellent Unsatisfactory or not reported
KEY: Good PoorFair
1 2 3 4 5 6 7 8 9 10
Each of the measures is worth up to 10 points; Best score=100*
This is a lot of data. How do I use it in making my healthcare decisions? First:See where your hospital scores on each of the measures above.
Make note of where your hospital did really well. Have confidence in those areas if you or a loved one have to be hospitalized in the future.
Second:Identify areas where your hospital scored below your comfort level.
Third:If you or a loved one are in the hospital, be sure to ask questions of your provider regarding your areas of concern. Be involved!
Fourth:
Last years ranking
*Points assigned: 10 points 0 points7.5 points 2.5 points5 points
° All hospitals used the Avatar Patient Satisfaction tool with the exception of CMMC, which uses Press-Ganey to measure satisfaction.
As of April 2, 2007
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NHPGH Benchmark
Reports
2005-2007
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ePrescribing
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(1) Institute of Medicine. Preventing Medication Errors, 2006
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ePrescribing Benefits
ePrescribing results in • improved patient safety by prevention of
medical errors, • improved efficiencies for physicians and
pharmacists, • increased formulary compliance,• reduced medical costs, and • improved patient satisfaction.
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Core Components
ePrescribing has three core quality improvement and efficiencycomponents:
• Medication history. This information may come from a variety of sources, including electronic medical records, pharmacy claims data, or from prescriber-to-pharmacy transactions.
• Drug-to-drug interaction and allergy alerts. These provide decision support rules at the point of prescribing and combine this information with health insurance formularies and pharmacy benefit plans to assist the prescriber in their drug selection.
• Bi-directional pharmacy communication. This allows the prescribing practitioner to electronically write the prescription and transmit it to the pharmacy. Additionally, the pharmacy may request refills electronically without needing to fax or call the prescriber.
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3 Ways to Connect
Phone/PDAComputerElectronic Medical
Record
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NH’s Approach
In October 2006, the Governor issued a challenge to the industry to make ePrescribing happen
The NH Citizens Health Initiative provides project management, education, and marketing resources to stimulate the market
Active partnerships have been developed with providers, employers, payers, and ePrescribing industry to provide a “market” based solution to ePrescribing implementation
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NH’s Progress to Date
~50% of clinicians have an EMR with some level of electronic prescribing; “eRx Lite”; the base is largely in place
More than 80% of our pharmacies are ready to accept fully electronic prescriptions
Significant payer connectivity to RxHub or SureScripts
Payers – Providers – Employers Anthem/WellPoint partnership with NEPSI/Sprint 2007Keene Clinic rolled in spring 2008The Municipal Association is providing funding via their PBM contract to assist 40 high prescribers in 2008Several FQHCs, specialists, and hospitals are actively pursuing
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Health Information Technology & Exchange
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“We are looking for a system that will include electronic medical records, a system that will allow us to reduce medical errors, reduce duplicative procedures, control costs, help with encouraging pay for performance for health care providers, and ensure that patients are getting the highest standards of care.”
~ New Hampshire Governor John Lynch
Health Information Technology & Exchange (HIT/HIE)
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HIT/HIE: Setting the Stage
Federal GovernmentWhite HouseHHS ONC Strategic PlanHISPCAHRQ
NH Connects for HealthNH Citizens Health Initiative
Vision and PrinciplesSupport of Executive Order
National Governors Association eHealth Alliance
National Standards Development
HITSP, HL7, ANSI, ASTM, ISO, CCHIT
New England Telehealth Consortium (FCC)New England HIEs
VITL (VT)HealthInfoNet (ME)MAShare (MA)Rhode Island HHS (RI)
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April 28, 2008
Individual and Population Health & Well-being
Health IT solutions must support the needs of BOTH
“perspectives”
Population Health(Public health, Research, Quality,
Emergency preparedness)
Health Care(Higher Quality, More Efficient,
Patient-Focused)
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57
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April 28, 2008
Nationwide Health Information Network (NHIN)
Health Bank orPHR Support Organization
Community #1
IntegratedDelivery System
Community Health Centers
Community #2
CDC VA
CMS
DoD
SSA
Mobilizing Health Information Nationwide
The Internet
Standards, Specifications and Agreementsfor Secure Connections
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Source: ONC Federal HIT Strategic Plan 2008-2012
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Percentage of Office Practices UsingElectronic Medical Records
27%
73% 68%
32%
65%
35%45%
55%
0%10%20%30%40%50%60%70%80%
Single SpecialtyPractice
Multi SpecialtyPractice
Hospital/Institution Other
Yes No
Overall: 46% yes and 54% no
Source: UNH Survey Center, 2006
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Should Patients Have Access to Own Electronic Medical Records?
Yes, Definitely; 16%
Yes, Probably; 42%
No; 42%
Source: UNH Survey Center, 2006
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Pharmacies
Labs
Doctors Radiology
Public Health
Hospitals/Clinics Insurers
Move From This….
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Pharmacies
Labs
Doctors Radiology
Public Health
Hospitals/Clinics Insurers
HIE
To This….
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HIE Motivation
Quality and Safetyex. ADEs & increased clinical knowledge
Administrative Efficiencyex. 90% of 30B transactions are fax, mail, phone
Longitudinal Medical Recordex. Ability to see across provider settings & portability
Public Healthex. Disease surveillance & reporting
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Key Implementation Issues
Governance / Legal Structure
Privacy and Security
Technical Architecture
Start Up Funding / Sustainability
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72
Commercial Claims Medical Care Expenditures for NH Residents by State w/
Pharmacy REMOVED CY 2006
NH, 83%
VT, 1%MA, 10%ME, 1%
Other, 4%
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State of the State – HIT / HIE
•Competition for investment dollars (physical plant, Federal shortfalls)
•A system that can afford to invest
•Privacy and security picture is incomplete; controlled substances cannot be ePrescribed
•Few regulatory barriers
•Industry slow to adopt interchange standards
•ME & VT are developing statewide health information exchanges; NH interest exists
•ePrescribing “lite” wide spread•ePrescribing adoption is increasing
•Increasing “haves” and “have nots”•High levels of investment in electronic medical records
The RubThe Good News
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Vision for NH Health Care Information Technology and Exchange in 2014
…there is a need to recognize the interrelationships and importance of patient privacy, patient safety, and public health….the following vision for HIT/HIE for 2014:
Private and Secure. A patient’s personal health information will be secure, private, and accessed only with patient consent or as otherwise authorized or required by law.
Promotes Quality, Safety, and Efficiency. HIT and HIE will serve as vehicles to promote quality and patient safety, increase efficiencies in health care delivery, and improve public health;
Electronic. All health care providers will use a secure, electronic record for their patients’ personal health information;
Accessible. All patients will have access to a secure, electronic, and portable health record;
Equitable. HIT will be a vehicle to support equitable access to health careservices.