Health Care Spending Benchmark and 

Opioid Response

Kara Odom Walker, MD, MPH, MSHS

Cabinet Secretary

Join us on Twitter: @Delaware_DHSS1

DELAWARE ACADEMY OF FAMILY PHYSICIANSMarch 14, 2018John Ammon Education Center, Christiana Care Health System

Delaware’s Road to Value

Support patient‐centered, coordinated care.

Prepare the health provider workforce and infrastructure.

Improve health for special populations.

Engage communities.

Ensure data‐drivenperformance.

Pay for Value

Improved Quality and Cost

#ourhealthDE2

Why the Benchmark Is Important

• Delaware’s per‐capita health care costs are more than 25% above the U.S. average.

• Delaware’s health care spending is expected to more than double by 2025.

• Health care costs consume at least 30 percent of Delaware’s budget.

#ourhealthDE3

Delaware’s Overall Health Is Poor

• Our population is older and aging faster. 

• We are sicker than the average state. 

• Our investments have not led to better outcomes —we are ranked 30th in America’s Health Rankings. 30

RANKED

#ourhealthDE4

SOURCE: Delaware Office of Management and Budget; DEFAC Expenditure Reports.1- Infrastructure funds reported from Transportation Trust Fund expenditures, not General Fund.2- Salaries are not inclusive of public education salaries.3- Healthcare includes employee health benefit expenditures and Medicaid expenditures.4- Public safety expenditures include expenditures by DSHS, DOC, and Youth Rehabilitative Services (DSCYF)

• During this same time frame, General Fund revenue collection has grown by just 7.6%.

• Health care costs now account for about 30% of the state’s budget .

Increasing Health Care Costs

DELAWARE GENERAL FUND EXPENDITURES1, FY2013 VS. FY2017

 $‐

 $200

 $400

 $600

 $800

 $1,000

 $1,200

 $1,400

FY 2013 FY 2017

Salaries2 Health Care3 Public Ed Infrastructure Public Safety4

+$202M(+22%)

• Crowds out necessary investments in: Salaries Education Infrastructure Public Safety5

#ourhealthDE

Delaware Spends More on Health Care Than Most Other States

PER CAPITA PERSONAL HEALTH CARE EXPENDITURES, 2014

NOTE: District of Columbia is not included.SOURCE: Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, CMS, 2017.

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

UT AZ GA NV CO ID TX NM NC AL HI SC TN AR CA VA OK MS KS LA WA KY OR MI FL MO IA MT IL IN WY NE MD WI OH NJ MN SD PA WV ME RI NH NY ND CT VT DE MA AK

State

NATIONAL AVERAGE

#ourhealthDE6

Delaware’s Total Health SpendingWill Double from 2015 to 2025

$6.7$7.1

$7.5$7.9

$8.4 $8.6$9.0

$9.5$10.2

$11.0$11.9

$12.8

$13.8

$14.8

$16.0

$17.2

$18.5

$19.9

$21.5

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

ACTUAL

PROJECTED

2%

3%

5%

SOURCES: Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, CMS, 2017; 

Year

Growth Target

5%

3%

2%

DELAWARE’S ACTUAL AND PROJECTED PERSONAL HEALTH CARE EXPENDITURES, 2007—2025(BILLIONS OF DOLLARS)

#ourhealthDE7

Per Person Spending in Delaware Is Higher Than the National Average in Every Category of Service

UNITED STATES AND DELAWARE PER CAPITA SPENDING BY SERVICE, 2014

SOURCE: Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, CMS, 2017.

$3,079

$1,874

$1,114$1,216

$614

$146

$4,078

$2,259

$1,525 $1,438

$757

$197

UNITED STATES DELAWARE

Hospital Care Physician andClinical Services

Drugs andOther Medical Nondurables

Nursing Home,Home Health, andOther Personal Care

Dental and OtherProfessional Services

Medical Durables

8#ourhealthDE

Private Medicare Medicaid

Medicare and Medicaid Account for Nearly 40%of Delaware’s Health Spending

SOURCE: Centers for Medicare & Medicaid Services, Health Expenditures by State of Residence, CMS, 2017.

16%

64%

Private/Other$6.1

TOTAL PERSONAL HEALTH EXPENDITURES BY PAYER IN DELAWARE, 2009(MILLIONS OF DOLLARS)

Medicaid$1.51

Medicare$2.0

20%

#ourhealthDE

Opportunities and Threats to Better Health

• We purchase health care for a greater share of the population than most other states.

• We have made progress on moving to value‐based payment models.

• The current pace of adoption of downside risk may not be sufficient to achieve our goals.

#ourhealthDE10

Our Objectives:Improved Choice and Better Delivery

• Give Delawareans choices and information to help them make better health care decisions.

• Reinforce healthy choices via institution and neighborhood design.

• Support primary care infrastructure that allows for improvements.

#ourhealthDE11

Strategy One

Improve Health Care Quality and Cost

• Establish a value‐based, health focused, public health framework.

• Create systems of care centered on quality, patient experience and costs with a strong primary care foundation.

• Reduce unnecessary and inappropriate care.

$

#ourhealthDE12

Strategy Two

Pay for Value

• Establish a health care spending benchmark that can examine cost drivers.

• Reorient data‐driven monitoring of cost toward value and put this information in the hands of physicians.

• Require cost and quality thresholds in Medicaid Managed Care Organization contracts. 

#ourhealthDE13

Strategy Three

Support Patient‐Centered, Coordinated Care • Create all‐payer ACOs to facilitate integration of services and patient‐centered medical homes.

• Support and pay for coordination of care across settings.

• Create reimbursement approaches for safety‐net services. 

• Examine the Health Resources Board’s authority to both allow for system growth and right‐sizing.

#ourhealthDE14

Strategy Four

Support the Health Care Provider Workforce and Health Care Infrastructure Needs

• Support primary care workforce, dental, behavioral health, and health‐professions education.

• Increase racial and ethnic diversity of workforce.

• Prepare for safety‐net providers’ increased needs.

• Invest in telehealth and coordination of services for at‐risk populations.

• Invest in provider‐readiness infrastructure.

#ourhealthDE15

Strategy Five

Improve Health Care for Special Populations

• Strengthen capacity to promote health equity for people with disabilities.

• Continue to focus on maternal‐child health.

• Establish a trauma‐informed system of care.

• Use patient‐centered medical homes for prison‐reentry population.

#ourhealthDE16

Strategy Six

Engage Communities

• Improve community‐based wellness initiatives, including ACEs, obesity prevention and tobacco cessation.

• Create population‐health metrics and community data‐driven approaches.

#ourhealthDE17

Strategy Seven

Ensure Data‐Driven Performance

• Use public‐private collaboration to establish quality and cost targets.

• Create methodology for ACOs to interpret quality and cost goals.

• Align all payers with total‐cost‐of‐care models leveraging DHIN capacity and HCC‐’like’ authority.

• Use a multipronged approach to strengthen the exchange and Medicare ACO strategies.

#ourhealthDE18

What’s Included in the Benchmark

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BASED ON AFFORDABILITY,

QUALITY AND TOTAL COST OF HEALTH CARE

Value-Based Payments

Bundled Payments

Episodic Payments

Managed Care Per Member Per Month

(PMPM)All-Inclusive

Population-Based Payments

Accountable Care

Organizations

Patient-Centered

Medical Homes

Managed Care Organizations

Integrated Delivery Reform

Payment Reform

Benchmark and Quality: What’s Next

20

How You Can Get Involved 

• Visit ChooseHealthDE.com’s relaunched website to read more about the benchmark:https://www.choosehealthde.com/Health‐Care‐Spending‐Benchmark

• Read more at the Health Care Commission website:http://dhss.delaware.gov/dhcc/global.html

• Watch archived Facebook Live videos of benchmark summits:Facebook.com/DelawareDHSS or youtube.com/DelDHSS

• View the DHSS report to JFC on the benchmark or Delaware’s Road to Value white paper, visit:http://dhss.delaware.gov/dhss/dhcc/global.html

• Send public comments on either report via email to: OurHealthDE@state.de.us

21#ourhealthDE

SUBSTANCE USE DISORDER RESPONSE

22

IN 2016, OVERDOSE DEATHS MORE THAN DOUBLE TRAFFIC DEATHS

Traffic Deaths in Delaware

120Overdose Deaths in Delaware

30823

DELAWARE’S TREATMENT LANDSCAPE

8,150 public treatment admissions for addiction in 2016. Heroin was the most common primary drug listed at time of admission.

Thousands more sought private treatment, in-state or out-of-state.

In the past decade, the number of Delawareans with Substance Use Disorder nearly doubled from 6,000 to 11,000.

During the same period, the number of people receiving SUD treatment increased by 500% from 1,000 to 5,000 – leaving a gap of 6,000. 24

STATE’S TREATMENT RESPONSE

Withdrawal Management: Two centers in the state.

Residential Treatment: Increased capacity across 4 locations.

Young Adult Opiate Residential Treatment: Doubled capacity.

Sober Living Beds: Doubled capacity.

Outpatient Treatment: Expanded services to include full continuum of support.

Recovery Response Center: Newarkand Ellendale centers for 24/7 crisis.

25

• Created by HB 220, signed by Governor Carney on August 16, 2017.

• Representatives from state agencies, professional communities and the public.

• Successor to the Prescription Drug Action Committee.

• Created to operate under the umbrella of the Behavioral Health Consortium.

ADDICTION ACTION COMMITTEE

26

ADDICTION ACTION COMMITTEE WORKING GROUPS

Pain Management: Ensure access to non-opioid approaches to pain management.

Safe Prescribing: Provider education and practice change support.

Access to Treatment: Access to comprehensive treatment; engage individuals into treatment; build a recovery system.

Criminal Justice: Engage individuals into treatment from the criminal justice system.

Public Education: Youth and their families; general public.

27

Executive Sponsor: Karyl Rattay

1. Reduction in substance abuse, non-fatal Overdoses and overdose deaths

STRATEGIC OBJECTIVESPerspective

Ass

ets

Hea

lth

S

tatu

sIm

ple

men

tati

on

Pro

cess

&

Lea

rnin

g

Strategic Focus: Prevent Substance Abuse

DHSS Strategy Map

5. Surveillance 6. Communication

8. Partnerships 9. Workforce7. Grants, Contracts, and

Payment Strategies

2. Prevent life-threatening

adverse outcomes

3. Diagnose, engage, treat and support individuals with

addictions and substanceuse disorders

4. Reduce the need toself-medicate, control accessto addictive substances andpromote protective factors

Vision: Delaware has a coordinated and comprehensive approach to prevent, identify, effectively treat and support those impacted by substance use disorder.

Revised 09-22-2017

2828

OVERDOSE PREVENTION AND SUD TREATMENT

Naloxone Access: Increased access without a prescription (SB 48).

Medicaid Changes: Removed barriers to addiction treatment (SB 109).

Prescription Monitoring Program (PMP): Department of State issued new prescriber regulations to cover patients’ first-time use of opioids and for treatment of chronic pain.

Relaunched HelpIsHereDE: Relaunched our one-stop website for information and services related to addiction prevention, treatment and recovery.

29

TIMINGFinding treatment at the moment of readiness.

EVIDENCE-BASED THERAPYIncreased access to evidence based treatment options, including medication assisted therapy.

LEVEL OF CAREMore options at the right level of care balancing resources, social circumstance, and severity.

RE-ENTRYOthers need access when, and if they have to start from the beginning.

OUR TREATMENT SYSTEMS NEED WORK

30

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LOOKING AHEAD: SUBSTANCE USE DISORDER TREATMENT STRATEGY

Substance Use Disorder Treatment System

Engaging, comprehensive, coordinated, integrated, high-quality, and person-centered.

Through Centers of Excellence – to cover the entire state.

Facilitating This Transition

Request for Proposals for the technical assistance to support a Centers of Excellence model is out.

DHSS expects the centers to open in 2018.

Behavioral Health Consortium

Led by the Lt. Gov., with oversight of entire system.

32

WHERE YOU COME IN: MEDICATION-ASSISTED THERAPY (MAT) LANDSCAPE IN DELAWARE

There are approximately 90 registered MAT providers in Delaware, representing 6.5% of primary care physicians.

33

THANK YOU

#ourhealthde

34

MEDICAID SPENDING IS HIGHER IN DE COMPARED TO NATIONAL

$13,063

$16,859

$3,278 $2,577

$5,736

$21,255 $21,875

$6,011

$3,799

$8,046

Aged Individuals withDisabilities

Adults Children Total

National DE

Medicaid per enrollee spending$ Thousands; Medicaid total spending, CY 2014

• DE has 5th highest total per enrollee Medicaid spending by state• DE has 3rd highest total per enrollee Medicaid spending by state for aged population; 4th highest for adults, 6th highest for

children

Source: Kaiser Family Foundation

DRAFT

Upper limit: $28,179Parents in household of three

Lower limit: $16,642for individual without children

DRAFT

GROWTH IN MEDICAID

FY 08 FY 09 FY 10 FY 11 FY 12 FY 13 FY 14 FY 15 FY 16 FY 17 (est.)

Monthly Average 152,316 160,018 173,771 193,633 207,067 212,693 217,658 224,198 220,000 222,000

 ‐

 50,000

 100,000

 150,000

 200,000

 250,000N

U

M

B

E

R

O

F

E

L

I

G

I

B

L

E

S

FISCAL YEAR

Medicaid Eligible Clients FY 08‐ FY 17Includes Affordable Care Act Growth in FY 15 ‐ FY 17

MEDICAID COST PER MEMBERPER MONTH

Commercial individual market

11%

20%

3%

27%

State employees2

(over 122,000 covered lives)

Medicaid1

(over 222,000 recipients)

20%

Commercial self-insured

13%

Medicare(17,000 state retirees)

6%Uninsured

Commercial fully insured

1 Excluding duals2 Excluding members with supplemental Medicare, estimated

Source: CMS Medicare Enrollment Dashboard; Census Population Without Health Insurance Coverage by State: 2013 to 2015; CMS-64 VII Group Break Out Report March 2016; Delaware Health Care Commission Presentation March 3, 2016, “Delaware’s Health Insurance Marketplace: Update on Activity”; State of Delaware Final Report on the State Employees Health Plan Task Force submitted December 15, 2015; MACPAC; AHIP Center for Policy and Research 2014 report “Trends in Medigap Enrollment and Coverage Options”; Employee Benefit Research Institute November 2012 Vol. 33 No. 11; United States Census Bureau QuickFacts

More than 50% under federal/state authority (Medicaid, State employees, retirees and exchange)

DELAWARE’S HEALTH INSURANCE LANDSCAPE

42

Health Care Cost Institute Analysis

• 2016 data from employer sponsored plans

• Included 26% of claims from 5 insurers in Delaware, not Highmark or AmeriHealth

To read more: http://www.healthcostinstitute.org/report/

43

Despite limited data: • Ranked 13th by total cost• 8 states have “older

populations”• 3rd highest inpatient costs• 13th highest outpatient costs

To read more: http://www.healthcostinstitute.org/report/