Kenneth E. Thorpe, Ph.D.Emory University

The Carter CenterHealth Care Reform: Challenges And Opportunities for Behavioral HealthNovember 5, 2009

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• Intertwined issues—Value for health spending—Cost containment—Health security

• Policy options—Care coordination inside and outside the

traditional health system—Prevention—Payment reforms

• Evidence• Reform prospects

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No care coordination in FFS Medicare 95% of spending in Medicare linked to

chronically ill patients Six chronic conditions (diabetes,

others) account for 40% of rise in Medicare spending—mainly conditions requiring drug and ambulatory care

High rates of preventable hospital admissions and readmissions

A third of the rise in spending traced to the doubling of obesity

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Long-term savings Lifetime health spending for obese

seniors is 15%-40% than for normal-weight peers with no chronic disease

Near-term savings RCTs show savings potential of

>$10 billion/year in Medicare with existing care management protocols

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Siloed care that does not integrate mental health, acute care, and chronic disease prevention, treatment, and management

Fragmentation 40% primary care docs in groups <4 More than ½ of people with serious chronic

conditions see >3 different physicians yearly Separation of prevention and treatment Outdated payment and delivery system

designed largely for acutely ill not chronically ill patients.

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Prevention Health risk appraisal and personalized

care plan added to Medicare No cost sharing for USPSTF “disease

detection” screenings Care management-system reform

ACOs – accountable care organizations Medical home pilots

Payment reforms

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Prevention and care management Identify key functions in successful models

that improve quality and reduce costs, such as: Coordinated care across providers and settings Transitional care Patient support, especially for medication

adherence Community-based care and support

Key: scaling and replication Federal investment ($30B)

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Community Prevention

Hospital

HEALTH INFORMATION TECHNOLOGY

Outcome Metrics, Evaluation

Bundled Payments

Specialists

Specialists

Specialists

Targeting the right patients Medication and testing adherence Transitional care programs Close integration with the coordinating

provider practice Ability to link with and refer to effective

community-based interventions Real-time evaluation and information on

clinical markers with feedback

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Medicare demos Integrated practices achieve better outcomes

and savings Savings up to 5% possible in current system

Penn transitional care RCTs 56% reduction in readmissions; 65% fewer

hospital days Average costs $4,845 lower

YMCA-DPP 11 lbs (~5%) weight loss; 58% diabetes Improved control of other CVD risk factors

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Trust for America’s Health community-based interventions Short-term ROI 1:1 Longer-term ROI ~6:1

Value of HIT Improved care coordination and administrative

processes Properly implemented and widely adopted,

annual savings from efficiency alone could be $77 billion or more

Health and safety benefits could double savings

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Medication adherence Adherence generally low: 50%-65% for common

chronic conditions such as hypertension and diabetes

Nonadherence is costly: ~$100 billion/year for hospitalizations alone

Proven strategies: patient education; improved dosing schedules; additional open clinic hours; improved communication between providers and patients

Adherence ROI: 7:1 for diabetes, 5.1:1 for hyperlipidemia, 3.98:1 for hypertension; overall healthcare spending 15% lower for CHF

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Community-based prevention $10/person/year could yield more than $16

billion in medical cost savings annually within 5 years

Coordinated care Meta-analysis of chronic disease

management studies showed 36%-45% drop in readmissions; 35%-45% drop in total hospital costs; ROIs from 1.4 to 32.7; Medicare savings from reduced CHF readmissions of $424 million per year

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Coordinated care Interventions for diabetes resulted

in $685-$950 drop in per patient per year costs; 9% drop in all-cause hospitalizations; 71% drop in ER/hospital utilization; 21% fewer total claims

Transitional care $25 billion investment in CHTs over

10 years could produce savings of $100 billion over the same period

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Prevention is not a single intervention Interventions must be evidence-based

Growing body of research shows what works

Integrated prevention is based in both the community and the health system Primary, secondary, and tertiary prevention are all

essential

Payment reform is critical Incent prevention through payment revisions

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State-level efforts pave the way Private sector is also innovating Senate bill released October 26 House bill introduced October 29

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Expand the capacity of two independent, advisory task forces — the U.S. Preventive Services Task Force (USPSTF) and the Task Force on Community Preventive Services (TFCPS) — to undertake rigorous, systematic reviews of existing science

Invest in prevention research to expand the evidence base

Eliminate cost‐sharing on recommended preventive services delivered by Medicare, Medicaid, and public option insurance (or Health Insurance Exchange)

Deliver community preventive services Invest in state, territorial, and local public health

infrastructure Provide grants to implement TFCPS‐recommended services

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Establish Prevention and Wellness Trust funded at $2.4 Billion in FY2010 and rising to $3.5 Billion in FY2014: $30 million in each of FY 2010-2014 to fund the activities

of the Clinical and Community Preventive Services Task Force.

$100 million in FY 2010 for prevention and wellness research and rising to $300 million in FY2014.

$1.1 billion in FY 2010 for community-based prevention and wellness services and rising to $1.6 billion in FY2014.

$800 million in FY2010 for core public health infrastructure and activities for state and local health departments rising to $1.3 Billion in FY2014.

$350 million in each of FY2010-2014 for core public health infrastructure and activities for CDC.

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Mandates national public-private partnership for a prevention and health promotion outreach and education campaign

“Community Transformation” grants for implementation, evaluation, and dissemination of proven evidence-based community preventive health activities to reduce chronic disease rates, address health disparities, and develop a stronger evidence base of effective prevention

“Healthy Aging, Living Well” program to improve the health of the pre-Medicare-eligible population to help control chronic disease and reduce Medicare costs. Pilot programs would evaluate chronic disease risk factors,

conduct evidence-based public health interventions, and ensure that individuals identified with or at risk for chronic disease receive clinical treatment to reduce risk

Community Health Teams

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Medicare pilots to test bundled payments

Value-based purchasing in Medicare to pay hospitals based on performance – focus on preventable readmissions

Care coordination – especially for “duals” – patients eligible for both Medicare and Medicaid

Comparative effectiveness research: focus on clinical services

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HouseHouse SenateSenate

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