Bringing Value to the Table
Without Ending Up on the Menu
R. Allen Coffman, M.D., F.A.A.P.
President TN Chapter of the AAP
Highland Pediatrics, Hixson, TN
Assistant Clinical Professor, UTCOM/TCTCH
Chattanooga, TN
Disclosure Statement of
Financial Interest
• I, Allen Coffman,
DO NOT have a financial
interest/arrangement or affiliation with
one or more organizations that could
be perceived as a real or apparent
conflict of interest in the context of the
subject of this presentation.
Disclosure Statement of
Unapproved/Investigative Use
I, Allen Coffman,
DO NOT anticipate discussing the
unapproved/investigative use of a
commercial product/device during this
activity or presentation.
Disclosures
GOALS
1. Identify several megatrends in pediatric medicine
2. Discuss the Value-Based Medicine approach to
practice, it's purpose and benefits
3. Discuss the instability of a national medical
system heavily financed by Employer-based
payment
4. Describe gaps in reality of pediatric practice and
the expectations of government, payors and
patients
5. Encourage you in your practice of medicine
Growth in Total Health Expenditure Per Capita,
U.S. and Selected Countries, 1970-2008
$8,000
Per Capita Spending - PPP Adjusted
$7,000
$6,000
United States
$5,000
Switzerland
Canada
$4,000
OECD Average
Sweden
$3,000
United Kingdom
$2,000
$1,000
$0
1970
1975
1980
1985
1990
1995
2000
2005
Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350en (Accessed on 14 February 2011).
Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are
PPP adjusted. Break in series: CAN(1995); SWE(1993, 2001); SWI(1995); UK (1997). Numbers are PPP adjusted. Estimates for Canada and Switzerland in
2008.
Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en
(Accessed on 14 February 2011).
Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are
PPP adjusted.
National Health Expenditures per Capita, 19602010
NHE as a Share of GDP
5.2%
7.2%
9.2% 12.5% 13.8% 14.5% 15.4% 15.9% 16.0% 16.1% 16.2% 16.4% 16.8% 17.9% 17.9%
Notes: According to CMS, population is the U.S. Bureau of the Census resident-based population, less armed forces overseas.
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 1960-2010; file nhegdp10.zip).
Total Health Expenditure Per Capita,
U.S. and Selected Countries, 1970, 1980, 1990,
2000, 2008
$8,000
Per Capita Spending - PPP Adjusted
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$-
Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en
(Accessed on 14 February 2011).
Notes: Data from Australia and Japan are 2007 data. 2008 figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. 2000
figured for Belgium are OECD estimates. Numbers are PPP adjusted. Break in Series AUS (1998); AUSTRIA(1990); BEL(2003, 2005); CAN(1995); FRA(1995);
GER(1992); JAP(1995); NET(1998, 2003); NOR(1999); SPA(1999, 2003); SWE(1993, 2001); SWI(1995); UK (1997. Starting in 1993 Belgium used a different
methodology.
1970
1980
1990
2000
2008
Total Expenditure on Health as a Share of GDP,
U.S. and Selected Countries, 1970, 1980, 1990, 2000,
2008
18%
16%
Health Spending as Percent of GDP
14%
12%
10%
8%
1970
6%
1980
1990
4%
2%
0%
Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350en (Accessed on 14 February 2011).
Notes: Data from Australia and Japan are 2007 data. 2008 figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. 200
figures for Belgium are OECD estimates. Break in Series AUS (1998); AUSTRIA(1990); BEL(2003, 2005); CAN(1995); FRA(1995); GER(1992); JAP(1995);
NET(1998, 2003); NOR(1999); SPA(1999, 2003); SWE(1993, 2001); SWI(1995); UK (1997). Starting in 1993 Belgium used a different methodology.
2000
2008
10%
Public Health Expenditure as a Percentage of
GDP,
U.S. and Selected Countries, 2008
9%
8%
Percentage of GDP
7%
6%
5%
4%
3%
5.7%
6.3%
6.5%
6.6%
7.0%
7.2%
7.2%
7.3%
7.4%
7.4%
7.4%
7.7%
8.1%
8.1%
2%
1%
0%
Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350en (Accessed on 14 February 2011)
Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates.
8.7%
Public and Private Health Expenditures as a
Percentage of GDP,
U.S. and Selected Countries, 2008
18%
16%
Percentage of GDP
14%
12%
8.5%
10%
8%
1.5%
2.8%
1.3%
1.5%
2.5%
2.1%
1.7%
3.1%
7.7%
7.3%
2.4%
2.5%
8.1%
8.1%
Private
Expenditure
Public
Expenditure
2.5%
4.4%
6%
4%
2%
6.6%
5.7%
7.2%
7.2%
6.5%
7.0%
8.7%
6.3%
7.4%
0%
Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en
(Accessed on 14 February 2011).
Notes: Data from Australia and Japan are 2007 data. Figures for Canada, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted.
Distribution of National Health Expenditures, by Type
of Service (in Billions), 2010
Nursing Care Facilities &
Continuing Care Retirement
Communities, $143.1 (5.5%)
NHE Total Expenditures: $2,593.6 billion
Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment,
etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity,
research, and structures and equipment, etc.
Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the
Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health
Expenditures by type of service and source of funds, CY 1960-2010; file nhe2010.zip).
Cumulative Increases in Health Insurance Premiums, Workers’
Contributions to Premiums, Inflation, and Workers’ Earnings,
2000-2010
Notes: Health insurance premiums and worker contributions are for family premiums
based on a family of four.
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2011.
Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual
Inflation (April to April), 1999-2011. Bureau of Labor Statistics, Seasonally Adjusted
Data from the Current Employment Statistics Survey, 1999-2011 (April to April).
Average Annual Worker and Employer Contributions to
Premiums and Total Premiums for Family Coverage,
1999-2011
$13,375*
$12,680*
$12,106*
$11,480*
$10,880*
$9,950*
$9,068*
$8,003*
$7,061*
$6,438*
$5,791
* Estimate is statistically different from estimate for the previous year shown (p<.05).
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2011.
$13,770*
$15,073*
Pediatric
Megatrends
•
•
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•
•
Value Driven Care/Variable Value Definition
Leadership/Patient Expectation Gap
Employer-Based Care
Prevention/Personal Liberty
Shift in Disease Chronicity
New Technology/EHR/HIT
Increasing Cost/Complexity of Business
MT
Best Practice
MT
Best Practice
Community
Standard of Care
MT
Best Practice
What
Families
Value
Community
Standard of Care
MT
Best Practice
What
Payors
Value
MT
What
Families
Value
Community
Standard of Care
Paid Services
Best Practice
What
Payors
Value
MT
What
Families
Value
Community
Standard of Care
MT
Value-Based Medicine
“Although most individuals would be
quick to say that their health care
is critical to them, they have better
information available to them
about airlines, restaurants, cars
and sellers on eBay than they do
about their healthcare.”
Porter, M. E. and Teisburg, E. O. Redefining
Health Care. Boston: Harvard Business
School Publishing. p 54
MT
Value-Based Medicine
• Practice of medicine based on the value
conferred by a systematic intervention.
• Value is the ability to measure improvement in
both length of life and quality of life.
• Standardizes parameters used in valuing our
interventions, and aims to do it well enough to
put it into policy, or at least help physicians know
the best way to proceed.
• Projected $123.9 billion savings in 2004 ($1.7
trillion)
MT
Value-Based Medicine
Evidence-based medicine
• practice of medicine
incorporating the highest level
of scientific evidence available
• inception of the term in 1992
• Combats the innate biases of
clinical practice deduction
MT
Value-Based Medicine
Patient-perceived value
• conferred by healthcare
interventions for the resources
(dollars) expended
• Dependant on quality of life
instruments
• Functional – AHA Functional
Capacity Classification,
Modified Rankin Scale
• Preference – Standard
Gamble, Willingness to Pay,
Time Tradeoff
MT
Value-Based Medicine
Value-based medicine
• Converts best evidence-based
data to value based form using
the preferences of patients who
have lived with the disease or
health state under study.
• Patient-perceived value of
virtually any intervention in
healthcare can then be
compared to that of any other
intervention using the qualityadjusted life-year (QALY) as a
common outcome measure.
• Cost-utility can be calculated
from the dollars expended for
the value ($/QALY) gained
A Value Based Medicine approach to health
care delivery is important because it…
A Value Based Medicine approach to health
care delivery is important because it
standardizes the parameters used to value
medical intervention so that medical
providers and patients can make better
decisions
MT
Value-Based Medicine
Melissa Brown, M.D.
Director of the Center for Value-Based Medicine, and is on
the faculty at University of Pennsylvania and the Leonard
Davis Institute of Healthcare Economics
MT
Patient-Centered Outcomes
Research Institute
• The Institute will spearhead efforts to prioritize and fund
Comparative Effectiveness Research (CER)
• Establish an objective research agenda;
• Develop research methodological standards;
• Contract with eligible entities to conduct the research;
• Ensure transparency by requesting public input; and
• Disseminate the results to patients and healthcare
providers.
MT
MT
Value-Based Medicine
•
•
•
•
•
•
Patient Care Management
Medical Home
Patient/Family Centered Care
Critically Assessed Topics
Evidence-Based Clinical Pathways
Health-Care Quality
MT
Value-Based Medicine
MT
NCQA ACO Metrics
Quality Metrics to Measure Better Care for
Individuals
• 1)Patient/Caregiver Experience (7
measures)
• 2)Care Coordination (16 measures,
including transitions of care and HIT)
• 3)Patient Safety (2 measures)
MT
NCQA ACO Metrics
Quality Metrics to Measure Better Health for
Populations
• 4)Preventive Health (9 measures)
• 5)At-Risk Population/Frail Elderly Health
(31 measures) on the following:
Diabetes, Heart Failure, CoronaryArtery
Disease, Hypertension, Chronic Obstructive
Pulmonary Disease, Frail Elderly
MT
Institute for Health Care Delivery
Research
Intermountain Healthcare
http://intermountainhealthcare.org/qualitya
ndresearch/institute/Pages/home.aspx
Intermountain Healthcare
• 1995 Community Acquired Pneumonia Project (Sanpete
County, Utah)
• Initial triage criteria for hospitalization, the choice of initial
antibiotics, the work flow to get antibiotics started quickly
and a conversion protocol to shift inpatients to medications
that could be delivered in the out-patient setting
• Cost dropped 12.3
• Revenues dropped 17.5 percent because complications fell
MT
Leadership/Patient Expectation Gap
MT
Ambulatory Health Clinic Impact on
National Economy
2008
2009
2010
• Health care and social assistance ..................
1,006.3
1,053.7
1,109.2
• Ambulatory health care services ........................
487.2 (3.4)
506.4 (3.6)
549.3 (3.8)
• Hospitals and nursing and residential care facilities
431.6
457.0
465.6
• Social assistance..........................................
87.5
90.3
94.3
Donald D. Kim, Teresa L. Gilmore, and William A. Jollif. “Annual Industry Accounts Advance Statistics on GDP by Industry for 2011.” U.S. Bureau of Economic
Analysis. May 2012. Web. 3 May 2012.
MT
Leadership/Patient Expectation Gap
Insurance Exchanges
• Each state to build IT platform
• Each state negotiate with major insurers
• CMS would build façade and integrate SSI and
IRS data
• State would run application for Medicaid and
Medicare programs through the exchange
• Subsides would than run through states
exchange and financially support exchanges
15
15
16
3
2
Statehealthfacts.org
MT
MT
Leadership/Patient Expectation Gap
Accountable Care Organization
• Network of health care providers that band together to
provide the full continuum of health care services for
patients
• Receives a payment for all care provided to a patient,
and would be held accountable for the quality and cost
of care
• Proposed pilot programs in Medicare and Medicaid
would provide financial incentives for these
organizations to improve quality and reduce costs by
allowing them to share in any savings achieved as a
result of these efforts
MT
Why ACOs?
• “The ACO is designed to provide greater efficiency in the
provision of care. Its intent is to create an organization
that takes out the seams between the physicians and the
institutions and outpatient care -- so it’s really something
that conceptually makes a great deal of sense.”
Barry Ostrowsky, CEO of Barnabas
Health, parent of Newark Beth Israel.
MT
Why ACOs?
Overarching Goals of the Shared Savings Program
• Better care for individuals
– Improve individual patient experiences of care along the IOM 6 domains
of quality: safety, Effectiveness, patient-centeredness, timeliness,
efficiency, and equity
• Better health for populations
– Encourage better health for entire populations by addressing underlying
causes of poor health, such as physical inactivity, behavioral risk
factors, lack of preventive care and poor nutrition
• Lower growth in expenditures
• Lower the total cost of care resulting in reduced expenditures
MT
Leadership/Patient Expectation Gap
Independent Practice Association
• Network of physicians in a region or community—solo practitioners
and groups of physicians—who agree to participate in an association
to contract with health maintenance organizations, other managed
care plans, and also vendors for the benefit of the each of the
physicians in the IPA
• Two distinct options an IPA may take with regard to its managed care
operations: assume financial risk for its physician members; or, allow
the third-party payors with which the IPA contracts to continue to act
as the insurer, and, therefore ultimately the insurer remains financially
accountable for the deals they strike with the IPA.
MT
MT
Leadership/Patient Expectation Gap
Medicine – Why Did I Choose to Work in this
Industry?
•
•
•
•
Rethink health paradigm
Restructure care delivery
Redesign cost accounting
Do it with no capital added
to system
• No stability in the market
MT
Scope and Magnitude of Health
Management Change
“It is going to be difficult because it really is a
major change in the way that healthcare has
traditionally been delivered. Overall, we think
accountable care is inevitable regardless of the
outcome of federal healthcare reform” because
of economic forces at work that will require
attacking the high cost of care.
Dr. Louis Bezich, chief of staff at Cooper
University Hospital, a member of the Camden
(NJ) Coalition
MT
Scope and Magnitude of Health
Management Change
“This is very complicated,” Cantor said. “It is conceptually
simple: Providers save money and share in the savings,
and in the process improve care. But how do you
measure improvement? What activities are allowable
and required? What is the approval process? How do the
dollars flow? There are a lot of moving parts.”
Joel Cantor, Director Rutgers Center for State Health
Policy (The organization that is assisting NJ with
Medicaid ACO law, evaluating cost impact and do
annual ACO evaluation)
MT
Leadership/Patient Expectation Gap
MT
Employer-Based Care
•
•
•
•
U.S. only major economy with this pervasive price
discrimination.
Large plan patients are subsidized by members of
small groups,
The un-insured and out-of-network patients pay higher
list prices.
Artificially high list prices make more patients unable to
pay, driving up uncompensated care expenses, which
leads to even higher list prices and pressure for even
bigger discounts to large groups.
Changes in the U.S. population source of
insurance from 1987 to 2009
United States Census Bureau
Health Insurance Coverage Status and Type of Coverage by Sex, Race and
Hispanic Origin: 1987 to 2005
Percentage of the U.S. population is quickly
shifting to public insurance or no insurance
United States Census Bureau
Health Insurance Coverage Status and Type of Coverage by Sex, Race and
Hispanic Origin: 1987 to 2005
MT
Dr. Robert Galvin
Director of Global Health
General Electric
"We need to find the Oprah [Winfrey] of healthcare," he
says. To some extent, employees might not trust an
employer or a health plan as much as they would trust a
third-party advocate who offers independent
recommendations on healthcare choices. "If Oprah ever
gets into this game, the 10% of consumers who will
change on their own will become 70% who will change
because they have a trusted person to listen to," he
says.
MT
Prevention/Personal Liberty
Florida Gun Law Would
Make It Illegal For
Doctors To Counsel
Parents On Gun Safety
MT
Increasing Disease Chronicity
MT
New Technology/EHR/HIT
• Working closely with Health Information
Partnership for Tennessee
• Partnering with other physician professional
groups in Tennessee to focus message about
HIT
• Pushing for Standards
in Medical Data
MT
MT
Increasing Cost of Business
Overhead
MT
Initial ACO Startup Costs
•
Tom Scully, former Center for Medicare & Medicaid Services (CMS)
administrator and current partner at New York private-equity firm Welsh
Carson Anderson & Stowe, said, "The start-up cost of a real ACO is
probably $30 million and up in a midsize market.“
•
CMS estimated it will take $1.7 million per ACO, based on a 2008 study of
the Physician Group Practice Demonstration project.
•
The American Hospital Association (AHA), however, estimated ACO startup costs are between $5.3 to $12 million, depending on the hospital size.
•
In addition to legal and start-up costs, there also are other accreditation
costs, should providers elect to use the voluntary National Committee for
Quality Assurance (NCQA) ACO accreditation launched in November for an
independent assessment before participating in the governmental Shared
Savings or Pioneer ACO programs.
MT
MT
20/20 View of the Future
•
Jeff Goldsmith is president of Health Futures
Inc., a health-care consulting firm, and an
associate professor of public-health sciences
at the University of Virginia, in Charlottesville.
Tom Scully, the Center for Medicare and Medicaid
Services administrator from 2001 to 2004. Mr.
Scully is a former chief executive of the Federation
of American Hospitals. He also is currently a
partner at Welsh Carson Anderson & Stowe.
MT
20/20 View of the Future
•
The major savings for Medicare are to be found by keeping people out of the hospital,
and reducing the incomes of the specialists who dominate hospital politics.
•
The ACO actually looks like a terrible business deal for providers. In order to get any
shared savings, they will have to spend millions on consulting, systems, care
managers and IT staff, give up a dollar in immediately reduced income, and maybe, if
they check all the boxes right, get 50 or 60 cents back in 18 months.
•
The biggest problem with the ACO, however, isn't the faulty business proposition, but
the patient's role. Before managed care, most patients didn't understand they were
getting a poorly coordinated, dangerous product. The only reason for them to tolerate
managed care's restrictions was to save themselves money—lower premiums and
lower cost sharing.
•
Managed care became something done to patients by their employers and by doctors
and hospitals that patients believed were working for them. Patients have to become
more integrated in market
MT
20/20 View of the Future
• ACOs—measure doctors and pay them for better outcomes. Except
that the incentives are very small, the change will be slow, and we
are just nibbling at real system reform.
• The goal of ACOs was to organize doctors to focus more on patients
and keep the patients out of hospitals. Instead, doctors are selling
practices to hospitals in droves.
• If the doctors had the capital to organize comprehensive ACOs to
control their own fate and drive us to more efficient care, I would be
bullish on ACOs. But doctors are again along for the ride, not driving
the bus.
MT
20/20 View of the Future
• Focus on patient individual health record
• Aggressive in following, funding medical
economic study of bundled payment
• Innovate in a responsible way that is rewarded
and sustainable
• Recognize we know the market better than
anyone AND most of us know little about
medical economics and risk
• Continue to look for ways to invite the patient
into the market place
Erika Bliss,
MD
QLIANCE – Seattle, Washington
President &
CEO
• The Qliance Vision
•
Our vision is to reinvent primary health care via a network of medical
practices employed by and directly accountable to our patients. By
combining a culture of high quality care and service with best practices in
medicine, technology and business, we will:
– Enable the vast majority of Americans, regardless of health or economic status,
to access exceptional primary care and service.
– Enable our physicians and other providers to deliver exceptional primary care
and service, free of constraints from third party reimbursement.
•
We intend that the success of this great company will benefit our
employees, partners, investors and every American seeking medical care.
TNAAP SUPPORTS PEDIATRIC
PRACTICE
• Pediatric Council
Dr Suzanne Berman
• Practice Managers Network
• Simple, functional and reliable
communication
• Persistent and robust relationship with the TNCARE
Bureau and Insurers
• EPSDT, START, HEALED, Medical Home
• Resources to manage change
MT
ADVOCACY
• KYAAP, NCPS, TNAAP and VA-AAP
are organizations focusing on pediatric
medical care issues in your community
• Open to Local Initiatives
• Media Involvement
• National Professional Organizations
• Synergy Building – “Tearing down the
silos”
• Don’t be shy about financial
sustainability
GOALS
1. Identify several megatrends in pediatric medicine
2. Discuss the Value-Based Medicine approach to
practice, it's purpose and benefits
3. Discuss the instability of a national medical
system heavily financed by Employer based
payment
4. Describe gaps in reality of pediatric practice and
the expectations of government, payors and
patients
5. Encourage you in your practice of medicine
Bibliography
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Hibbard, J.H., J. Stockard and M. Tusler. “Does Publicizing Hospital Performance Stimulate Quality Improvement Efforts?” Health Affairs 22, no. 2
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“Current Population Survey, 1988 to 2006 Annual Social and Economic Supplements.” U.S. Census Bureau. 2006. Web. 24, April 2012
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AMERICA. August 2010. Web. 12 May 2012.
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