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LOOKINGFORWARD:THEFUTUREOFMEDICAIDANDTHEHEALTHCARESYSTEM
IanMorrisonPhD
www.ianmorrison.com
Twitter@seccurve
BASICRULESFORFUTURISTS
• Alwaysmakeforecastsaboutthingsthatarefaroff• Makesomanyforecaststhatoneofthemhastoberight• Nevergivepeopleanumberandayearinthesamesentence• Whateveryoudo,don’ttalkaboutelectionsthedayofanelection
OUTLINE
• ElectionsMatter• AmericanHealthcare:ProgressandPromise• LookingForward:
– TheFutureofTheHealthCareSystem– TheFutureofMedicaid
• LeadingChange
ELECTIONSMATTER
BREXITORBLOWOUT?
SCOTLAND,NORTHERNIRELANDANDLONDONVOTEDTOREMAIN
SCOTLAND,NORTHERNIRELANDANDLONDONVOTEDTOREMAIN:NEWSTODONALDTRUMP
OLDER,LESSWELLEDUCATEDANDNATIONALISTICVOTERSMORELIKELYTOBREXIT
THEPARTISANDIVIDEONHEALTHCARE
Source:Harvard/PoliticoOctober2016
VIEWONACAAREBASEDONVIEWSONGOVERNMENTROLEINIMPROVINGHEALTHCARESYSTEM
Source:Harvard/PoliticoOctober2016
WHATSHOULDHAPPENTOACA?
Source:Harvard/PoliticoOctober2016
REALITIESOFAPOLARIZEDAMERICA– 2016AND2018
• MajorchangesinhealthpolicyonlyoccurwhenonepartyholdsthePresidencyandbothHousesofCongress
• SomemajorchangesoccurwhenonepartyholdsthePresidencyandoneHouseofCongress
• Onlysmallincrementalchangesoccurotherwise– withtheexceptionofafewnon-polarizedissues.
CHANGESINACAWITHDEMOCRATWIN
• Morefundsforsubsidiesforall
• Subsidiestoreducehigh-deductibleplans
• Effortstoexpandcoveragetosomeuncoveredgroups
• Morefundsforprevention
• Someinterventioninpharmapricingpolicies
• Reductionoreliminationof“Cadillacinsurancetax”
• Debatesbutnoactionon‘Medicareforall’/Single-Payer– butstate“publicoptions”likely
• Maybe,morestatesexpandMedicaid
MAJORCHANGESINACAWITHREPUBLICANWIN
• MajorstructuralchangestoACA– changedname
• Endofmandates– individual/corporate
• Eliminationorreductionof“Cadillacinsurancetax”
• Establishingstatepre-existingconditionpools
• LessfederalsubsidiesforuninsuredandMedicaid
• MorestatediscretionforMedicaidspending
• Lessinsuranceregulation
AMERICANHEALTHCARE:PROGRESSANDPROMISE
• CoverageExpansion– Obamacare:ExchangesandManagedMedicaid
• PaymentReform– ACOs,MACRA,MedicareAdvantage,ManagedMedicaid,Bundlesandvalue
basedpaymentinprivatesector• VolumetoValue
– PaymentreforminconcertwithshifttoPopulationHealth,ProvidersatRisk• ConsolidationandIntegration
– Plans,healthsystemsandphysiciansmergingandpartneringmoreandmore• DeliveryShifttoAmbulatoryEnvironment
– Outpatient,alternatesiteandretail• ITInfrastructure
– UbiquitousEHRs,Telehealth,BigData,andConsumerfacingapps• EnhancingtheConsumer(andProvider)Experience
– HighDeductiblehealthcareisabluntinstrument– HighbarofserviceinaworldofApple,OpenTable,andUber
BIGDROPINUNINSUREDUNDEROBAMACARE
Date of download: 7/12/2016 Copyright © 2016 American Medical Association. All rights reserved.
Decline in Adult Uninsured Rate From 2013 to 2015 vs 2013 Uninsured Rate by StateData are derived from the Gallup-HealthwaysWell-Being Index as reported by Witters and reflect uninsured rates for individuals 18 years or older. Dashed lines reflect the result of an ordinary least squares regression relating the change in the uninsured rate from 2013 to 2015 to the level of the uninsured rate in 2013, run separately for each group of states. The 29 states in which expanded coverage took effect before the end of 2015 were categorized as Medicaid expansion states, and the remaining 21 states were categorized as Medicaid nonexpansion states.
Figure Legend:
BIGDROPINUNINSUREDINMEDICAIDEXPANSIONSTATES
LOOKINGFORWARDATAMERICANHEALTHCARE
10BigStoriesfor2016andBeyond• ServingShallow-PocketedConsumers• Consolidation:GoodorBad?• Employers:StayorGo?• ProviderPricesforPrivateInsurance• SpecialtyPharmaceuticals• MakingVolumetoValueReal• PopulationHealth• PhysicianDiscontent• InnovationatScale• MassiveMedicaid
SERVINGSHALLOW-POCKETEDCONSUMERS
CUMULATIVEINCREASESINHEALTHINSURANCEPREMIUMS,WORKERS’CONTRIBUTIONSTOPREMIUMS,INFLATION,ANDWORKERS’EARNINGS,
1999-2016
98%
160%
213%
92%
167%
242%
24%45%
60%
21%35% 44%
0%
50%
100%
150%
200%
250%
300%
199920002001200220032004200520062007200820092010201120122013201420152016
HealthInsurancePremiums
Workers'ContributiontoPremiums
SOURCE:Kaiser/HRETSurveyofEmployer-SponsoredHealthBenefits,1999-2016.BureauofLaborStatistics,ConsumerPriceIndex,U.S.CityAverageofAnnualInflation(ApriltoApril),1999-2016;BureauofLaborStatistics,SeasonallyAdjustedDatafromtheCurrentEmploymentStatisticsSurvey,1999-2016(ApriltoApril).
$5,277$4,955$4,823$4,565$4,316$4,129$3,997*$3,515$3,354$3,281*$2,973*$2,713$2,661*$2,412*$2,137*$1,787*$1,619$1,543
$12,865$12,591*
$12,011$11,786
$11,429*$10,944*
$9,773$9,860*
$9,325*$8,824
$8,508*$8,167*
$7,289*$6,657*
$5,866*$5,274*
$4,819*$4,247
201620152014201320122011201020092008200720062005200420032002200120001999
WorkerContribution
EmployerContribution
$18,142*
AVERAGEANNUALWORKERANDEMPLOYERCONTRIBUTIONSTOPREMIUMSANDTOTALPREMIUMSFORFAMILYCOVERAGE,1999-2016
*Estimateisstatisticallydifferentfromestimateforthepreviousyearshown(p<.05).
SOURCE:Kaiser/HRETSurveyofEmployer-SponsoredHealthBenefits,1999-2016.
$5,791
$6,438*
$7,061*
$8,003*
$9,068*
$9,950*
$10,880*
$11,480*
$12,106*
$12,680*
$13,375*
$13,770*
$15,073*
$15,745*
$16,351*
$16,834*
$17,545*
16%21%*
35%*40%
46%50% 49%
58%*61% 63% 65%
6% 8% 9%13%*
17%22%*
26% 28%32%
39%*45%
10% 12%*18%*
22%*27%*
31%34%
38%41%
46%51%
0%
10%
20%
30%
40%
50%
60%
70%
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
AllSmallFirms(3-199Workers)AllLargeFirms(200orMoreWorkers)AllFirms
*Estimateisstatisticallydifferentfromestimateforthepreviousyearshown(p<.05).NOTE:TheseestimatesincludeworkersenrolledinHDHP/SOsandotherplantypes.Averagegeneralannualhealthplandeductibles forPPOs,POSplans,andHDHP/SOsareforin-networkservices.SOURCE:Kaiser/HRETSurveyofEmployer-SponsoredHealthBenefits,2006-2015.
PERCENTAGEOFCOVEREDWORKERSENROLLEDINAPLANWITHAGENERALANNUALDEDUCTIBLEOF$1,000ORMOREFORSINGLECOVERAGE,BYFIRMSIZE,2006-2015
CUMULATIVEINCREASESINHEALTHINSURANCEPREMIUMS,WORKERS’CONTRIBUTIONSTOPREMIUMS,INFLATION,ANDWORKERS’EARNINGS,1999-2015
88%
138%
203%
75%
158%
221%
20%
42%56%
17%31% 42%
0%
50%
100%
150%
200%
250%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
HealthInsurancePremiums
Workers'ContributiontoPremiums
SOURCE:Kaiser/HRETSurveyofEmployer-SponsoredHealthBenefits,1999-2015.BureauofLaborStatistics,ConsumerPriceIndex,U.S.CityAverageofAnnualInflation(ApriltoApril),1999-2015;BureauofLaborStatistics,SeasonallyAdjustedDatafromtheCurrentEmploymentStatisticsSurvey,1999-2015(ApriltoApril).
INSUREDADULTSWITHLOWERINCOMESWEREMORELIKELYTOREPORTTHEYHADDELAYEDORAVOIDEDGETTINGCAREBECAUSEOF
THEIRCOPAYMENTSORCOINSURANCE
Note:FPLreferstofederalpovertylevel.Source:TheCommonwealthFundHealthCareAffordabilityTrackingSurvey,September–October2014.
30 28 28 24
46
10 10 12 1021
0
25
50
75
Hadamedicalproblem,butdidnotgotoadoctororclinic
Didnotfillaprescription
Skippedamedicaltest,treatment,orfollow-uprecommendedbyadoctor
Didnotseeaspecialistwhenyouoryour
doctorthoughtyouneededto
seeone
Atleastonecost-related
accessproblem
<200%FPL 200%FPLormore
Insuredadultsages19–64whopayacopaymentorcoinsurance
Percentresponding“yes”
25
DOESSATISFACTIONMATTER?COMPAREDTOWHAT?
2010(A)
2012(B)
2013(C)
2014(D)
2015(E)
2016(F)
77% 79% 84% 81% 79% 77% Satisfactionwithyourinsurancebenefits
Insuranceplanmeetsmy/myfamily’sneedsvery/extremelywell
Satisfactionwithoutofpocketcostsforhealthcareservices
Preparedfor:StrategicHealthPerspectivesBase:AllUSAdults(2010n=2775,2012n=2000,2013n=2501,2014n=2501,2015n=5037,2016n=10011splitsampled)Source:Q600:Howsatisfiedordissatisfiedareyouwitheachofthefollowing?;Q185:Thinkingnowaboutallthedifferentcomponentsofyourhealthinsuranceplan,howwelldoesyourplanmeetyour/yourfamily’shealthneeds? Significancetestedat95%
GeneralImpressionofHealthInsurance(Top-2Box%)
58% 59% 66% 62% 61% 61%
Satisfactionwithoutofpocketcostsforprescriptionmedications 62% 66% 72% 66% 67% 66%
69% 66% 55% 56% Only47%ofExchangebasedplanholdersfeeltheirplanmeetsneedsveryorextremelywell,54%of
Medicaid,61%ofMedicareand56%ofthosewithcommercialplans
However…
F ABDEF
AEF AF
A ABDEF
A A A
ABDEF
AB A A
DEF EF
26
Somechangetowardsthepositive,but1in4consumersremainspowerless
Preparedfor:StrategicHealthPerspectives
Base:AllUSAdults(2014n=2501,2015n=5037,2016n=30052)Source:Q90Howwouldyoudescribeyourfeelingsaboutthehealthcareyoureceivetoday,includinghowmuchyoupayforitandthebenefitsyoureceive?Pleaseselectallthatapply.
CONSUMERSEMOTIONSTOWARDSHEALTHCARETHEYRECEIVENotmuchchangeNationallybutCaliforniansaresignificantlymorepositivein2016
ConsumerEmotionsTowardsHealthcareTheyReceive
9%
17% 19%
37%
28%
15%
23%
11% 14%
6%
20%
13%
32%
24%
17%
31%
14% 18%
9%
21%
15%
34%
24%
14%
26%
12% 17%
141516 141516141516
Empowered Hopeful Relieved Accepting Neutral Resigned/Givenup Powerless Depressed Angry
SHPCONSUMERS2016
Significantoverprioryear
13%
37%
24% 18%
27%
14%
21%
10%
California2016inRed
13%
141516 141516 141516 141516 141516 141516
STRATEGICHEALTHPERSPECTIVES℠
COSTMATTERSBECAUSECONSUMERSPAYMOREOFTHEINCREASE…THISMAKESTHEMFEELMOREPOWERLESS
Preparedfor:StrategicHealthPerspectivesBase:AllUSAdults(n=10011splitsample)Q660.Pleaseindicateifanyofthefollowinghappenedtoyouinthepastyear
28%Receivedabalancebillforcaretheythoughtwascovered
8% Receivedabillforhospitalservices''notinnetwork''eventhoughthe
hospitalwasinnetwork13%EXCHANGE
TOTAL
12% 21%
10% 13% 20% 36%
18% 22%
Resigned/Givenup Powerless Depressed Angry
14% 25%
11% 15% 21% 35%
21% 22%
Resigned/Givenup Powerless Depressed Angry
Havenot
Have
Havenot
Have
California21%
California6%
California13%
28
WHOISBORDERLINE?
9% 21% 15%
34% 24%
14% 26%
12% 17% 7%
15% 7%
15% 14% 30%
48% 31%
41%
Empowered Hopeful Relieved Accepting Neutral Resigned/Givenup Powerless Depressed Angry
40% HaveEmployerbasedinsurance
42% Had3+doctorvisitslastyear
32% Had1+ERvisitslastyear
51%Receivedabalancebillforcaretheythoughtwascovered
GenPop
20% Areuninsured
TheyareNOT onpublicinsurance!
7% HaveMedicaid
29
STRATEGICHEALTHPERSPECTIVES℠
AboveAverage
Average*
384748596066768890909394101111
143149161
181205Lowmonthlypremiums
Hasalowdeductible
Lowcopay fordoctorvisits
Accesstoallmedicalimagingatreasonablecost-sharing/co-pay
Reasonablecostsharing,orcopay levelsforhospitalization
Directaccesstoallspecialists(noreferralneeded)
Includesanextensivenetworkofdoctors
Accesstoleadinghospitalsinmyarea
Coveragefordependents
Coverageformedicalcareatretailclinicsorurgentcarecenters
Lowcopay forgenericdrugs
Accesstocuttingedgemedicaldevicesandmedications
Accesstobrandnamedrugsatreasonablecost-sharing,orco-pay,levels
Providesmewithcashincentivesorrewardsforhealthybehavior
Coverageforawideselectionofbrandnamedrugs
Includesanextensivenetworkofhospitals
Coverageforover-the-countermedications
Accesstospecialtyhospitals(i.e.children’shospitals)
TheinsurancebrandisanameIknowandtrust
LOWOUTOFPOCKETCOSTREMAINSCRITICALINPICKINGINSURANCEConsumersconcernedwithpremiums,deductiblesandcopays…reasonablecostsharingforhospitalservicesandretailcliniccoveragearesurging.
BASE:ALLQUALIFIEDRESPONDENTS(2015n=5037)Q65Respondentsweregivenamaximumdifferencetradeoffexerciseinwhichtheywereforcedtochoosethemostpreferredandleastpreferredplanfeature.*Averageis100,andthescoresrepresentimportancerelativetothataverage.
RelativeImportanceofBenefit
SHPCONSUMER2015
BelowAverage
Wasbelowavg in2014
Evenhigherthan2014
30
STRATEGICHEALTHPERSPECTIVES℠
OUTOFPOCKETCOSTCONCERNSAREBIPARTISAN
Preparedfor:StrategicHealthPerspectivesBase:AllUSAdults(n=10011splitsample),PartyAffiliations(Republicann=2666,Democratn=3328,Independentn=2826)Source:Q60Ifwecouldgreatlyimproveoneofthese,whichONEwouldyouchoose?
Ifwecouldgreatlyimproveoneofthese,whichONEwouldyouchoose?
Reducingtheout-of-pocketcostofhealthcaretotheconsumer
Improvingthequalityofcare
Reducingthecostofhealthcaretothegovernment(andthetaxpayer)
Reducingthenumberofpeoplewithinadequateornohealthinsurance
43%
19%
19%
19%
GenPop
47%
19%
24%
10%
Republican
43%
20%
21%
16%
Independent
39%
18%
15%
28%
Democrat
PartisanDifferencesinHealthCarePriorities
CONSOLIDATION:GOODORBAD?
HEALTHPLANCONSOLIDATIONCONTINUES
• AetnabuysHumanafor$37billionmakinga$115billionrunratecompany
• AnthemclosesonCignain$54billionmakesa$117billionrunratecompany
• NewRivalsfor$154billionUnitedHealthGroup
• Other:– Centene buysHealth
Netfor$6.3billion
PROVIDERCONSOLIDATIONCONTINUES
TheMassiveConsolidationcontinuestoward100-200LargeRegionalSystems
– Doctorsrunningtohospitals– Hospitalsconsolidatingregionally– Roleofprivateequityandforprofitsinconsolidation– Focuson“Essentiality”mayrunintoAttorneyGeneralsandAnti-Trustconcerns
– Therichgetricher:significantreturnstoscaleandtointegration
– Doctorsdiscretioninselectionofspecifictechnologiesandclinicalprotocolswillbeincreasinglyconstrainedbylargemotivatedhealthsystemsthatemploythem
33
EMPLOYERS:STAYORGO?
STRATEGICHEALTHPERSPECTIVES℠
Projectionsfor2016:Widerangeofestimates7.5
9.7 10.3
14.713.0
10.68.5 8.0
6.0 6.0 7.0 6.0 5.4 5.24.1 4.4 4.0
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
HealthcaretrendafterplanandcontributionchangesCPI-U
WellsFargo
Mercer
EMPLOYERSARESEEINGAPROLONGEDRESPITEFROMDOUBLE-DIGITPREMIUMINCREASES,BUT THESEARESTILL
RUNNINGATTWOTIMESCPI
SOURCE:Towers-WatsonNBGHAnnualSurveys(2014-2015)
TOWERSWATSON
18% 21% 27%
44% 46%
33% 26%
45%
59%
58% 45%
58% 53%
87% 88%
2010 2011 2012 2013 2014 2016
FEWEREMPLOYERSARELOOKINGFORANEXIT;CONTINUETOFEELRESPONSIBILITYFOREMPLOYEEHEALTHNEEDS
*AskedonlyofEmployerswith50ormoreemployeesBase:AllEmployerHealthBenefitDecisionMakers(n=340)Q800:Pleaseindicateyourlevelofagreementwiththefollowingstatements.Doyoustronglyagree,somewhatagree,somewhatdisagreeorstronglydisagree?
Company’sPositiononEmployer-SponsoredHealthcare:ProvidingBenefits(Top-2Box%- DescribesCompletely/VeryWell)
Itisourresponsibilitytoensureouremployees'healthneedsaremet
Mycompanyisactivelyexploringwaystogetoutofprovidinghealthinsurancetoouremployees
Employer-basedhealthinsurancewillsoonbecomeathingofthepast
Mycompanyfeelsitisworthittopaythepenaltyassociatedwithnotprovidingemployeehealthbenefitsratherthanprovidinghealthbenefitstoouremployees.*
55%57%58%
54%53%50%50%
53%50%52%49%
52%48%*47%46%44%45%44%
66%67%69%69%68%68%66%
63%65%66%65%63%64%62%61%62%63%61%
62%63%65%63%62%61%60%59%59%60%59%59%58%56%56%55%56%55%
20%
30%
40%
50%
60%
70%
80%
199920002001200220032004200520062007200820092010201120122013201420152016
AllSmallFirms(3-199Workers)AllLargeFirms(200orMoreWorkers)
PERCENTAGEOFALLWORKERSCOVEREDBYTHEIREMPLOYERS’HEALTHBENEFITS,INFIRMSBOTHOFFERINGANDNOTOFFERINGHEALTHBENEFITS,BYFIRMSIZE,1999-2016
*Estimateisstatisticallydifferentfromestimateforthepreviousyearshown(p<.05).
SOURCE:Kaiser/HRETSurveyofEmployer-SponsoredHealthBenefits,1999-2016.
PROVIDERPRICESFORPRIVATEINSURANCE
MEDICARESPENDINGVERSUSPRIVATESPENDING:ADIFFERENTSTORY
Source:citedinNYTimes,December,15th,2015
PAYMENTTOCOSTRATIO(ILLUSTRATIVE)
0
0.5
1
1.5
2
2.5
3
Uninsured Medicaid MedicareCommercial PayerDemented Saudi Prince
0.07
0.69 0.89
1.5
3
Payment to Cost Ratio
Source:MorrisonEstimates,inotherwordsagoodguess
PAYMENTTOCOSTRATIO(ILLUSTRATIVE)
0
0.5
1
1.5
2
2.5
3
UninsuredMedicaid MedicareExchangeCommercial PayerDemented Saudi Prince
0.07
0.690.89
1.21.5
3Payment to Cost Ratio
Source:MorrisonEstimates,inotherwordsagoodguess
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42
70%
80%
90%
100%
110%
120%
130%
140%
150%
94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14
Private Payer
Medicaid(1)
Medicare(2)
AGGREGATEHOSPITALPAYMENT-TO-COSTRATIOSFORPRIVATEPAYERS,MEDICAREANDMEDICAID,1994– 2014
Source:AnalysisofAmericanHospitalAssociationAnnualSurveydata,2014,forcommunityhospitals.(1) IncludesMedicaidDisproportionateSharepayments.(2) IncludesMedicareDisproportionateSharepayments.
AMERICANHOSPITALASSOCIATION
SPECIALTYPHARMACEUTICALS
STRATEGICHEALTHPERSPECTIVES℠
ENDOF“PATENTCLIFF”ANDEXPLOSIONINSPECIALTYSPENDINGPUTSRXINDUSTRYINTHESPOTLIGHT
HEP-C?TAKEATHREEMONTHLUXURYVACATIONTOEGYPTANDGETYOUREMPLOYERTOPAYFORIT
Thecostofa12weekcourseofSovaldi is$84,000intheUS,$900inEgypt.
84daysattheNileRitzCarltonat$250pernight=$21,00084Daysmealallowanceat$100perday=$8,400BusinessClassAirfarefromSFO =$2,800
TOTAL$32,200
SavingstoYourEmployer$51,800
OptionsBringyourspouse/partner Add$11,20010dayLuxuryNileSpaCruiseforTwoAdd$11,120
TOTAL$54,520
SavingstoYourEmployer$29,480
46
STRATEGICHEALTHPERSPECTIVES℠
MAJORITYCONTINUETOSUPPORTPRICECONTROLS
Whilemoststillfeeltheneedforpricecontrolsforpharmaandhospitals,physicianpricecontrolsignificantlydroppedthisyear
StrategicHealthPerspectives,2016ConsumerResearch,NielsenConsumerInsightsBase:AllUSAdults(n=30052)Source:Q80Howmuchdoyousupportoropposethefollowingideas?
72%
Pricecontrolsorcapsonpharmaceutical/medicaldevicemanufacturers
+0
67%
Pricecontrolsorcapsonhospitals
-1
60%
Pricecontrolsorcapsonphysicianpayment
-10
LevelofSupportforPriceControls(Top2Box:Strongly/SomewhatSupport)
Changefrom2015:
MAKINGVOLUMETOVALUEREAL
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pany
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48
Base:AllHospital-BasedExecs(2016:n=205;2015:n=200;2014:n=202)Q980:Whichofthefollowingbestdescribesyourhospital’s/hospitalsystem’s“riskbearing”strategy?
Hospitalscommittingtoclinicalintegrationforcontractingw/payersbutfullriskonlyforthefew
HospitalRiskManagementStrategy
RISKBEARINGSTRATEGIESVARYCONSIDERABLY
SHPHOSPITALS2016
41%
29%
19%
10% 1%
31% 25% 26%
12% 8%
30% 28% 27%
9% 6%
Noplanstotakeriskbeyondmodestsharedsavingsandpay-for-
performancearrangements
Experimentingw/riskarrangements,butsmall
partofrevenue
Committedtoclinicalintegrationorganizationstrategyforcontracting
w/payers
BuildinganACOmodelthatiscapableoftakingrisksuchasMedicareAdvantageoremployer
directcontracting
Committedtomovingthemajorityofrevenuestofullyatriskwithin5
years
201420152016
THETENSION
Bundles•Moreisstillbetter• Encouragesimprovement•Noteverythingiseasilybundled
• “Screwmeonthebundle,andI’llscrewyouontherest”
PopulationHealth/Risk/AccountableCare
• Frequency•Appropriateness•DeterminantsofHealthcare• TheMutualDisrespectProblem
•SocialWorknotMedicalCare
WHATPOPULATIONLEVELANALYTICSREVEAL
• The5/50Problem– 5%accountfor50%ofspending– 1%accountfor20%– Bottom50%accountforabout2%
• Segmentationofpopulations• Whatyouwillfind…
– HONDAS– BehavioralHealth– EndofLifeCare– Cancer– Frailelderly– SocialWorknotMedicalCare– SpecialtyPharmaceuticals
THETRUCK,THEREFRIGERATORANDTHEBUS
POPULATIONHEALTHMANAGEMENT
• Segmenthigh-riskpopulations• Harnessadvancedanalytics• Usepatientregistriesandmedicalhomes• “Nooutcome,noincome”• Goupstream• Eatyourowncooking• Focusonthewholepopulation• Meetpeopleintheirlives• Emphasizewellnessandprevention• Thinkoutsidethebox• LeverageTechnology• Partner,partner,partner
Notes:GDPreferstogrossdomesticproduct.Source:E.H.BradleyandL.A.Taylor,TheAmericanHealthCareParadox:WhySpendingMoreIsGettingUsLess,PublicAffairs,2013.
HEALTHANDSOCIALCARESPENDINGASAPERCENTAGEOFGDP
12 12 11 11 1216
9 8 9 10 9
21 2120 18 15
9
16 15 11 10 11
0
10
20
30
40
FR SWE SWIZ GER NETH US NOR UK NZ CAN AUS
Healthcare
Percent
7075
8085
90Ex
pect
ed A
ge a
t Dea
th fo
r 40
Year
Old
s in
Yea
rs
0 20 40 60 80 100Household Income Percentile
EXPECTED AGE AT DEATH VS. HOUSEHOLD INCOME PERCENTILEFOR MEN AT AGE 40
Bottom 1%: 72.7 Years
Top 1%: 87.3 Years
New York City
San Francisco
Dallas
Detroit
7075
8085
90Ex
pect
ed A
ge a
t Dea
th fo
r 40
Year
Old
s in
Yea
rs
0 5$30k
10$60k
15$101k
20$683k
Household Income Ventile
RACE-ADJUSTED EXPECTED AGE AT DEATH VS. HOUSEHOLD INCOME FOR MEN IN SELECTED MAJOR CITIES
MASSIVEMEDICAID
MASSIVEMEDICAID
• USMedicaidPopulationedgesoutFranceandtheCongofortop19spotintotalpopulationwith72,650,000enrollees
• USMedicaidspendingedgesoutArgentinafortop25economiesat$540billion
• USMedicaidisbiggerthanWal-Martby$50+billion
MASSIVEMEDICAID
• ChurninginMedicaideligibles andexchangepopulation• Whowilltaketheseenrolleesandwhatwillbethefinancialimpactonprovidersthatdotakethem?
• Medicaidcoverskids,mums,expansionpopulations,supportsthedualeligibleandisthedefaultLTCpolicyforthemiddleclass
• CanwedesignfinanciallysustainabledeliverymodelsforMedicaid?
• Medicaidisdominantforlowincomeandchildren
• Medicaidpopulationhassignificantchurnofapproximately25%
• ExchangePopulationhas40%churnduemainlytochanginglifecircumstances
• Getto65andyouare“homefreeonMedicare”….atleastfornow
• RepublicansmaymoveageofMedicareeligibilityup
• Democratsmaymoveageofeligibility(orbuyin)down
INNOVATIONATSCALE
61
THESCOUTBADGEPROBLEM
PatientCenteredMedicalHome
AccountableCareOrganization
Telehealth Initiative
PatientPortal
ReadmissionReductionProgram
DiabetesDiseaseRegistry
QuantifiedSelfApp
CareBundles
RemotePatientMonitoring
E-Consults
Buthowmany?Andwhatisthedenominator?
STRATEGICHEALTHPERSPECTIVES℠
LOOKINGTO2020
• Pressureonpublicpaymentsourceswillcontinue• PrivatePayerswillnottoleratecostsshiftwillingly• Exchanges,MedicareAdvantage,ManagedMedicaidandConsumer
Engagementamongemployersmakesmarketmoreretail• Longrunthreepayersegments:ManagedMedicaid,HDHP(Exchangeand
Employer)andMedicareAdvantage/ACOincreasepressuretodelivervalue• CareRedesignforhigherperformance
– MigratingBusinessmodeltoRisk– Carecoordinationandmanagementacrossthecontinuumofcare– Alignmentofallphysicians,nursesandcaregiverswiththisprocess– Consumerfacinginnovationindeliveryandtele-health– InnovationatScale
• Governanceandleadershiptosustainitall
THREEFUTURESFORAMERICANHEALTHCARE
• Berwickian Nirvana:LargeintegrateddeliverysystemssuccessfullyinnovateandtransformcaretomeettheTripleAimspurredbymajorpaymentreformbypublicandprivatepayers
• DarwinianConsumerism:Federalsubsidiesandsupportarecutandhealthcareadaptstoaworldofhighdeductiblesandeconomicrationing
• DumbPriceControls:Democraticmajorityadministrationregulatesbudgetsandpriceslockinginmassiveregionalandinstitutionalinequitiesandunjustifiedclinicalvariation
THREEFUTURESFORMEDICAID
• Berwickian Nirvana:– InnovateinpartnershipwithManagedCareOrganizationsandpursuePopulationHealthInitiativeswithlikemindedproviderswhowanttobearrisk
– Combineallsocialspendingintargeted,focusedinitiativestoraisethewellbeingofcommunitiessufferingmultipledeprivationfromlackofeconomicopportunity,poverty,criminaljusticefailures,housingandtransportationinadequacies
• DarwinianConsumerism:IfFederalsubsidiesarecuteither:– BringbackDisproportionateShare– Institute“FairShare”whichmandatesthatproviders(includingphysicians)taketheirfairshareofuninsuredandMedicaid
• DumbPriceControls:Focusonmanagingquality,appropriatenessandoutcomeinaworldofadministeredprices
LEADINGCHANGE
• Maintainandexpandcoverage• Fixthefinancialgotchasforvulnerablepatients• Reducechurnbyextendingeligibilityforacalendaryear
• Consolidateandintegrateforvaluenoteconomicpower
• Innovateatscale• Improvethepatientandproviderexperience• Harnessthenewscience• Leaddon’tfollowtothefuture
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