My objective. Professor R. Lawrence Van Horn Ph.D Owen Graduate School of Management - Vanderbilt University

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1 R. Lawrence Van Horn, Ph.D, MPH, MBA Executive Director for Health Affairs Associate Professor of Economics and Management Associate Professor of Health Policy Associate Professor of Law My objective Tell a couple stories Reminisce about the good old days. Paint a few pictures about what things look like when the dust settles. Offer some thoughts on the role of Arkansas and Medicaid in the national conversation Give you a sense for things I think you should be practically focused on. Have some fun. 1

2 Disclaimer The views expressed herein reflect solely those of Prof. Van Horn and in no way reflect the opinions of his employer or any firm on which he serves as a director. A 45 YEAR PERSPECTIVE 2

3 A 45 years ago..(the good ol days) Economic Tension existed. 1. When I was a kid my parents paid for my visits to the pediatrician out of pocket. 2. We had major medical which reimbursed my parents for 80% of the cost of hospital care. 3. Elderly lived with their families. 4. As a population we were thinner. 5. I was hospitalized in a ward room. CONTRASTING HEALTH CARE WITH AIRLINE TRAVEL 3

4 Approx. $1,800 today 4

5 Airfare in 1960 The cheapest round trip to Europe was more expensive than a baby delivery Best Selling Album for 5 weeks in 1958 but.. In 1965 only 20% of Americans had ever flown on a plane in their lives In Today s parlance. We had an access problem 5

6 Professor R. Lawrence Van Horn Ph.D Owen Graduate School of Management Airline travel in Years Ago ( the great undoing) 1. Growing health care cost inflation 2. Growth of HMOs ruined price sensitivity 1. Comprehensive health benefit 2. Low cost sharing copays 3. Acknowledgement that health care costs were a problem for individuals and companies. Larry before he began Worrying about health care 6

7 Price of airline travel It was illegal to charge a fare of less than $1,442 (inflation adjusted $) in 1970 for a trip between LAX and NYC. Today: 7

8 Cost of a baby delivery today The average total price insurers paid was between $18,329 and $27,866, according to a recent report by Truven Health Analytics. That s a range of anywhere from a little over $2,000 out of pocket to more than $31,000. In 2012, the average cost in the US was $9,775 for a delivery, with the average Cesarean costing $15, 041 Roundtrip to Heathrow In 1960 this was more expensive than a baby delivery 8

9 Hospital wards 9

10 CPT Today I spend less out of pocket to take my kids to the pediatrician than my parents did 40 years ago. My grandma lives in a nursing home a state responsibility rather than my family. I am a balding middle aged fat man with a BMI of 30. I take 6 prescription drugs a day. I struggle to make good decisions 10

11 These are a few of my favorite things.. Things I like Mayonnaise ( on everything) Beer Red-meat Carbohydrates Cholesterol Afternoon naps Electric golf carts Things I don t Green leafy things Sweating Physical exertion Moderation Belts Personal Trainers My treadmill But my employer wants me to be healthy. 11

12 Today - sadly I engage in health care transactions daily which are value destroying. I have little ownership over my health. How Joe Q Public thinks about medical care Physicians were the smartest people in the class and they make scientifically determined treatment decisions in my best interests. Hospitals are safe places where coordinated care. Medical care will solve my problems. Point: There is a disconnect between what providers define as value and what patients define as value 12

13 Washington, D.C., October 23, 2013 New research estimates up to 440,000 Americans are dying annually from preventable hospital errors. This puts medical errors as the third leading cause of death in the United States, underscoring the need for patients to protect themselves and their families from harm. Life expectancy of women is declining in 43% of US counties Kindig et al. Health Affairs

14 What determines health? 40% behavior 30% genetics 15% social conditions 10% remedial health care 5% environment Steven A. Schroeder, M.D., We Can Do Better Improving the Health of the American People, New England Journal of Medicine, 357:12, p. 1221, Sept. 20,

15 ECONOMIC PICTURE The financial picture of the Jones Family (husband / wife and 2 kids) Income $33,220 Expenses $37,520» Shortfall $4,300 Credit Card Balance $191,000 But wait there is more Needed for Retirement $490,000 15

16 The financial picture of the Jones Family (husband / wife and 2 kids) Income $33,220 Expenses $37,520» Shortfall $4,300 Credit Card Balance $191,000 But wait there is more Needed for Retirement $490,000 Now multiply by $100 million and you have our Federal Budget. 16

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18 Problem with Interest Current debt is 37% higher than pre-crisis average. When the economy recovers and the government debt rolls over, that additional debt is going to increase government net interest payments by about 1.85 percent of GDP How much is 1.85% of GDP 1.85% of GDP is a LOT! (approx. $325B) Equivalent to spending this year on all military personnel (uniformed + civilian)+ all science, space, and technology research+ all spending on the environment, conservation, national parks, and natural resources+all spending on highways, airports, bridges, and all other transportation infrastructure. 18

19 Source: New York Times January 2012 The 20% impossibility proposition You can t get more than 20% of GDP through current tax system 19

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23 Medicare Facts When Medicare was first established, we were told that it would cost about $12 billion a year by the time 1990 rolled around. Instead, the federal government ended up spending $110 billion on the program in 1990, and the federal government spent approximately $600 billion on the program in MEDICARE is everything! The Medicare trustees report states that we are currently 37 TRILLION dollars short on our current obligations. Add Medicaid and other entitlements and we end up 54 TRILLION dollars short. To put this in perspective the US GDP is around 17 trillion. 23

24 Policy and Market Risks that affect health care delivery The Great Payment Shift A story of irrational exuberance VOLUME TO VALUE 24

25 THE PLAN TO MOVE MEDICARE FROM VOLUME TO VALUE GOAL: By 2018, 90 percent of all Medicare payments will be tied to quality or value including 50 percent via alternative payment models. 25

26 Overarching HHS Goals THE PLAN TO MOVE MEDICARE FROM VOLUME TO VALUE FFS WITH NO LINK TO QUALITY FFS WITH LINK TO QUALITY ALTERNATIVE PAYMENT MODELS POPULATION- BASED PAYMENTS Hospital Value-Based Purchasing Hospital Readmissions Program ACOs Bundled Payments Pioneer ACOs 2016: 30% of traditional FFS 2018: 50% of traditional FFS 2016: 85% of traditional FFS 2018: 90% of traditional FFS Are ACOs the Answer? Slightly more than half of the 114 organizations to join one of two Medicare accountable care efforts in 2012 did not reduce health spending below targets during their first 12 months trying to do so, newly released CMS data show. 26

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28 HHS Payment Taxonomy Framework THE PLAN TO MOVE MEDICARE FROM VOLUME TO VALUE Description Examples CATEGORY 1 CATEGORY 2 CATEGORY 3 CATEGORY 4 Fee For Service with No Link to Quality Payments are based on volume of services and not linked to quality or efficiency. Limited for Medicare Fee-for- Service Majority of Medicare payments now linked to quality Fee for Service with Link to Quality At least a portion of payments vary based on quality or efficiency of health care delivery. Hospital Value-Based Purchasing Physician Value-Based Modifier Hospital Readmission Reduction Program Hospital Acquired Condition Program Alternative Payment Models Built on Fee for Service Architecture Some payments linked to the effective management of a population or an episode of care. Payments still triggered by provision of services but opportunities for shared savings/risk. ACOs Medical Homes Bundled Payments Comprehensive Primary Care Initiative Comprehensive ESRD Medicare-Medicaid Financial Alignment FFS Model Population Based Payment Payment is not directly dependent on service delivery so volume is not linked to payment. Clinicians and organizations are paid and responsible for a beneficiary's care over a long period e.g. > 1 year, Eligible Pioneer ACOs in years

29 CBO report on value based payment 29

30 March 29 th Hospitals in Premier vs controls 30 day mortality found no evidence that the largest hospital based pay-for-performance program led to a decrease in 30 day mortality Is the Medical Home the Answer? After 3 years, patients improved in 1 of 11 quality categories No cost savings 30

31 The primary care land grab The Present ACA related changes State based exchange failures Failures of co-ops Bundled Payment Lackluster hospital performance in second half of year. 31

32 ACA Providers thought that the ACA would expand coverage and turn bad debt into compensated care. Uninsured pop has fallen 15% pts. But, it has accelerated changes in the employer sponsored market. This is where the major action is 145 million covered lives The Problem the Uninsured About million uninsured 11 million have income below the poverty line. 12 million have incomes in excess of 300% of the FPL ($66,000). 5 million have incomes in excess of 500% of the FPL ( $110,000) 10 million are not US citizens. 25% are eligible for Medicaid but haven t signed up. Source: 32

33 High level Health Reform Juices the demand side Expected 32M more customers Administration says 17.5M to 20M as of March M in public exchange (down 25%) Enhanced expectations free prevention Subsidized insurance through exchange for up to 65% of population (400% FPL) Relies on silver bullets on supply side for fix ACOs Value Based Payment Bundled Payment Patient Centered Medical Homes (PCMH) ACA Update Medicaid Expansion To date 28 states have expanded Enrollment in these states is up 27%. Non expansion states saw enrollment increases of 7%. (woodwork effect) Woodwork effect 2014 Tennessee 53,700 enrollees, a 4.3 percent increase Georgia 98,800 enrollees, a 5.8 percent increase. 33

34 Medicaid Expansion Does Medicaid Expansion improve Health? 34

35 BUT Wait: There are economic consequences for labor markets. There remains continued uncertainty around its implementation. We are broke. Economics are not sustainable 35

36 "At the beginning of this year, we noted that as part of this new day in health care, Americans would no longer be trapped in a job just to provide coverage for their families, and would have the opportunity to pursue their dreams," he said. "This CBO report bears that out, and the Republican plan to repeal the ACA would strip those hard-working Americans of that opportunity." Feb 2,

37 What about Arkansas? This month, CHS revised its fourth-quarter 2015 provision for bad debt up by $169 million -- and said that 40 percent, or about $68 million of that amount, was from patients being unable to pay deductibles and co-payments. Under individual Obamacare mid-level silver plans, the annual deductible was $2,556, and under less expensive, low-level bronze plans it was $5,328 in 2015, according to the Kaiser Family Foundation. 37

38 Americans are starting 2016 with more job security, but most are still theoretically only one paycheck away from the street. Approximately 63% of Americans have no emergency savings for things such as a $1,000 emergency room visit or a $500 car repair, according to a survey released Wednesday of 1,000 adults by personal finance website Bankrate.com the amount of wealth held by the middle class is shrinking. The share of income held by middle-income families has plunged to 43% of households in 2015 versus 62% in 1970, according to a report released last month by the nonprofit think tank Pew Research Center in Washington, D.C How much is too much? Patients are unlikely to pay medical bills that are greater than 5 percent of household income, according to the Advisory Board, a consulting firm to hospitals. Median household income in the U.S. is at about $53,000, suggesting that when out-of-pocket charges exceed $2,600 hospitals can forget about collecting, said Spencer Perlman, an analyst with Height Securities in Washington. 38

39 What do consumer s value? The Future Changing role of insurance New market entrants Fracturing of delivery market Transparency and redefinition in the unit of service. 39

40 Exhibit 8.3 Among Firms Offering Health Benefits, Percentage That Offer an HDHP/SO, by Firm Size, % 50% 40% 30% 20% 10% 33% 31% 27% 25% 26% 23% 22% 21% 18% 15% 15% 13% 13%* 10% 11% 7% 4% 4% 5% 39% 38% 38% 21% 18% 16%* 8% 26%* 32% 45% 43% 41%* 40% 52%* 0% Workers Workers 1,000 or More Workers * SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, Exhibit 7.9 Percentage of Covered Workers Enrolled in a Plan with a General Annual Deductible of $1,000 or More for Single Coverage, By Firm Size, % 60% All Small Firms (3-199 Workers) All Large Firms (200 or More Workers) All Firms 58%* 61% 63% 50% 40% 30% 20% 10% 0% 50% 49% 46% 46% 40% 38% 41% 35%* 34% 31% 39%* 27%* 21%* 22%* 32% 28% 16% 18%* 26% 12%* 22%* 10% 17% 13%* 6% 8% 9% * Estimate is statistically different from estimate for the previous year shown (p<.05). NOTE: These estimates include workers enrolled in HDHP/SO and other plan types. Average general annual health plan deductibles for PPOs, POS plans, and HDHP/SOs are for in-network services. SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits,

41 Exhibit 7.8 Percentage of Covered Workers Enrolled in a Plan with a High General Annual Deductible for Single Coverage, By Firm Size, % 80% All Small Firms (3-199 Workers) All Large Firms (200 or More Workers) All Firms 60% 63% 40% 39% 46% 36% 20% 12% 19% 0% Percentage of Covered Workers with a Deductible of $1,000 or More* Percentage of Covered Workers with a Deductible of $2,000 or More* SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, How One of the richest countries supplies hospital care - Singapore 41

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43 Currently has 17 locations in areas with high un-insurance and poor access. No appt. necessary Treat everything including chronic conditions: HTN etc. If you need labs maximum cost is $15 Some links to explore

44 The Health Care Reform Race Supply Side Push ACO / PCMH / Pop Health Value Based Reimbursement Continued consolidation Patients should value quality the way we define it. Demand Side Pull Employer shift to CDHP then DC Increased $$ exposure Innovation in delivery and locus producing solutions that consumers wish to buy Fracturing the health care consumption marketplace New players Walmart / Xerox / Google 44

45 Larry s Key s to success over next 3 years Create capacity to retain patients and stem out-market migration Telehealth partnerships Be mindful of taking on risk bearing contracts. Take down cost structure and move toward transparent pricing Be able to collect $$ from patients directly Must dos to be ready for value / risk / bundled contracting Understand population / risk Have a repeatable production method Have a system in place to adhere to production standard Have capacity to drive toward lower levels of treatment. Be capable of aligning incentives across providers. Cap exposure through re-insurance. 45

46 Trends to follow closely What is going on with the employer sponsored market in your area? % with high deductible? Move to defined contribution / private exchange? The continued migration toward the home as the locus of care. Migration of hospital service to ASCs. Evolving care delivery modalities From retail to telehealth to chronic care solutions Takeaways Our country has charted a 40 year path to increased expectations around what the government should provide, but cannot sustain. The past is the future You don t increase health of a population by encouraging more health care consumption More attention to how we live our lives day in day out has the greatest potential to improve health. The private sector will save America. 46

47 In closing (really. This is the last slide) After a 40 year hiatus the health care consumer is coming back The private sector will fracture the health care landscape The definition of the unit of purchase must evolve in constructive ways. It is incumbent on us as health care leaders to produce services that a typical household can afford. You solve the customer problem and you win ACCESS & COST 47