the future of healthcare: orchestrating the journey · american healthcare: progress & promise...

THE FUTURE OF HEALTHCARE: ORCHESTRATING THE JOURNEY

Ian Morrison PhD

www.ianmorrison.com

Twitter@seccurve

http://www.ianmorrison.com/

OUTLINE • Progress and Promise

• Looking Ahead: Six Key Themes

–Serving Shallow Pocketed Consumers

–Employers Stay or Go?

–Physicians in the New Age

–Massive Medicaid

–Making Volume to Value Real

–Elections Matter

• Leading Change: Respect, Reliability and Resilience

AMERICAN HEALTHCARE: PROGRESS & PROMISE • Coverage Expansion

– Obamacare: Exchanges and Managed Medicaid

• Payment Reform

– ACOs, MACRA, Medicare Advantage, Managed Medicaid, Bundles and value-based payment in private sector

• Volume to Value

– Payment reform in concert with shift to Population Health, Providers at Risk

• Consolidation and Integration

– Plans, health systems and physicians merging and partnering more and more

• Delivery Shift to Ambulatory Environment

– Outpatient, alternate site and retail

• IT Infrastructure

– Ubiquitous EHRs, Telehealth, Big Data, and Consumer facing apps

• Enhancing the Consumer (and Provider) Experience

– High Deductible health care is a blunt instrument

– High bar of service in a world of Apple, OpenTable, and Uber

BIG DROP IN UNINSURED UNDER OBAMACARE

SERVING SHALLOW-POCKETED CONSUMERS

CUMULATIVE INCREASES IN HEALTH INSURANCE PREMIUMS, WORKERS’ CONTRIBUTIONS TO PREMIUMS, INFLATION, AND

WORKERS’ EARNINGS, 1999-2016

98%

160%

213%

92%

167%

242%

24%

45%

60%

21%

35% 44%

0%

50%

100%

150%

200%

250%

300%

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Health Insurance Premiums

Workers' Contribution to Premiums

Workers' Earnings

Overall Inflation

SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2016. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2016; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999-2016 (April to April).

$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

2016

2015

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999Worker Contribution

Employer Contribution

$18,142*

AVERAGE ANNUAL WORKER AND EMPLOYER CONTRIBUTIONS TO PREMIUMS AND TOTAL

PREMIUMS FOR FAMILY COVERAGE, 1999-2016

*Estimate is statistically different from estimate for the previous year shown (p < .05).

SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 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

All Small Firms (3-199 Workers)

All Large Firms (200 or More Workers)

All Firms

* Estimate is statistically different from estimate for the previous year shown (p<.05).

NOTE: These estimates include workers enrolled in HDHP/SOs 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, 2006-2015.

PERCENTAGE OF COVERED WORKERS ENROLLED IN A PLAN WITH A GENERAL ANNUAL DEDUCTIBLE OF

$1,000 OR MORE FOR SINGLE COVERAGE, BY FIRM SIZE, 2006-2015

INSURED ADULTS WITH LOWER INCOMES WERE MORE LIKELY TO REPORT THEY HAD DELAYED OR AVOIDED GETTING

CARE BECAUSE OF THEIR COPAYMENTS OR COINSURANCE

Note: FPL refers to federal poverty level. Source: The Commonwealth Fund Health Care Affordability Tracking Survey, September–October 2014.

30 28 28 24

46

10 10 12 10

21

0

25

50

75

Had a medicalproblem, but did

not go to a doctoror clinic

Did not fill aprescription

Skipped a medicaltest, treatment,

or follow-uprecommended

by a doctor

Did not see aspecialist when

you or your doctorthought you

needed to see one

At least one cost-related access

problem

<200% FPL 200% FPL or more

Insured adults ages 19–64 who pay a copayment or coinsurance

Percent responding “yes”

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DOES SATISFACTION MATTER? COMPARED TO WHAT?

2010 (A)

2012 (B)

2013 (C)

2014 (D)

2015 (E)

2016 (F)

Prepared for: Strategic Health Perspectives Base: All US Adults (2010 n=2775, 2012 n=2000, 2013 n=2501, 2014 n=2501, 2015 n=5037, 2016 n=10011 split sampled) Source: Q600: How satisfied or dissatisfied are you with each of the following?; Q185: Thinking now about all the different components of your health insurance plan, how well does your plan meet your/your family’s health needs?

Significance tested at 95%

General Impression of Health Insurance (Top-2 Box %)

77% 79% 84% 81% 79% 77% Satisfaction with your insurance benefits

Insurance plan meets my/my family’s needs very/extremely well

Satisfaction with out of pocket costs for health care services 58% 59% 66% 62% 61% 61%

Satisfaction with out of pocket costs for prescription medications 62% 66% 72% 66% 67% 66%

69% 66% 55% 56%

Only 47% of Exchange based plan holders feel their plan meets needs very or extremely well

However…

F ABDEF

AEF AF

A ABDEF

A A A

ABDEF

AB A A

DEF EF

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Some change towards the positive, but 1 in 4 consumers remains powerless

Prepared for: Strategic Health Perspectives Base: All US Adults (2014 n=2501, 2015 n=5037, 2016 n=30052) Source: Q90 How would you describe your feelings about the health care you receive today, including how much you pay for it and the benefits you receive? Please select all that apply.

CONSUMERS EMOTIONS TOWARDS HEALTHCARE THEY RECEIVE Not much change Nationally but Californians are significantly more

positive in 2016

Consumer Emotions Towards Healthcare They Receive

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%

Empowered Hopeful Relieved Accepting Neutral Resigned/ Given up

Powerless Depressed Angry

SHP CONSUMERS 2016

Significant over prior year

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

13%

37%

24% 18%

27%

14%

21%

10%

California 2016 in Red

13%

12



CONSUMERS EMOTIONS TOWARDS HEALTHCARE THEY RECEIVE Not much change Nationally but Californians are significantly more positive in 2016


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%

14 15 16 14 15 16 14 15 16



SHP CONSUMERS 2016


13%

37%

24% 18%

27%

14%

21%

10%

California 2016 in Red

13%

14 15 16 14 15 16 14 15 16 14 15 16 14 15 16 14 15 16

STRATEGIC HEALTH PERSPECTIVES℠

COST MATTERS BECAUSE CONSUMERS PAY MORE OF THE INCREASE…THIS MAKES THEM FEEL MORE POWERLESS

Prepared for: Strategic Health Perspectives Base: All US Adults (n=10011 split sample) Q660. Please indicate if any of the following happened to you in the past year

28%

Received a balance bill for care they thought was covered

8% Received a bill for hospital services ''not in network'' even though the

hospital was in network 13% EXCHANGE

TOTAL

12% 21%

10% 13% 20%

36%

18% 22%

Resigned/ Given up


14% 25%

11% 15% 21%

35%

21% 22%

Resigned/ Given up


Have not

Have

Have not

Have

California 21%

California 6%

California 13%

14

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WHO IS BORDERLINE?

9%

21% 15%

34% 24%

14%

26%

12% 17%

7% 15%

7% 15% 14%

30%

48%

31% 41%

9% 20% 15%

34%

37%



40% Have Employer based insurance

42% Had 3+ doctor visits last year

32% Had 1+ ER visits last year

51% Received a balance bill for care they thought was covered

Gen Pop

20% Are uninsured

They are NOT on public insurance!

12%

California 2016 Borderline in Red

17%

24% 36%

15




CONSUMERS EMOTIONS TOWARDS HEALTHCARE THEY RECEIVE


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%



SHP CONSUMERS 2016


2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014


COST MATTERS BECAUSE CONSUMERS PAY MORE OF THE INCREASE…THIS MAKES THEM FEEL MORE POWERLESS

Prepared for: Strategic Health Perspectives Base: All US Adults (n=10011 split sample) Q660. Please indicate if any of the following happened to you in the past year

28%

Received a balance bill for care they thought was covered

8% Received a bill for hospital services ''not in network'' even though the

hospital was in network 13% EXCHANGE

TOTAL

12% 21%

10% 13% 20%

36%

18% 22%

Resigned/ Given up


14% 25%

11% 15% 21%

35%

21% 22%

Resigned/ Given up


Have not

Have

Have not

Have

17

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WHO IS BORDERLINE?

9%

21% 15%

34% 24%

14%

26%

12% 17%

7% 15%

7% 15% 14%

30%

48%

31% 41%



40% Have Employer based insurance

42% Had 3+ doctor visits last year

32% Had 1+ ER visits last year

51% Received a balance bill for care they thought was covered

Gen Pop

20% Are uninsured

They are NOT on public insurance!

18


Above Average

Average*

38 47 48

59 60

66 76

88 90 90 93 94

101 111

143 149

161 181

205 Low monthly premiums

Has a low deductible

Low copay for doctor visits

Access to all medical imaging at reasonable cost-sharing/co-pay

Reasonable cost sharing, or copay levels for hospitalization

Direct access to all specialists (no referral needed)

Includes an extensive network of doctors

Access to leading hospitals in my area

Coverage for dependents

Coverage for medical care at retail clinics or urgent care centers

Low copay for generic drugs

Access to cutting edge medical devices and medications

Access to brand name drugs at reasonable cost-sharing, or co-pay, levels

Provides me with cash incentives or rewards for healthy behavior

Coverage for a wide selection of brand name drugs

Includes an extensive network of hospitals

Coverage for over-the-counter medications

Access to specialty hospitals (i.e. children’s hospitals)

The insurance brand is a name I know and trust

LOW OUT OF POCKET COST REMAINS CRITICAL IN PICKING INSURANCE

Consumers concerned with premiums, deductibles and copays…reasonable cost sharing for hospital services and retail clinic coverage are surging.

BASE: ALL QUALIFIED RESPONDENTS (2015 n=5037) Q65 Respondents were given a maximum difference trade off exercise in which they were forced to choose the most preferred and least preferred plan feature. *Average is 100, and the scores represent importance relative to that average.

Relative Importance of Benefit

SHP CONSUMER 2015

Below Average

Was below avg in 2014

Even higher than 2014

19

OUT OF POCKET COST CONCERNS ARE BIPARTISAN

Prepared for: Strategic Health Perspectives Base: All US Adults (n=10011 split sample), Party Affiliations (Republican n=2666, Democrat n=3328, Independent n=2826) Source: Q60 If we could greatly improve one of these, which ONE would you choose?

If we could greatly improve one of these, which ONE would you choose?

Reducing the out-of-pocket cost of healthcare to the consumer

Improving the quality of care

Reducing the cost of health care to the government (and the taxpayer)

Reducing the number of people with inadequate or no health insurance

43%

19%

19%

19%

Gen Pop

47%

19%

24%

10%

Republican

43%

20%

21%

16%

Independent

39%

18%

15%

28%

Democrat

Partisan Differences in Health Care Priorities

EMPLOYERS: STAY OR GO?


Projections for 2016: Wide range of estimates

7.5 9.7 10.3

14.7 13.0

10.6 8.5 8.0

6.0 6.0 7.0 6.0 5.4 5.2 4.1 4.4 4.0

0

Health caretrend after…

CPI-U

Wel

ls F

argo

M

erce

r

EMPLOYERS ARE SEEING A PROLONGED RESPITE FROM DOUBLE-DIGIT PREMIUM INCREASES, BUT THESE ARE STILL RUNNING AT TWO TIMES CPI

2015: Trend after plan and contribution changes =4.0% (CPI-U= 2.0%) Projections for 2016: Wide range of estimates 4.2% (Mercer) to 8.6% (Wells-Fargo)

SOURCE: Towers-Watson NBGH Annual Surveys (2014-2015)

TOWERS WATSON


21%

79%

36%

64%

AND MORE ARE SAYING THAT BUSINESS PERFORMANCE SUFFERING AS A RESULT OF HEALTH INSURANCE COSTS

Base: All Employer Health Benefit Decision Makers (n=340) Q805 Which comes closest to your company’s attitude towards health insurance benefits?

Current Company Attitude towards Health Insurance Benefits

Our business performance is suffering due to health insurance costs

Health insurance costs have very little impact on our business performance

2014 2016

41% 53%

Significant year over year change

Significance: <50 significantly higher than 200-999. 50-199 also significantly higher than 1000-4999 and 5000+.

18% 21% 27%

44% 46%

33% 26%

45%

59%

58%

45%

58% 53%

87% 88%

2010 2011 2012 2013 2014 2016

FEWER EMPLOYERS ARE LOOKING FOR AN EXIT; CONTINUE TO FEEL RESPONSIBILITY FOR EMPLOYEE HEALTH NEEDS

* Asked only of Employers with 50 or more employees Base: All Employer Health Benefit Decision Makers (n=340) Q800: Please indicate your level of agreement with the following statements. Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?

Company’s Position on Employer-Sponsored Healthcare: Providing Benefits (Top-2 Box % - Describes Completely/Very Well)

It is our responsibility to ensureour employees' health needs aremet

My company is actively exploringways to get out of providinghealth insurance to our employees

28%

42% 40%

26%

28%

41% 41%

25%

2012 2013 2014 2016

Private Exchanges

THE APPEAL OF EXCHANGES FOR CONTROLLING COSTS CONTINUES TO COOL (AMONG COMPANIES OF ALL SIZES)

Base: All Employer Health Benefit Decision Makers (n=340) Q1100: How well does each of the following statements describe your company’s position on employer-sponsored healthcare? Does the statement describe your company completely, very well, well, somewhat well or not at all?

Company’s Position on Employer-Sponsored Healthcare:

(Top-2 Box % - Describes completely/very well)

“Exchanges provide us with an opportunity to better control our healthcare costs”

Significant year over year change

25%

27%

24%

27%

28%


41% 38%

34% 32% 31% 31% 31%

28% 27% 27% 26% 26% 25% 24% 23%

Increased emphasis on wellness and prevention

Focus more on primary care

Cost transparency tools for employees to make…

Aggressive management of specialty…

Negotiated reference pricing for specific…

Improved management of behavioral and…

Better manage heavy utilizers of care

Centers of Excellence models

Private exchanges

Focus on accountable care / ACOs

Direct contracting with hospitals

Promoting greater use of bundled payments

Narrow network health plans

Expanded use of Patient-Centered Medical…

Consumer Directed Health Plans (CDHP)

MOST EMPLOYERS DO NOT THINK CURRENT INITIATIVES WORK WELL TO CONTAIN COSTS

CDHPs are at the bottom, but even wellness at the top of the list isn’t viewed as very effective

Base: All Employer Health Benefit Decision Makers (n=340) Q1709 How well do you think each of the following initiatives will work to contain costs?

Works Extremely/Very Well to Contain Costs

26


72%

77%

79%

57%

64%

67%

63%

63%

52%

53%

55%

83%

88%

94%

77%

57%

76%

61%

71%

30%

63%

54%

Hospital

79%

75%

75%

72%

71%

68%

66%

66%

65%

59%

57%

51%

83%

81%

84%

72%

69%

77%

59%

70%

56%

57%

61%

Pharmaceutical (drug)…

The health care system…

Insurance companies

Hospitals

Unhealthy behaviors

The way we pay…

The Congress

The Affordable Care…

Medical device…

Doctors

The Democrats

The Republicans

Employer

Base: All Employer Health Benefit Decision Makers (n=340); All Consumers (n=9994); All Hospital-Based Execs (n=205); All Physicians (n=599) Q1030: How much are the following to blame for the high cost of health care?

Perceived Responsible Entities for High Healthcare Costs Blame for High Cost of Healthcare

(Top 2 Box: Some or A lot)

71% of Physicians blame insurers “A lot”

CONSUMERS AND EMPLOYERS BLAME PHARMA MOST FOR HIGH COSTS, WHILE PHYSICIANS AND HOSPITALS

BLAME INSURERS MOST

27

PHYSICIANS IN THE NEW AGE

28


CONSUMERS TRUST PHYSICIANS AND NON PROFIT ENTITIES MORE THAN THEY TRUST FOR PROFIT

HOSPITALS, HEALTH INSURERS AND PHARMACEUTICAL COMPANIES

Trustworthiness of Industries – Total (Top 2 Box: Very/Somewhat Trustworthy)

Prepared for: Strategic Health Perspectives Base: All US Adults (2016 n=10000 split sampled) Source: Q565 In your opinion, how trustworthy is each of the following industries?

45%

53%

61%

70%

73%

82%

82%

91%

Pharmaceutical companies

Health insurance companies

For-profit hospital systems

US Food and Drug…

Centers for Medicare &…

Non-profit hospital systems

Nonprofit voluntary health…

Physicians



CONSUMERS EMOTIONS TOWARDS THEIR HEALTHCARE BEGINNING TO SETTLE



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%



SHP CONSUMERS 2015


2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

2015

2016

2014

PHYSICIANS CONTINUE TO FEEL POWERLESS IN CURRENT SYSTEM

Physicians’ Feelings Towards Current Health Care System

Base: All Physicians (2016: n=599; 2015: n=626) Q1850: How would you describe your feelings about the health care system today? Please select all that apply.

2%

23%

1%

23%

16%

23%

43%

24% 23%

4%

23%

1%

24%

13%

21%

42%

24% 22%



2015

2016

2015

2016

2015

2016

2015

2016

2015

2016

2015

2016

2015

2016

2015

2016

2015

2016

SHP PHYSICIANS 2016

One in four physicians is depressed or angry about the health care system today – no change since last year.

Overall Satisfaction with Current Practice

Base: Office-Based Physicians (2016: n=452; 2015: n=476; 2014: n=434; 2013: n=432; 2012: n=461; 2011: n=377) Q800: Overall, how satisfied are you with your current practice situation?.

PHYSICIANS SATISFACTION WITH CURRENT PRACTICE DOWN

Satisfaction is at lowest level in six years, down 25 percentage points from 2011

80% 74% 76%

62% 68%

55%

20% 26% 24%

38% 32%

45%

2011 2012 2013 2014 2015 2016

NET Satisfaction NET Dissatisfaction

Significant change

(n=377) (n=461) (n=432) (n=434) (n=476) (n=452)

SHP PHYSICIANS 2016

Electronic Medical Records

Medical specialty societies

Medicare Part D prescription drug benefit

Hospitals

Integrated Health Systems

Pharmaceutical / Biotechnology companies

Medical device companies

Telemedicine

Affordable Care Act, ACA

American Medical Association

Center for Medicare/Medicaid Services (CMS)

Health insurance companies

High-deductible health plans

Concern about malpractice litigation

45%

33%

31%

30%

28%

26%

24%

24%

20%

19%

12%

9%

7%

5%

36%

12%

27%

30%

24%

30%

20%

15%

47%

26%

49%

71%

62%

71%

Helped/Hurt Ability to Provide Quality Patient Care Hurt Helped

Base: Office-Based Physicians (2016: n=452; 2015: n=476; 2014: n=466; 2013: n=432; 2012: n=461; 2011: n=377) Q815: In recent years, has each of the following helped or hurt your ability to provide quality patient care?

EHRS BOTH HELP AND HURT QUALITY CARE; TELEMEDICINE IS CATCHING ON

Significant change

+3

+12

-13

-7

+10

+7

+16

+7

SHP PHYSICIANS 2016

5%

9%

8%

12%

30%

20%

6%

10%

11%

15%

23%

23%

5%

11%

11%

10%

25%

24%

6%

11%

15%

16%

31%

26%

7%

11%

13%

15%

18%

31%

8%

12%

14%

16%

27%

35%

Bundled Payments

Capitated Payment

Global Payments

Episode-Based Payments

Pay-For-Performance

Salaried Payments

2016(n=452)2015(n=476)2014(n=466)

Willingness to Work under Various Models of Reimbursement (% Extremely/Very Willing)

Base: Office-Based Physicians (2016: n=452; 2015: n=476; 2014: n=466; 2013: n=432; 2012: n=461; 2011: n=377) Q1205: There are a number of different proposals being discussed for changing the way physicians are reimbursed. How willing would you be to work to work under the following models of reimbursement?

Significant change

PHYSICIANS INCREASINGLY WILLING TO WORK UNDER SALARY

SHP PHYSICIANS 2016

34

STRATEGIC HEALTH PERSPECTIVESTM

ONE IN THREE PHYSICIANS IS DRINKING THE BERWICK KOOL AID

Optimistic Intenders I haven’t reformed yet, but I want to.

Blazing Believers Integrating…and happy about it.

Reluctant Objectors Integrating…and NOT happy about it.

Independent Resisters I haven’t reformed, and don’t plan to.

Experience with Integration

Att

itu

de

to

war

ds

Inte

grat

ion

14%

30%

37%

20%

Back in 2012, we created a segmentation to understand how US doctors are dealing with all this consolidation and integration. Are they drinking the kool-aid? Or sitting it out?

Segmentation inputs include: • Use of EHRs • Knowledge about meaningful use criteria • % of medication DAW vs generic allowable • P12M experience on salary, management by health plan,

or use of evidence based guidelines

• Willingness to work in solo practice • Perceptions on physician responsibility for patient

treatment compliance

THE SEGMENTATION OF BERWICKIAN NIRVANA

35


THE FORCE AWAKENS – RESISTERS ARE COMING BACK

Believers are increasing but Resisters are also growing once again.

0 0 0 0

32% 25% 14% 20% 30%

16% 19% 35% 20%

14%

22% 23% 24%

21% 20%

23% 34% 28% 39% 37%

2012 2013 2014* 2015 2016

BlazingBelievers

ReluctantObjectors

OptimisticIntenders

B

*The 2014 sample skewed a bit different (higher solo practice than the population).

THE SEGMENTATION OF BERWICKIAN NIRVANA (2)

36


CAREGIVERS IN THE NEW AGE

• Increasing complexity of clinical medicine

• Increasing administrative complexity

• Demanding patients

• Increasing workload as coverage expands and complexity increases

• The burden of the Electronic Health Records and the rise of scribes

• But…compared to what?

• Leading the transformation of care delivery

• Overcoming Improvement Fatigue

MASSIVE MEDICAID

MASSIVE MEDICAID

• US Medicaid Population edges out France for top 20 spot in total population with 70,515,716 enrollees

• US Medicaid spending edges out Argentina for top 25 economies at $540 billion

• US Medicaid is bigger than Wal-Mart by $50 + billion

MASSIVE MEDICAID

• Churning in Medicaid eligibles and exchange population

• Who will take these enrollees and what will be the financial impact on providers that do take them?

• Medicaid covers kids, mums, expansion populations, supports the dual eligible and is the default LTC policy for the middle class

• Can we design financially sustainable delivery models for Medicaid?

• Medicaid is dominant for low income and children

• Medicaid population has significant churn of approximately 25%

• Exchange Population has 40% churn due mainly to changing life circumstances

• Get to 65 and you are “home free on Medicare” ….at least for now

• Republicans may move age of Medicare eligibility up

• Democrats may move age of eligibility (or buy in) down

MAKING VOLUME TO VALUE REAL

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Base: All Hospital-Based Execs (2016: n=205; 2015: n=200; 2014: n=202) Q980: Which of the following best describes your hospital’s/hospital system’s “risk bearing” strategy?

Hospitals committing to clinical integration for contracting w/ payers but full risk only for the few

Hospital Risk Management Strategy

RISK BEARING STRATEGIES VARY CONSIDERABLY

SHP HOSPITALS 2016

41%

29%

19%

10% 1%

31%

25% 26%

12%

8%

30% 28% 27%

9% 6%

201420152016

Significant YOY change

43

HALF OF ALL EMPLOYERS WILLING TO CONSIDER CONTRACTING WITH LOCAL HOSPITAL/HOSPITAL SYSTEM

Consider Contracting with Local Hospital or System to Provide Health Insurance

Base: All Employer Health Benefit Decision Makers (n=340) Q816 Would your company consider offering a health insurance plan provided by a local hospital or hospital system rather than one offered by an insurance company?

14%

7% 6%

19%

34%

19%

2016

Yes, definitely

Yes, probably

No, don'thave enoughemployees inonegeography

53% Would consider

29%

28%

32%

32% Would Not Consider

WHAT POPULATION LEVEL ANALYTICS REVEAL

• The 5/50 Problem

– 5% account for 50% of spending

– 1% account for 20%

– Bottom 50% account for about 2%

• Segmentation of populations

• What you will find… – HONDAS

– Behavioral Health

– End of Life Care

– Cancer

– Frail elderly

– Social Work not Medical Care

– Specialty Pharmaceuticals

THE TRUCK, THE REFRIGERATOR AND THE BUS

ELECTIONS MATTER

47

REALITIES OF A POLARIZED AMERICA – 2016 AND 2018

• Major changes in health policy only occur when one party holds the Presidency and both Houses of Congress

• Some major changes occur when one party holds the Presidency and one House of Congress

• Only small incremental changes occur otherwise – with the exception of a few non-polarized issues.

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CHANGES IN ACA WITH DEMOCRAT WIN

• More funds for subsidies for all

• Subsidies to reduce high-deductible plans

• Efforts to expand coverage to some uncovered groups

• More funds for prevention

• Some intervention in pharma pricing policies

• Reduction or elimination of “Cadillac insurance tax”

• Debates but no action on ‘Medicare for all’ / Single-Payer – but state “public options” likely

49

MAJOR CHANGES IN ACA WITH REPUBLICAN WIN

• Major structural changes to ACA – changed name

• End of mandates – individual/corporate

• Elimination or reduction of “Cadillac insurance tax”

• Establishing state pre-existing condition pools

• Less federal subsidies for uninsured and Medicaid

• More state discretion for Medicaid spending

• Less insurance regulation

50

OPTIONS FOR MAKING MEDICARE FINANCIALLY SOLVENT IN THE LONG-TERM

• Taxes raised?

• Providers paid less?

• Beneficiaries / less benefits?

• Health care delivery system changes – • efficiency / value?

WILD CARD

LEADING CHANGE: THE HEALTHCARE SYSTEM

• Maintain and expand coverage

• Fix the financial gotchas for vulnerable patients

• Consolidate and integrate for value not economic power

• Innovate at scale

• Improve the patient and provider experience

• Harness the new science

• Lead don’t follow to the future

LEADING CHANGE: HQI

• Continue to innovate at scale for higher performance on the Triple Aim

• Respect, Reliability and Resilience will be required

• The delivery system needs to be transformed

– Clinical redesign

– Scope of Practice expansion

– Creative use of new technologies

– More focused on the ambulatory environment and the continuum of care

– Serving an expanded coverage population of low-income Americans

– Meeting people in their lives

• Remember what brings you to work

the future of healthcare: orchestrating the journey · american healthcare: progress & promise...

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