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Transcript of The Future of Medicine and Physicians Role in Innovation Ian Morrison PhD .
The Future of Medicine and Physicians Role in Innovation
Ian Morrison PhD
www.ianmorrison.com
Outline
• Key Issues Driving Change• Healthcare 2020– Private Purchaser
• Consumer• Employer• Exchanges
– Public Purchaser• Medicare• Medicaid
– Payment Reform– Delivery System Transformation– Physician Engagement with Change and Innovation
3
Key Issues: ACA and Coverage Expansion
• ACA is the “the Law of the Land”…at least until the 2016 Election
• Two Americas• Public Exchanges got off to very rocky start, year two saw less
drama• Private Exchanges gaining momentum, but question has
shifted from why not to why?• Exchanges both public and private shift the market toward
retail• Insurers are consolidating partly as a result of ACA and
coverage expansion by public sector
Health Plan Consolidation Continues
• Aetna buys Humana for $37 billion making a $115 billion run rate company
• Anthem closes on Cigna in $54 billion makes a $117 billion run rate company
• New Rivals for $154 billion UnitedHealth Group
• Other:– Centene buys Health Net
for $6.3 billion
5
Key Issues: Health Systems
• Accountable Care is a megatrend, but maybe not ACOs• Medicare Advantage may be the end game for some • Pressure on costs and and delivering value intensifies • Hospital “prices” under intense scrutiny by press and
purchasers• “Learning to live on Medicare” means taking out 10-20% of
costs (more for academic institutions) and Medicare reimbursement rates will keep getting pressurized
• From Volume to Value means high cost procedure oriented specialties (cardiovascular, ortho, neuro, oncology) move from key assets to liabilities in a capitated environment, how long, how much is extremely uncertain
• Focus on Primary Care
6
Key Issues: Health Systems
• The Massive Consolidation continues toward 100-200 Large Regional Systems– Doctors running to hospitals– Hospitals consolidating regionally– Role of private equity and for profits in consolidation– Focus on “Essentiality” may run into Attorney Generals and Anti-Trust concerns– The rich get richer: significant returns to scale and to integration– Doctors discretion in selection of specific technologies and clinical protocols will be
increasingly constrained by large motivated health systems that employ them• Purchasers are extremely unhappy and are using consumer incentive tools, Skinny
Networks and Spot Market trends as counter forces e.g. CalPers reference pricing• Care coordination of transitions will be at a premium• From fill the hospital to empty the hospital, it is going to be economically and culturally
challenging• Will doctors, nurses and consumers go along with all this?• No matter what we must redesign the delivery system: and it needs to be science-
based, technology-enabled and consumer friendly
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7Base: All Hospital-Based Execs (2015: n=200)Q715: Please indicate how much you agree or disagree with each of the following statements.
Health systems in the east are a bit more skeptical, pragmatic about the reasons behind consolidation.
REGIONAL VARIATION IN ATTITUDES TOWARDS CONSOLIDATION
SHP HOSPITALS 2015
*New attribute in 2015
Hospitals need to be increasingly wary of antitrust considerations when integrating with other hospitals.*
54%Agree
In the short term, our efforts towards consolidation are more about bargaining leverage than about quality or value (even if we get there eventually).*
48%Agree
East(n=42)
Midwest(n=52)
South(n=57)
West(n=49)
67%South 54% 46% 53%
East(n=42)
Midwest(n=52)
South(n=57)
West(n=49)
60%West 58%West 42% 35%
Why is it different this time?• The ACA is a stimulator and accelerator of change• We have hit the wall of affordability for business, government and
households • The data and tools are better for quality measurement and care
management• The commitment of leaders to change is greater• Doctors have been “softened up” for employment and integration by
bombardment of ACA, meaningful use, and lifestyle pressures• Consumers have been “empowered”• Slow but inexorable movement to value based purchasing may have hit
tipping point in 2015• Personalized precision medicine calls the bluff on solo practice• Population health requires scale and integration• Healthcare journalists no longer defenders of FFS and opposed to
managed care but now data-driven champions of transparency• There are high profile champions of change not just Kaisinger…but AHA
elites, large regional systems, and new enablers
“Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018.
Perhaps even more important, our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018.
Alternative payment models include accountable care organizations (ACOs) and bundled-payment arrangements under which health care providers are accountable for the quality and cost of the care they deliver to patients.”
Sylvia Burwell, CMS Administrator, January 26th, NEJM
CMS States Clear Value Goals for Medicare
•Chaired by Richard Gilfillan MD CEO of Trinity
•Major health systems, payers and other stakeholders committing to 75% of their business in value-based models by 2020
•Participants include Advocate, Ascension, Trinity, Providence, Partners and more
•California Players include Dignity, Heritage, Providence, Blue Shield, Optum and Aetna
•More at hctf.org
Healthcare Transformation Taskforce
The Tension
Bundles• More
is still better economically for providers
• Encourage improvement of teams on dimensions they actually control and that patients care about
• But what do you do about the complex co-morbid and the fact that not everything is easily bundled
• “Screw me on the bundle, and I’ll screw you on the rest”
Population Health/Risk/Accountable Care• Freque
ncy• Appro
priateness
• Determinants of Healthcare
• The Mutual Disrespect Problem
• Social Work not Medical Care
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
STRATEGIC HEALTH PERSPECTIVES℠
STRATEGIC HEALTH PERSPECTIVES℠
STRATEGIC HEALTH PERSPECTIVES℠
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.
0
25
50
75
30 28 2824
46
10 10 12 10
21
<200% FPL 200% FPL or more
Insured adults ages 19–64 who pay a copayment or coinsurance
Percent responding “yes”
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Prepared for: Strategic Health PerspectivesBase: All 2014 US Adults (n=2501)Source: Q1850 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 DON’T FEEL “EMPOWERED” BY ESCALATION IN COST SHIFTING
Consumer Emotions Towards Healthcare They Receive
9%
17% 19%
37%
28%
15%
23%
11%14%
Empowered Hopeful Relieved Accepting Neutral Resigned/ Given up Powerless Depressed Angry
This year, again, 3 in 10 (29%) say they had to forego medical care due to cost this (vs. 30% in 2013) & and 2 in 10 (23%) asked a doctor for a cheaper medication (vs. 24% in 2013)
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Prepared for: Strategic Health PerspectivesBase: All 2014 US Adults (n=2501)Source: Q1850 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 AT RISK FEEL EXTREMELY POWERLESS, NEGATIVE
Consumer Emotions Towards Healthcare They Receive
9%
17% 19%
37%
28%
15%
23%
11%14%
4%
12%
5%
14% 14%
46%
57%
42%
48%
Total Borderline
Empowered Hopeful Relieved Accepting Neutral Resigned/ Given up Powerless Depressed Angry
Borderline are those who have major burden of health care cost and are
extremely concerned about ability to pay for a serious health problem.
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This year, significantly more say they are powerless, angry, resigned, and depressed; fewer are relieved, though slightly more are hopeful.
Prepared for: Strategic Health PerspectivesBase: All US Adults (2014 n=2501, 2015 n=5037)Source: Q47 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 feel less empowered and accepting of their healthcare
Consumer Emotions Towards Healthcare They Receive
9%
17% 19%
37%
28%
15%
23%
11%14%
6%
20%
13%
32%
24%
17%
31%
14%18%
2014 2015 2014 2015 2014 2015 2014 2015 2014 2015 2014 2015 2014 2015 2014 2015 2014 2015
Empowered Hopeful Relieved Accepting Neutral Resigned/ Given up Powerless Depressed Angry
4% 14% 5% 37% 43% 52%15% 8% 62%
BORDERLINE(n=433)
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Below Average
Average*
AboveAverage
Low monthly premiums
Keeping my current doctor(s)
Unrestricted access to all medical technologies
Low copay costs for generic drugs
Coverage for dependents
Direct access to all specialist(s)
Direct access to leading specialist(s) in my area
Reasonable copays for brand name drugs
Unrestricted access to cutting edge medical devices
Choice of hospitals
Unrestricted access to cutting edge drugs
Access to all brand name drugs at low cost-sharing
Coverage for a wide selection of brand name drugs
Access to prestigious institutions
198
153
119
111
110
106
100
90
88
82
73
72
57
42
Base: All US Adults Less Than 65 (2010 n=2501, 2012 n=2052, 2013 n=1546), 2014 n=1233 in half sample)Respondents were given a maximum difference trade off exercise in which they were forced to choose the most preferredand least preferred plan feature.
2014 rank
3 yr trend
2013 rank
2012 rank
1 -- 1 1
2 2 5
3 -- 3 4
4 -- 5 3
5 ▲ 7 2
6 -- 6 10
7 ▼ 4 11
8 -- 9 6
9 -- 8 8
10 ▲ 12 13
11 ▼ 10 7
12 ▼ 11 9
13 -- 13 12
14 -- 14 14
CONSUMERS CONSISTENTLY VALUE LOWER PREMIUMS, WANT TO KEEP CURRENT DOCTOR
Relative Importance of Benefit, Under Age 65
TRENDED
Virtually no difference over prior year in benefit tradeoffs
SHP CONSUMER 2014
THE POLICY CONTEXT
Obama Care: The Original Simple Version
• Coverage Expansion to 30 million people by 2015 on– 15 million through Medicaid Expansion– 15 million through subsidized health insurance exchanges
• Regulation of health insurance practices– Guaranteed issuance– Individual Mandate
• Paid for by supplementary Medicare Tax on $250K+ earners and “voluntary” taxes on healthcare stakeholders
• Promising pilots and processes for reimbursement reform– Patient Centered Medical Homes– Accountable Care Organizations– Innovation Center at CMS
• The Cadillac Tax
NOTES: *AR and IA have approved waivers for Medicaid expansion; MI has an approved waiver for expansion and plans to implement in Apr. 2014. NH passed legislation approving the Medicaid expansion in March 2014; the expansion will start July 1, 2014. WI amended its Medicaid state plan and existing waiver to cover adults up to 100% FPL, but did not adopt the expansion. IN and PA have pending waivers for alternative Medicaid expansions. These states along with MO, VA, UT have been classified as Open Debate on the Medicaid expansion decision. SOURCE: State Decisions on Health Insurance Marketplaces and the Medicaid Expansion, 2014, KFF State Health Facts, http://kff.org/health-reform/state-indicator/state-decisions-for-creating-health-insurance-exchanges-and-expanding-medicaid/.
Current Status of State Individual Marketplace and Medicaid Expansion Decisions, 2014
WY
WI*
WV
WA
VA*
VT
UT*
TX
TN
SD
SC
RI PA*
OR
OK
OH
ND
NC
NY
NM
NJ
NH*
NV NE
MT
MO*
MS
MN
MI*MA
MD
ME
LA
KY KS
IA*
IN* IL
ID
HI
GA
FL
DC
DE
CT
CO CA
AR*AZAK AL
State-based Marketplace and Not Moving Forward with the Medicaid expansion (1 State)
Federally-Facilitated or Partnership Marketplace and Not Moving Forward with the Medicaid Expansion (23 States)
Federally-Facilitated or Partnership Marketplace and Moving Forward with the Medicaid Expansion (11 States)
State-based Marketplace and Moving Forward with the Medicaid expansion (16 States including DC)
Big Drop in Uninsured under Obamacare
STRATEGIC HEALTH PERSPECTIVES℠
Uninsured Rate Has Dropped Almost Everywhere
Even in states not expanding Medicaid, uninsured rates have fallen
Minnesota had Exchange ChallengesWisconsin did the Badger Care Switcheroo
United States Total Minnesota WisconsinPopulation 310,197,000 5,076,000 6,794,000
Marketplace Plan Selected 2014
8,019,763 48,495 139,815
Marketplace Plan Selected 2015
11,688,074 59,704 207,349
Medicaid Enrollment Pre ACA
57,794,096 873,040 985,531
Medicaid Enrollment February 2015
70,515,716 1,029,334 1,053,400
% Increase 20.3% 17.9% 6.9%
Source: KFF from DHHS, May 1 2014, March 2015
Oregon Medicaid grew 69% over the same period
How to Pick a Health Plan on an Exchange
• Step 1. Decide on the diseases you and your family are going to have in the coming year
• Step 2. Find the best doctors and hospitals for those diseases
• Step 3. Identify which plans offer those doctors and hospitals
• Step 4. Select the cheapest plan• Step 5. If there are no affordable plans with all the
doctors and hospitals you want, go back to Step 1 and pick some new diseases
Private Purchasers will Act by 2020
• Short Term (1-3 years)– Transparency on Cost and Quality– CDHP/HDHP– Benefit Buy Downs (including retirees and spouses)– Reference Pricing– Private Exchanges– Narrow Networks– Out of Network Prices
• Longer Term (3-10 Years)– Stay or Go– Defined Benefit to Defined Contribution– Activist Engagement– Cadillac Tax 2018
Two Competing Visions
Berwickian Nirvana of large Accountable Care Organizations encourages rationalization of the delivery system
Atomistic view of consumers armed only with High Deductible health plans will impose market discipline on providers
See E. Emanuel et al., "A Systemic Approach to Containing Health Care Spending," and J. Antos et al., "Bending the Cost Curve through Market-Based Incentives," www.NEJM.org, Aug. 1, 2012.)
Employers Are Seeing a prolonged respite from double-digit premium increases, but these are still running at two times CPI
Projections For 2015: Trend before plan & contribution changes =6.5% Trend after plan and contribution changes =5.0% CPI-U= 2.5%
SOURCE: Towers-Watson NBGH Annual Surveys (2014-2015)
Private Purchasers reassessing their role
Redefinition of benefits: Buy-downs (CDHP) and elimination or scaling back of commitment to spouses, dependents, retirees and early retirees, part timers etc
Consideration of the role of Exchanges and possible ‘exit’ from employer-sponsored benefits
Growing interest in direct contracting with providers and ‘accountable’ systems
Pushing greater responsibility onto employees to encourage them to shop based on cost, quality (movement toward defined contribution strategy, more limited plan offering, consumer shopping tools).
More activist wellness including biometric screeningSource: Personal Communication, PBGH, 2013
2009 2010 2011 2012 2013 2014
18%21%
27%
44% 46%
0.26
0.45
0.59 0.58
96%91% 88% 91% 90% 91%
Employers are of two minds on providing health insurance
* Asked only of Employers with 50 or more employeesBase: All Employer Health Benefit Decision Makers (n=337)Q800: Please indicate your level of agreement with the following statements. Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?
Agreement with Statements About Healthcare(Top-2 Box % - Agree Somewhat/Strongly)
58%
87%89%
Health care premiums should be tax deductible
My senior management is paying more attention to the cost of our health benefits offerings
It is our responsibility to ensure our employees' health needs are met
My company is actively exploring ways to get out of providing health insurance to our employees
Employer-based health insurance will soon become a thing of the past
My company feels it is worth it to pay the penalty associated with not providing employee health benefits rather than provid-ing health benefits to our employees.*
SHP EMPLOYERS 2014
Exploring ways to get out of providing it, and feeling a responsibility to employees
Coinciding with economic improvement, the perceived value of employer healthcare in the labor market is on the upswing
Note: Scale changed (added “well” in the middle) in 2012Base: All Employer Health Benefit Decision Makers (n=337) 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 (Labor Market)(Top-2 Box % - Describes Completely/Very Well)
2007 2008 2009 2010 2011 2012 2013 2014
87% 87%
76%
67% 69%
49%
57%61%
53% 54%
66%
58%
45%51%
58%
25% 22% 25% 26%32%
39% 41%
Provide health benefits to stay labor market competitive
Employees view health benefits as compensation requirement
Generous benefits compensate for lower salaries
SHP EMPLOYERS 2014
STRATEGIC HEALTH PERSPECTIVES℠
• Large Diversified company with unions and high wage base.
• Very sophisticated Purchaser using consumerism and DB to DC for retirees to reduce benefit burden.
• Spread across a dozen or more regional markets
GE:
• Bifurcated workforce: Theme Park workers and Johnny Depp
• Geographic Concentration in Orange County California and Orange County Florida
• Consumerism strategy and engagement with local delivery systems
Disney:
• National retailer with 2 million plus associates
• Centers of Excellence Model for high cost cases
• Eliminating coverage for part-timers and encouraging them to use exchanges
Wal-Mart
• Large pharmacy/retail chain• Private Exchange model outsourced
to AON/Hewitt• 142,000 signed up• Insured product model• Choice causes buy-down• 80% picked silver or bronze
Walgreen’s
• Geographic concentration of fabrication plants and facilities: OR, NM, and CA
• Healthcare treated just Like any supplier: tough performance requirements
• Going direct e.g. Presbyterian in New Mexico, onsite clinics
Intel
• War for talent• Average age 12• Want the primary care on campus
and telehealth for everything else
Silicon Valley Employer Network
• Large public purchaser system• Unionized workers• Pioneered reference pricing as shot
across the bow of providers• In the retiree health benefits
business big time• Wants high performing HMO product
CALPERS
Seven Large Employer Archetypes How do these archetypes view their benefit responsibilities?
UK
NOR
GER
NETH NZ
SWIZ
AUS
US
CAN FR
SWE
0
20
40
60
80
100
6958 56 56 54
49 4639 38 36 35
Access to After-Hours Care
Percent
95 9590 90
81 80 78 7668
4635
Adults, 2013Easy getting after-hours care
without going to the ER
Primary care physicians, 2012Practice has arrangement for patients’
after-hours care to see doctor or nurse
Source: 2012 and 2013 Commonwealth Fund International Health Policy Surveys.
Base: Needed care after hours. * In Norway, doctors asked whether their practice had arrangements or there were regional arrangements.
Silicon Valley Elite EmployersSay “Bring the Doctors to Us”
Kaiser’s Mobile Health Van
PAMF’s Care A Van• Brocade• Cadence• KLA Tencor• Marvell• Net App• Nvidia• Oracle
• San Desk• Symantec• Synopsys• Varian• VM Ware• Yahoo
• Facebook• E Bay• Net App• Nvidia
• Oracle • Stanford • VM Ware• Yahoo
Stanford Health Care Onsite and Nearsite Clinics• Qualcomm• Dreamworks• Santa Clara Nearsite Clinic
Public Purchasers
• Medicare Advantage is surprisingly resilient• Medicaid expansion is massive in half the
country• Public exchanges will grow after a rocky start• Public employers have huge retiree health
benefit problems• Public payers more dominant by 2020
Medicare Advantage Enrollment is Highly Variable Across the Country (0% to 53%) and Growth Continues
38
Boomers, Young People Attracted to Medicare Advantage
Harvard School of Public Health/SSRS poll, Mat 13-26, 2013.
Total 18-29 30-49 50-64 65+
(When you retire,) If you had a choice, would you prefer to get your Medicare health insurance benefits from…
The current government Medicare program
34% 26% 28% 33% 57%
A private health plan, such as a PPO or HMO offered through Medicare
56% 65% 63% 57% 29%
Don’t know/refused 10% 7% 8% 9% 13%
Massive Medicaid, 2015• 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
• Medicaid expansion is a big deal in the states that are doing it…e.g. California Medi-Cal has 12.2 million enrollees and a budget in excess of $90 Billion for 2014-15 FY most from Federal sources
• Oregon Medicaid enrollment now over 1,000,000 a 69 % increase over pre ACA levels
• The last mile of enrollment• Churning in Medicaid eligibles• Who will take these enrollees and what will be the
financial impact on providers that do take them?
Ahead of the Curve on Value-Based Payment• “The future is already here…it
is just not evenly distributed”– William Gibson
• California has 55.4% in value-based payment (in all in-network commercial based payment) up from for 41.8% in 2013
• US has leapt up to 40% in 2014 up from 10.9% in 2013 according to CPR exceeding CPR’s 2020 goal of 20%
Source: Catalyst for Payment Reform, 2014
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smaller standalone
medium standalone or smaller systems
larger standalone or system
Completely Fee for Service
Completely CapitatedPayments
Evenly Split
Total:
(0) (50) (100)
Anticipated Growth in Capitation/Value
IN 5 YRS 51
TODAY:35
Smaller
Larger
Mid Size
TODAY:38
TODAY:36
TODAY:31
IN 5 YRS 49
IN 5 YRS 56
IN 5 YRS 52
(↓2%)
EVEN LARGE SYSTEMS ANTICIPATE ONLY HALF CAPITATED PAYMENTS IN NEXT 5 YEARS
Base: All Hospital-Based Execs (2015: n=200; 2014: n=202; 2013 n=210)Q705/Q706/Q707: Many hospitals are starting to be paid differently for their services, moving from a fee for service environment to more capitation or value based payments. Where is your hospital/hospital system on the spectrum today, and where will you be five years from now?
SHP HOSPITALS 2015
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Completely Fee for Service
Completely CapitatedPayments
Evenly Split
Total:
(0) (50) (100)
Anticipated Growth in Capitation/Value
IN 5 YRS 47
TODAY:27
PCPs
Hospital based
Specialists
Office based Specialists
TODAY:31
TODAY:22
TODAY:33
IN 5 YRS 51
IN 5 YRS 45
IN 5 YRS 47
PCPS ANTICIPATE FASTER MOVE, BUT STILL ONLY HALF OF PAYMENTS CAPITATED IN 5 YEARS
Base: All Physicians (2015: n=626; 2014 n=600)Q1280: Many physician practices are starting to be paid differently for their services, moving from a fee for service to more capitation or value based payments. Where is your practice on the spectrum today, and where will you be in five years from now?
SHP PHYSICIANS 2015
Health Systems Taking RiskLots of big systems showing interest but patient flow through these models is not large except for legacy players
Referral management (preventing leakage from the IDN) can provide FFS fuel for transformation to risk
“Eat your own cooking” is a common starting point
Link to ACO strategy
Link to going direct to employers or exchanges e.g. North Shore Long Island Jewish
Link to Population Health Interest and Clinical Integration Organization strategy
STRATEGIC HEALTH PERSPECTIVES℠
Health Systems Taking Risk• Health Systems with Legacy Health Plans
– Inter-Mountain, Sharp, Presbyterian, Spectrum Health, Providence• Health Systems that recently built, acquired or merged with a Health Plan
function– Partners (Boston), Sutter, Dignity Health (Western Healthcare Advantage), Memorial
(Long Beach), Baylor Scott and White, North Shore Long Island Jewish, Ascension, CHI• Health Systems that are going deep on Commercial ACO plans and/or CMS
ACOs with plan partners– Montefiore, Steward, Aetna Whole Health (Inova, Banner, Aurora), Memorial
Hermann, Stanford– Vivity (UCLA, Cedars, Memorial, Torrance, Good Samaritan, PIH, Huntington and
Anthem Blue Cross) – About Health/Blue Priority Anthem Wisconsin
• Health Systems “Go Your Own Way”– Evolent Health (UPMC and Advisory Board Offering) includes Piedmont/Wellstar,
Medstar
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47Base: All Hospital-Based Execs (2015: n=200; 2014: n=202)Q980: Which of the following best describes your hospital’s/hospital system’s “risk bearing” strategy?
Directional growth in hospitals committing to clinical integration for contracting w/ payers.
Hospital Insurance Risk Management Strategy
MAJORITY EXPLORING RISK BEARING STRATEGIESSHP HOSPITALS 2015
31%
25% 26%
12%8%
41%
29%
19%
10%
1%
20152014
51% of smaller hospitals have no plans
No real differences by size of system
No Plan On Journey
At the end of the day, people trust hospitals more than health plans
SupermarketsHospitals
Online Search EnginesBanks
Computer Hardware CompaniesOnline Retailers
Electic and Gas UtilitiesComputer Software Companies
Packaged Food CompaniesAirlines
Car ManufacturersLife Insurance Companies
Pharmaceutical and Drug CompaniesHealth Insurance Companies
Telecommunications CompaniesManaged Care Companies, such as HMOs
Social Media CompaniesOil Companies
Tobacco Companies
4034
3527
2223
2014
1113
712
4
43
3028
1818
1715
1413
111111
1010
77
66
43
2013 2003
Source: Harris Poll, December 2013
SOURCE: Harris Poll for STRATEGIC HEALTH PERSPECTIVES
% Trust in Industries
42 % Trust none of the Industries on the
list
STRATEGIC HEALTH PERSPECTIVES℠
NEW THINKING: SOME EXAMPLES
Montefiore
An AMC on the way to being an at risk integrated system of care
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Base: All Hospital-Based Execs (2015: n=200; 2014: n=202)Q417: Which of the following best describes your approach to the management of the referrals from physicians affiliated with your hospital?
Increasing awareness, intent to do something about it
Current Approach to Referral Management from Physicians Affiliated with Hospital
MANAGING REFERRALS: CONTINUED FOCUS
We have already made significant investments in an organized referral management system and are actively keeping more referrals within our
employed physician network
We have identified that modifying referral patterns of our medical staff is a critical success factor in our clinical integration strategy and we are
planning to actively manage referrals in the future using an organized approach to keep more referrals within our facilities/ medical groups
We recognize that there is considerable inpatient and outpatient volume that "leaks" to our competitors because our medical staff does not refer
exclusively to our facilities, but we have no immediate plans to influence those referrals beyond offering privileges
We do not actively manage referral patterns of the physicians who admit to our facilities and have no plans to do so beyond offering hospital
privileges
Not sure not applicable
18%
41%
30%
7%
6%
18%
45%
24%
10%
7%20142015
SHP HOSPITALS 2015
The Work
• Centrality of Clinical Integration• Health IT as platform not panacea• Learning to live on Medicare• Managing Business Model Migration• Building a culture of Quality and
Accountability – “We have the anatomy of an Accountable Care
Organization but none of the physiology”
The Scout Badge Problem
Patient Centered Medical Home
Accountable Care Organization
Telehealth Initiative
Patient Portal
Readmission Reduction Program
Diabetes Disease Registry
Quantified Self App
Care Bundles
Remote Patient Monitoring
E-Consults
But how many? And what is the denominator?
STRATEGIC HEALTH PERSPECTIVES℠
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STRATEGIC HEALTH PERSPECTIVES℠
GENERAL OUTLOOK FOR PHYSICIANS IN 2015
More are resigned, while more are moving into integrated practices
A solid minority is really frustrated and despondent
EHRs* are a huge source of frustration across the board
Fundamentally this is a pocketbook issue
We used to think things
couldn’t change
unless the docs were
happy
The docs aren’t really
happyBut things
are changing
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PHYSICIAN SURVEY, KEY FACTS 2015
• Physician satisfaction with their own practice fluctuates over time but is still 68/32 net positive in 2015 compared to 70/29 in 2002
• But, as in last three years physicians are 26% optimistic versus 55% pessimistic about the practice of medicine today
• One Third support ACA versus 55% oppose
• Majority (68%) of physicians see impact on their practice of ACA as negative only 22% positive
• 23% of physicians claim to be in an ACO up from 10% last year and 7% in 2013
• 19% of physicians claim to be in an Patient Centered Medical Home up from 6% last year and 4% in 2013
• 14% claim to be in a narrow network (up from 11% last year) offering a typical discount of 29%
• 74% of physicians say they “will continue to see and accept new” Medicare patients (59% for Medicaid and 80% for exchange)
• Solo physicians less likely to be participative in future trends compared to affiliated group practice and those physicians who are in Integrated Delivery Systems
Source: Nielsen, Strategic Health Perspectives, 2015 Confidential
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STRATEGIC HEALTH PERSPECTIVES℠
Overall Satisfaction with Current Practice
SHP PHYSICIANS 2015
Base: Office-Based Physicians (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?.
MANY PHYSICIANS STILL DISSATISFIEDThough it may be rebounding from last year’s historic low, 1 in 3 doctors is still dissatisfied with his or her practice situation.
2011 2012 2013 2014 2015
80%74% 76%
62%68%
20%26% 24%
38%32%
NET Satisfaction NET Dissatisfaction
Significant change
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2%
23%
1%
23%16%
23%
43%
24% 23%Physicians
SHP PHYSICIANS, CONSUMERS 2015
Base: All 2015 Physicians (n=626)Q1850: How would you describe your feelings about the health care system today? Please select all that apply.
Empowered Hopeful Relieved Accepting Neutral Resigned/ Given up Powerless Depressed Angry
6%
20%13%
32%
24%17%
31%
14%18%
Consumers
PHYSICIANS CLOSELY RESEMBLE CONSUMERS IN EMOTION, FRUSTRATION AROUND HEALTH CARE
Base: All US Adults (2015 n=5037)Q47 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.
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Medical School Preparation, Programs Used for Today’s Healthcare*
SHP PHYSICIANS 2015
Base: All 2015 Physicians (n=626)Q1851: How well do you feel medical school prepared you for practicing medicine in today’s healthcare system?Q1852: Have you used any of the following to help you adapt to changes in our healthcare system? Please select all that apply.
2015
11%
34%
39%
13%2%
Extremely well
Very well
Somewhat well
Not very well
Not at all well
16%
45%
*New in 2015
CME widely cited as a way to help adapt to changing system.PHYSICIANS FEEL UNPREPARED FOR TODAY’S MEDICINE
Continuing medical education
Post graduate business certificate programs
An MBA or other management degree
Something else
None of the above
80%
5%
3%
14%
15%
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BUT ARE THEY RESIGNED TO IT?
Optimistic IntendersI haven’t reformed yet, but I want to.
Blazing BelieversIntegrating…and happy about it.
Reluctant ObjectorsIntegrating…and NOT happy about it.
Independent ResistersI haven’t reformed, and don’t plan to.
Experience with Integration
Attitu
de to
war
ds
Inte
grati
on
20%
20%
39%
21%
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 (1)
SHP PHYSICIANS 2015
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CHANGE IS HARDER TO RESIST
2012 2013 2014* 2015
23% 34% 28% 39%16%
19% 35% 20%22%23%
24% 21%32% 25% 14% 20%
Independent ResistersReluctant Ob-jectorsOptimistic In-tendersBlazing Be-lievers
B
*The 2014 sample skewed a bit different (higher solo practice than the population).
Total Experienced “Integration”
45% 57% 52% 60%
THE SEGMENTATION OF BERWICKIAN NIRVANA (2)
Believers are increasing and Resisters are shrinking. Once they are in, they may become more accepting—perhaps not happy about it per se, but going along with the program.
SHP PHYSICIANS 2015
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STRATEGIC HEALTH PERSPECTIVES℠
More Satisfied• Work in IDNs• Younger • Lean left politically• More optimistic about future of medicine
Less Satisfied• Age 50+, more years in practice• More FFS compensation• Less optimistic about future of medicine
WHO IS SATISFIED WITH THEIR EHR?Overall satisfaction is low across the board, with no real differences by specialty or affiliation. A few differences stand out:
84% 65% 62%
16% 35% 38%
NET Practice DissatisfactionNET Practice Satisfaction
BC
A A
EHRSatisfied
A EHRNot Satisfied
CEHRSmwt Satisfied
B
SHP PHYSICIANS 2015
27% 46% 27%
Satisfied Somewhat Not Satisfied
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Physicians
SHP PHYSICIANS, CONSUMERS 2015
Base: All 2015 Physicians Using EMR (Satisfied 148, Not Satisfied 153)Q1850: How would you describe your feelings about the health care system today? Please select all that apply.
Empowered Hopeful Relieved Accepting Neutral Resigned/ Given up Powerless Depressed Angry
Base: All US Adults (2015 n=5037)Q47 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.
3%
34%
1%
38%
15% 16%
42%
13% 15%
0%
18%
2%
17%14%
27%
44%
31%35%
Satisfied with EMR Not Satisfied with EMR
Though equally powerless, those satisfied with EHR system more than twice as likely to feel hopeful, accepting.
EHR DISSATISFACTION LEADS TO DEPRESSION, ANGER
Looking to 2020• Pressure on public payment sources will continue• Private Payers will not tolerate costs shift willingly• Exchanges and DB to DC among employers makes market more retail• Consumer becomes more important as decision-maker• Long run three payer segments: Managed Medicaid, HDHP (Exchange and
Employer) and Medicare Advantage/ACO increase pressure to deliver value• Care Redesign for higher performance
– High Reliability Organizations– Migrating Business model to Risk– Care coordination and management across the continuum of care– Alignment of all physicians, nurses and caregivers with this process– Consumer facing innovation in delivery and telehealth – Innovation at Scale
• Governance and leadership to sustain it all
Implications for Physicians
• Consolidation and integration continue leading to constraints on clinical and economic autonomy for many, but new opportunities for innovators
• Mixed signals for a long time– Volume to value– RVU productivity
• Overcoming Improvement Fatigue– Physician leadership– Strategic communication on the why of change– The Quadruple Aim
• Innovation for higher performance • Remember what brought you to medicine