health it statistics

8/17/2019 health it statistics

1/53

Health Care IndustryTrends 2016Ready-to-Use Presentation Slides

Market Innovation Center


2/53

2

23

1

Road Ma!

"2016 The #dvisory $oard Co%!any & advisory.com

Pay%ent Re'or%

Provider Market

Pur(haser $ehavior

Provider Sele(tion


3/53


3

3

Pay%ent Re'or%

& U!date on )alue $ased Pur(hasin* Pro*ra%

& U!date on $undled Pay%ents& U!date on #((ounta+le Care ,r*aniations


4/53


Sour(e. Health Care #dvisory $oard intervie/s and analysis

Continuum of Medicare Risk Models

BundledPayments

SharedSavings

SharedRisk

FullRisk

& Hos!ital )$PPro*ra%

& Hos!italRead%issionsRedu(tion Pro*ra%

& H#C Redu(tionPro*ra%

& Merit-$ased

In(entive Pay%entSyste%

& MSSP Tra(k 10 sharin*4 & MSSP Tra(k 260 sharin*4

& MSSP Tra(k 3u! to 5 sharin*4

& e7t-8eneration #C, 90-9sharin*4

& e7t-8eneration #C, o!tional'ull !er'or%an(e risk4

& Medi(are #dvanta*e !rovider-s!onsored4

Pay-for-Performance

& $undled Pay%ents'or CareI%!rove%entInitiative $PCI4

Increasing Financial Risk


5/53


Pay%ent Tar*ets :e%onstrate Co%%it%ent to ;;S1 #lternatives

U!date on )alue $ased Pur(hasin* Pro*ra%

Sour(e. HHS< =Pro*ress To/ards #(hievin* $etter Care< S%arter S!endin*< Healthier Peo!le availa+leat. htt!.??///hhs*ov?< a((essed ;e+ruary 201@ Health Care #dvisory $oard intervie/s and analysis

14 ;ee-'or-Servi(e

CMS Sets Targets for alue-Based Payments

2015 2016 2018

!"#

$"#

%"#

&ggressive Targets for Transition to Risk

Percent of Medicare Payments Tied to Risk Models

2015 2016 2018

'"#

'%#

("#

FFS Increasingly Tied to alue

Percent of Medicare Payments Tied to Quality

Medi(are Shared

Savin*s Pro*ra%

Patient-CenteredMedi(al Ho%e

$undled Pay%ents 'or CareI%!rove%ent Initiative

E x a m p l e s o f Q u a l i f y i n

R i s k M o d e l s

Hos!ital-#(Auired ConditionRedu(tion Pro*ra%

Hos!ital Read%issionsRedu(tion Pro*ra%

Hos!ital )alue-$asedPur(hasin* Pro*ra%

Merit-$ased In(entive

Pay%ent Syste%

E x a m p l e s o f Q u a l i t y !

" a l u e P r o r a m s


6/53


6

Mandatory Risk Pro*ra%s Takin* a Toll on Providers

Sour(e. Rau B< =1


7/53"2016 The #dvisory $oard Co%!any & advisory.com

5U!date on $undled Pay%ents

BPCI Partici0ation Continues to Fluctuate

1%" $1!

2110-%31

4)"""5

!3#%1#

(#

#cute $are%ospitals

P&ysician Practices

P#$Pro'iders2

14 $undled Pay%ents 'or Care I%!rove%ent Initiative24 In(ludes S;s< HH#< In!atient Reha+ilitation ;a(ilities< and Gon*-ter% #(ute Care Hos!itals34 :oes not add to 100 +e(ause #/ardees not initiatin* e!isodes in $CPI are not in(luded

Sour(e. CMS< =$undled Pay%ents 'or Care I%!rove%ent $PCI4 Initiative. 8eneral In'or%ation ;e+ruary2016@ The Ge/in 8rou!< =CMS $undled Pay%ents 'or Care I%!rove%ent $PCI4 Initiative Models 2-. ear 1valuation J Monitorin* #nnual Re!ort Banuary 201@ Health Care #dvi sory $oard intervie/s and analysis

Total /um6er of BPCI Partici0ants

#s of (anuary 2016

Ty0es of +rgani7ations Partici0ating in BPCI$

Episode )nitiators as of (anuary 2016



9

CMMI1 Pro*ra% ReAuires ,rtho!edi( $undlin* in 65 Sele(t Markets

14 Center 'or Medi(are and Medi(aid Innovation24 Criti(al #((ess Hos!itals34 $undled Pay%ents 'or Care I%!rove%ent Initiative

+rtho0edic Bundling /o, Mandatory

*ey Proram +eatures

Mandatory in 43 markets

o a!!li(ation !ro(ess@C#Hs1 and $PCI2 Phase II!arti(i!ants e7e%!t

Retros0ective 6undle

CMS /ill !ay ea(h !roviderse!arately< (ondu(t annualre(on(iliation !ro(ess

Com0rehensive e0isode

In(ludes all related Part #and Part $ servi(es 'or F0days !ost-dis(har*e

The Com0rehensive Care for 8oint Re0lacement 9C8R: Model

Focus on ;oints

#vera*e e7!enditurevaries 'ro% K16



F



10

1F

0 23

9F #C,s Boin in 201< ;e/ 8eneratin* Shared Savin*s in ;irst ear

Sour(e. S!italni( P< =Certi'i(ation o' Pioneer Model Sav in*s CMS< #!ril 10< 201@ availa+le at ///(%s*ov@ =Shared Savin*s Pro*ra% ;ast;a(ts CMS< #!ril 201< availa+le at. ///(%s*ov@ CMS< =;a(t Sheets. Medi(are #C,s (ontinue to su((eed in i%!rovin* (are< lo/erin*(ost *ro/th Se!te%+er 16< 201< availa+le at ///(%s*ov@ M(Clellan M et al< =Chan*es eeded to ;ul'ill the Potential o' Medi(areLs #C,Pro*ra% Health #''airs $lo*< #!ril 9< 201< availa+le at ///healtha''airsor*?+lo*@ Health Care #dvisory $oard intervie/s and analysis

14 Medi(are Shared Savin*s Pro*ra%24 ;or the 2012 and 2013 (ohorts@ !er(enta*es

%ay not add to 100 due to roundin*

MSSP Continues to =ro, >es0ite Mi?ed Results

Medicare &C+ Program =ro,th Continues

!4#

!3#

14#

+ne-@uarter of MSSP &C+s Share in Savings+irst Performance ,ear 2

%eld -pendin .elo/.enc&mark Earned

-&ared -a'ins

Reduced -pendinid ot Qualify

for -&ared -a'ins

id ot %old-pendin .elo/

.enc&mark Pioneer #$3 M--P

#$3

Total

Medicare #$3s

#s of #pril 2015

http://www.cms.gov/http://www.cms.gov/http://www.cms.gov/http://www.cms.gov/http://www.cms.gov/http://www.cms.gov/http://www.cms.gov/http://www.cms.gov/http://www.cms.gov/http://www.healthaffairs.org/bloghttp://www.healthaffairs.org/bloghttp://www.healthaffairs.org/bloghttp://www.healthaffairs.org/bloghttp://www.cms.gov/http://www.cms.gov/http://www.cms.gov/



11

Pro0osed MSSP Rule ncourages More Risk

Tra(k 1 Tra(k 2 Tra(k 3

& ,!tion to rene/ 'orse(ond three-year ter%

& Savin*s rate redu(ed to0 'or se(ond ter%

& Shared savin*s< loss ratere%ains at 60 +ased onAuality !er'or%an(e

& Revises MSR1 and MGR2 'ro% 'i7ed 2 to varia+le2-3F +ased onnu%+er o' +ene'i(iaries

& $ene'i(iary attestation

& Shared savin*s u! to5< shared losses 'ro%0-5 +ased on Auality

!er'or%an(e

& ;i7ed 2 MSR and MGR

& Pros!e(tive assi*n%entand +ene'i(iary attestation

& Pro*ra% /aivers3

Tra(k Three In(or!orates ;eatures o' Pioneer #C, ModelPro0osed Tracks for the Medicare Shared Savings Program

Sour(e. :avis ri*ht Tre%aine< =Eee!in* Tra(k o' the Tra(ks. Pro!osed #C, Re*ulations #lter MSSP;inan(ial Models :e(e%+er 11< 201< availa+le at ///d/t(o%@ M(:er%ott< ill J %ery< =CMS

#C, Pro!osed Rule to 7tend ,ne-Sided Risk Tra(k hile In(entiviin* Per'or%an(e-$ased Risk:e(e%+er 1F< 201< availa+le at ///%/e(o%@ Health Care #dvisory $oard intervie/s and analysis

14 Mini%u% Savin*s Rate24 Mini%u% Goss Rate34 In(lude the S; 3-day rule< telehealth /aiver< ho%e health /aiver< and P#C re'errals /aiver

Aey Takea,aysfor Providers

& n(oura*es !roviders hesitant to assu%e do/nside risk to re%ain in !ro*ra%@redu(es lon*-ter% attra(tiveness o' u!side-only (ontra(ts

& Tra(k 3 !rovides o!tions 'or !roviders to Aui(kly assu%e %ore risk

& Provides 'le7i+ility 'or or*aniations /ith varyin* (a!a+ilities to assu%e risk

http://www.dwt.com/http://www.mwe.com/http://www.mwe.com/http://www.mwe.com/http://www.mwe.com/http://www.dwt.com/



1212

Provider Market

& ;inan(es

& )olu%e Per'or%an(e

& Mer*ers and #(Auisitions& Partnershi!s and #''iliations

& I%a*in* Centers

& #%+ulatory Sur*ery Centers

& Pri%ary Care et/ork

& Telehealth



13;inan(es

Sour(e. #ltaru% Institute< Health Se(tor Trend Re!ort< Mar(h 201< a((essed #!ril 201@ Toi B< =US Health-Care S!endin* Is on the

Rise #*ain $loo%+er* $usiness/eek< ;e+ruary 19< 201< availa+le at. ///+loo%+er*(o%@ :avidson P< =Health (are s!endin* *ro/thhits 10-year hi*h US# Today< #!ril 1< 201< availa+le at. ///usatoday(o%@ #lt%an :< =Health S!endin* is Risin* More Shar!ly

#*ain The all Street Bournal< ;e+ruary 25< 201< availa+le at. ///+lo*s/s(o%@ Health Care #dvisory $oard interv ie/s andanalysis

*ealth S0ending on the Rise &gain

2006 2004 2008 200 2010 2011 2012 201 20170

1

2

3

6

5

9

F

10

4.%#63

9

39 3F 3F1

36

%."#

9:-: %ealt&;$are -pendin)s on t&e Rise #ain



1

Hi*her S!endin* :oes ot Auate Pri(e 8ro/th 'or Hos!itals

Sour(e. #ltaru% Institute< Health Se(tor (ono%i( Indi(ators. Pri(e $rie'<Mar(h 201< Mar(h 201< Mar(h 2013< Mar(h 2012< availa+le at.///altaru%or* @ Health Care #dvisory $oard intervie/s and analysis

But *os0ital Price =ro,th >o,n for First Time

&nnuali7ed *os0ital Price =ro,th) 8an. !""-8an. !"%

(an: >10 (an: >11 (an: >12 (an: >1 (an: >17 (an: >15

-0

00

0

10

1

20

2

30

3

03

16

25

2F

1

-01

!"% *os0ital Price=ro,th >o,n &cross&ll Payer Classes

Medi(are !ri(e *ro/th2F4

Medi(aid !ri(e *ro/th

014

Co%%er(ial !ri(e *ro/thlo/est *ro/th rate sin(e20024

16

http://www.altarum.org/http://www.altarum.org/http://www.altarum.org/



1

Modest =ro,th &ntici0ated for the /ear Term

In!atient and Hos!ital $ased ,ut!atient )olu%e Proe(tions

Sour(e. #dvisory $oard In!atient and ,ut!atient Market sti%ators@ #dvisory $oard resear(h and analysis

14 Co%!ound #nnual 8ro/th Rate

In0atient olume)

C&=R

2017;201

$ardiac -er'ices

2euroloy

=eneral -urery

3rt&opedics

=eneral Medicine

2eurosurery

3'erall

".(#

-.-#

-.-#

-.1#

!.3#

".%#

*os0ital-Based +ut0atientolume) C&=R

2017;201

3rt&opedics

=eneral -urery

E?M

$ardioloy

Radioloy

3ncoloy

3'erall

$.-#

!.!#

-.1#

!.$#

-.1#

-.3#

!."#

9!.3#:$.#

16

) l P '



16

olumes Continuing to Shift +ut0atient

Sour(e. =Re!ort to the Con*ress. Medi(are Pay%ent Poli(yMedP#C< Mar(h 201< availa+le at. ///%ed!a(*ov@ #dvisory$oard Co%!any In!atient and ,ut!atient Market sti%ators@ MarketInnovation Center intervie/s and analysis

14 ,ut!atient servi(es re!resent entire %arket re*ardlesso' site o' serv i(e in(ludes hos!ital-+ased settin*s<

#SCs< other 'reestandin* !roviders and !hysi(iano''i(es4

Medicare olume =ro,th$umulati'e Percent $&ane

&ll Payer olume =ro,th Pro;ections

2017;201

,ut!atient Servi(es !er ;;S Part $ $ene'i(iary

$$."#

93."#:

2006 201

!"#

-3#

-'#

-!#

10

60

-F0

-130

,u!atient In!atient

$ardiac-er'ices

"ascular-er'ices

3rt&opedics

eurosurery

)olu%e Per'or%an(e

15

15

http://www.medpac.gov/http://www.medpac.gov/http://www.medpac.gov/http://www.medpac.gov/



15

Sour(e. CMS< =2013 #nnual Re!ort o' the $oards o' Trustees o' the ;ederal Hos!ital Insuran(eand ;ederal Su!!le%entary Medi(al Insuran(e Trust ;unds May 31< 2013< avai la+le at.htt!.??do/nloads(%s*ov?'iles?TR2013!d' @ Health Care #dvisory $oard intervie/s andanalysis

Medicare to Become Ma;ority of olume 6y !"!!

Pro;ected /um6er ofMedicare Beneficiaries

Millions of .eneficiaries

0

53

605

63

66

&verage In0atient Case Mi?By olume

n @ 485 %ospitals

2012 2022

1!#

%'#

(#

%#

$$#

!%#

4# !#

Medi(are

Medi(aid

Co%%er(ial

Sel'-Pay

2017 2016 2018 2020 2022

15

19M d # i iti

http://downloads.cms.gov/files/TR2013.pdfhttp://downloads.cms.gov/files/TR2013.pdfhttp://downloads.cms.gov/files/TR2013.pdf



19

200 2010 2011 2012 201 2017

%"

44

'4 '(

(' (%

Mer*ers and #(Auisitions

Sour(e. $e(kers Hos!ital Revie/< =The ear o' F Hos!ital Transa(tions 201< avai la+le at. ///+e(kershos!italrevie/(o%?@ #%eri(an Hos!ital #sso(iation< ;ast ;a(ts 2016< availa+le at. htt!.??///ahaor*?resear(h?r(?stat-studies?'ast-'a(tssht%l Health Care #dvisory $oard intervie/s and analysis

M& Continue at a Steady Rate

*os0ital and *ealth SystemM& &ctivityTotal eal "olume

/um6er of *os0itals Part of a *ealthSystem

2



1FPartnershi!s and #''iliations


Five Ma;or Ty0es of Provider Partnershi0

>escri0tion

Merger or&cDuisition

;or%al !ur(hase o' one or*aniationLs assets +y another< or the (o%+ination o't/o or*aniationsL assets into a sin*le entity

Clinically-Integrated*os0ital /et,ork

Colle(tion o' hos!itals (ontra(tin* ointly in order to su!!ort i%!roved(oordination< out(o%es@ %odeled a'ter !hysi(ian CI net/orks

&ccounta6le Care+rgani7ation

Inde!endent entity< o/ned +y one or several inde!endent or*aniations< thata((e!ts risk-+ased (ontra(ts and distri+utes shared savin*s

RegionalColla6orative

;le7i+le u%+rella stru(ture< o'ten en(o%!assin* %any inde!endentor*aniations o' si%ilar *eo*ra!hy< that %ay serve as 'oundation 'or 'urtherinte*ration

Clinical &ffiliation Ty!i(ally +ilateral a*ree%ent to (oo!erate around a !arti(ular initiative orservi(e line@ %ay involve lo(al or national !artners

1F

20I%a*in* Centers



20I%a*in* Centers

Sour(e. #dvisory $oard I%a*in* ,ut!atient Market sti%ator@I%a*in* Per'or%an(e Partnershi! intervie/s and analysis

+ut0atient Imaging olume =ro,th Positive

9(#

#

%#4#

!#

!#

16'#

!1#

#!#

!4#

"#

yr *ro/th 10 yr *ro/th

Market-s!e(i'i( volu%e 'ore(asts (an +e 'ound in The ,ut!atient I%a*in* Market sti%ator

+ut0atient olume =ro,th Pro;ections All Providers, by Modality

2014-2024

21#%+ulatory Sur*ery Centers

http://www.advisory.com/Research/Imaging-Performance-Partnership/Tools/2010/Outpatient-Imaging-Market-Estimatorhttp://www.advisory.com/Research/Imaging-Performance-Partnership/Tools/2010/Outpatient-Imaging-Market-Estimatorhttp://www.advisory.com/Research/Imaging-Performance-Partnership/Tools/2010/Outpatient-Imaging-Market-Estimator



21

Total /um6er of Medicare-Certified &SCs

2008 200 2010 2011 2012 201 2017 2015 F

%"41

%%!

%!!'

%$"3%$41

%11%141

&SC =ro,th at &ll-Time Eo,

Sour(e. =Re!ort to the Con*ress. Medi(are Pay%ent Poli(y MedP#C< Mar(h201@ #SC #sso(iation< availa+le athtt!.??///as(asso(iationor*?advan(in*sur*i(al(are?/hatisanas(?nu%+ero'as(s!er state

#%+ulatory Sur*ery Centers

et !er(ent *ro/th'ro% !revious year

1.!#

223-.3#

-.%# -.%#

-.-#".(# ".(#

2222Pri%ary Care et/ork

http://www.ascassociation.org/advancingsurgicalcare/whatisanasc/numberofascsperstatehttp://www.ascassociation.org/advancingsurgicalcare/whatisanasc/numberofascsperstatehttp://www.ascassociation.org/advancingsurgicalcare/whatisanasc/numberofascsperstatehttp://www.ascassociation.org/advancingsurgicalcare/whatisanasc/numberofascsperstate



22

& =ro,ing /et,ork of Immediate &ccess Choices

Markets Res!ondin* to Un%et eeds

Sour(e. Mehrota # et al< N)isits To Retail Clini(s 8re/ ;our'old ;ro% 2005 To 200F< #lthou*h Their Share ,' ,verall ,ut!atient )isits Re%ains Go/elivery Sites Filling the =a0

22Pri%ary Care et/ork

23



23

Retail clinic

)main center

9rent care clinic

#mBulatory surical center

Primary care clinic

Medical office Buildin

23

61

61

69

9

Current Ca!ital ,utlays< Planned Proe(ts Point to Sustained 8ro/th

Sour(e. 201 ;a(ility Plannin* Survey@ ;a(ility Plannin* ;oru%resear(h and analysis

Investment in +ut0atient Facilities =ro,ing

Percent of Res0ondents ,ith +ut0atient FacilityPro;ects Planned

2015;2018 n@ 1 %ospitals and %ealt& -ystems

Ca0ital &llocationfor &m6ulatory Investments

Percent of Total $apital 3utlays

2017201 250200

2

2



2

Retail Clinics ?0ected to Continue =ro,ing

14 #s o' ov 20124 #s o' Buly 201

34 Clini(s o/ned +y al%art@ al%art also leases retail s!a(e to!roviders in doens o' stores

Sour(e. #((enture< =u%+er o' US Retail Health Clini(s ill Sur!ass 2900 +y 2015< #((enture ;ore(asts 201@Mer(hant Medi(ine< =The ConvUr*entCare Re!ort )ol 9< o 5< Buly 201@ Market Innovati on Center intervie/sand analysis

2000;2015 1

stimated Total /um6er of Retail Clinics in the S

2000 2006 2004 2008 200 2010 2011 2012 201 2017 2015

202

'4'

$% 3!!!"

$%% 1'

153196F ('

Retailer

+0erationalRetail Clinics!

(3( 1! 4! '$ 3$

2

2


25/53


2

rgent Care Ri0e for Consolidation) >iversification

Sour(e. Mer(hant Medi(ine< =The ConvUr*entCare Re!ort )ol 9<o 5< Buly 201@ UC#,# =201 Ur*ent Care $en(h%arkin* SurveyRe!ort>@ Market Innovation Center intervie/s and analysis

14 #s o' 201324 #s o' Buly 201

+0erator

+0erationalrgent CareCenters!

!(" 44 14 1% !$

9rent care andonoin primary care

Exclusi'elyurent care

'%#

%#

Continued *ro/th likely in ur*ent (are(enters o''erin* on*oin* !ri%ary (are to+olster re'errals< relieve !ri%ary (areo''i(es< and %ana*e !o!ulation health

rgent Care Beginning to +ffer+ngoing Primary Care Services

#!!ro7i%ate nu%+er o' ur*ent(are (lini(s in o!eration in the

US

6100

#!!ro7i%ate nu%+er o' hos!italsand %ultis!e(ialty *rou!s o!eratin*

%ore than 'ive ur*ent (are sites@%ost !rovider or*aniations run

three or 'e/er sites

1

26Telehealth


26/53


26

TelehealthG ntangling the Terminology

Eey Ter%s and Ho/ They Relate to Telehealth Te(hnolo*ies

Telehealth

Sour(e. Market Innovation Center resear(h and analysis

se Cases Modalities Platforms

Pro'essionalConsultation

:ia*nosis andTreat%ent

Monitorin* andCare Coordination

Re%ote PatientMonitorin*

#syn(hronousStore-and-;or/ard

Tele!honi(

e+-+ased

Mo+ile<

S%art :evi(e

Eiosk

$luetooth-na+ledPeri!heral :evi(es

Real-ti%e)irtual )isits

>efining HTelehealthThe use o' %edi(al in'or%ation e7(han*ed 'ro% one site to anothervia ele(troni( (o%%uni(ations to i%!rove a !atientLs (lini(al healthstatus

; #merican Telemedicine #ssociation

Why in'est in tele&ealt&C What are t&e applicationsC How is tele&ealt& offeredC

25


27/53


25

Modalities >iffer 6y Reci0ient and Timing of Service

Ty!i(ally< Syn(hronous Provider-to-Patient Is Most ;avora+ly Rei%+ursed

Sour(e. Market Innovation Center resear(h and analysis

)ntended Recipient

T i m i n o f ) n t e r a c t i o n

Provider-to-Patient Provider-to-Provider

Synchronous

Real-ti%e !atient (onsultations

Co%%on a!!li(ations.

& )irtual !ri%ary (are

& )irtual ur*ent (are

& )irtual !re- and !ost-o!

Real-ti%e s!e(ialist (onsultations


& Telestroke

& TeleICU

& Tele!sy(hiatry

&synchronous

Ti%e la* +et/een !atient reAuestand su+seAuent !rovider res!onse


& Se(ure e-%essa*in*

& Re%ote !atient %onitorin*

& eara+les e*< ;it+it4

Ti%e la* +et/een initial !roviderreAuest and s!e(ialist res!onse


& Teleradiolo*y

& Tele!har%a(y

& Teleder%atolo*y

!

$1

29


28/53


Telehealth Pro;ected to Continue =ro,th

Proe(tions #*ree on 8ro/th< $ut Ho/ #**ressiveO

Sour(es. Her%an $< =)irtual reality. More insurers are e%+ra(in* telehealth Modern Health(are< ;e+ruary 2016< availa+le at.htt!.??///%odernhealth(are(o%?arti(le?20160220?M#8#I?30220FF90@ >8lo+al Tele%edi(ine Market Q 8ro/th< Trends and ;ore(asts 201-

20204 Mordor )ntellience< htt!.??///%ordorintelli*en(e(o%?industry-re!orts?*lo+al-tele%edi(ine-%arket-industry


29/53


Pur(haser $ehavior

& Co%%er(ial Payers

& %!loyers& Medi(are

& Covera*e 7!ansion

30Co%%er(ial Payers. Pu+li( 7(han*es


30/53


Sour(e. HHS< =Health Insuran(e Market!la(e 201 ,!en nroll%ent Period. :e(e%+er nroll%ent Re!ort :e( 30< 201@ HHS< =HealthInsuran(e Market!la(e 201 ,!en nroll%ent Period. Banuary nroll%ent Re!ort Ban 25< 201@ HHS< =,!en nroll%ent eek 13.;e+ruary 5< 201 Q ;e+ruary 1< 201< availa+le at. htt!.??///hhs*ov?health(are?'a(ts?+lo*@ HHS< =,!en nroll%ent eek 1. ;e+ruary

16< 201 Q ;e+ruary 22< 201< availa+le at. ///hhs*ov?health(are?'a(ts?+lo*@ HHS< =Health Insuran(e Market!la(es 201 ,!ennroll%ent Period. Mar(h nroll%ent Re!ort Mar(h 10< 201@ C$,< Banuary 201 $aseline. Insuran(e Covera*e Provisions 'or the #''orda+le Care #(t< availa+le at. ///(+o*ov@ ashin*ton Ti%es< =,+a%a(are ,''i(ial. 53 Million #%eri(ans #re Still nrolled and PaidU! Se!t 19< 201@ availa+le at. htt!.??////ashin*tonti%es(o% @ Health Care #dvisory $oard interv ie/s and analysis

Se(ond Round o' nroll%ent Hittin* Tar*ets

y *

14 Health and Hu%an Servi(es

Consumers Continue to Flock to Pu6lic ?changes

Second +0en nrollment Period 2ields /early ! Million nrollees

F

0

HHS1 Proe(tion

(."M-(.(M nroll%ent on'ederally 'a(ilitatede7(han*es< 201

99Mnroll%ent on staterun e7(han*es< 201

29M

201 enrollees a*ed19-3 (o%!ared to29 in 2014

29

emorap&ics Aarely 9nc&aned

+ederal Exc&anes ri'in Most Enrollment Total 2015 Plan -elections in t&e Marketplaces

'M201

nroll%ent

31

http://www.hhs.gov/healthcare/facts/bloghttp://www.hhs.gov/healthcare/facts/bloghttp://www.hhs.gov/healthcare/facts/bloghttp://www.hhs.gov/healthcare/facts/bloghttp://www.hhs.gov/healthcare/facts/bloghttp://www.hhs.gov/healthcare/facts/bloghttp://www.cbo.gov/http://www.cbo.gov/http://www.cbo.gov/http://www.washingtontimes.com/http://www.washingtontimes.com/http://www.washingtontimes.com/http://www.washingtontimes.com/http://www.cbo.gov/http://www.hhs.gov/healthcare/facts/bloghttp://www.hhs.gov/healthcare/facts/blog


31/53


7(han*e ,!tions Re'le(t Tou*her (ono%i( Reality 'or Insurers

Sour(e. CMS< 2016 Market!la(e #''orda+ility Sna!shot ,(to+er 26 201@ Eaiser ;a%ily ;oundation< =Monthly Si lverPre%iu%s 'or a 0 ear ,ld on-S%oker Makin* K30


32/53


#voidin* Pre%iu% In(reases the Pri%ary Motivation 'or Sho!!ers

Sour(e. The #dvisory $oard Co%!any :aily $rie'in*< =More than 1 Million #C# nrollees Chan*ed Their Health Plans Thisear Mar(h 2< 201< availa+le at. ///advisory(o%@ M(Einsey J Co< 201 ,P. Insi*ht into Consu%er $ehavior< Mar(h201< availa+le at. ///health(are%(kinsey(o% @ HHS< Health Insuran(e Market!la(es 201 ,!en nroll%ent Period. Mar(hnroll%ent Re!ort< Mar(h 10< 201< availa+le at. ///as!ehhs*ov@ Health Care #dvisory $oard interv ie/s and analysis

14 ;ederal %!loyee Health $ene'its Plan

?changes a More Fluid Market0lace Than ?0ected

S,itching Rates *igher Than ?0ected

Premium Increases the Primary Motivator

S/it(hers /ho (ited rise in %onthly!re%iu%s as a%on* to! threereasons 'or s/it(hin*

0D

100D

12 2F #vera*e annuals/it(hin* a%on*a(tive e%!loyees/ith ;H$P1 (overa*e

Returnin* 'ederale7(han*e enrollees(han*in* !lans in 201

2017 2015

!"# !!#

4%#43#

Catas tro!hi( Platinu% 8old Silver $rone

Most Continue to Select Silver) Bron7e PlansPlan -elections on %ealt&care:o' 2017;2015

33

http://www.advisory.com/http://www.healthcare.mckinsey.com/http://www.healthcare.mckinsey.com/http://www.healthcare.mckinsey.com/http://www.aspe.hhs.gov/http://www.aspe.hhs.gov/http://www.aspe.hhs.gov/http://www.aspe.hhs.gov/http://www.healthcare.mckinsey.com/http://www.advisory.com/


33/53


Insurers $ettin* Consu%ers ill Continue to Trade Choi(e 'or Pri(e

Sour(e. M(Einsey J Co< =Hos!ital et/orks. volution o' the Con'i*urations on the 201 7(han*es #!ril 201< availa+le at. ///health(are%(kinsey(o% @ Health Care #dvisory $oard intervie/s andanalysis

>es0ite Predictions) /et,orks Remain /arro,

/arro, /et,ork Plan >esigns Continueto >ominate ?change Market0laceet/ork .readt& in Aarest $ity of Eac& -tate

/arro, /et,ork Premium &dvantagesIncreasing +ver Time

1-23arro/ net/ork!re%iu%advanta*ein 201

11-15arro/ net/ork!re%iu%advanta*ein 201

Fe, Buying-0 to Broad /et,orks

15Consu%ers /ith narro/-net/ork!lans 'or year one that s/it(hed toa +road-net/ork !lan in year t/o

Median PMPM ifference +or Products +romt&e -ame Payer and Product Type

.road

arro/

9ltra arro/

$'#

1#

!#

1"#

$'#

!!#

201 201

3

http://www.healthcare.mckinsey.com/http://www.healthcare.mckinsey.com/http://www.healthcare.mckinsey.com/http://www.healthcare.mckinsey.com/


34/53


Sour(e. eHealth< =Health Insuran(e Pri(e Inde7 Re!ort 'or the 201 ,!en nroll%ent Period Mar(h 201< availa+le at.///ne/sehealthinsuran(e(o%@ HealthPo(ket(o%< =2016 #''orda+le Care #(t Market $rin*s Hi*her #vera*e Pre%iu%s 'orUnsu+sidied ove%+er 2< 201< availa+le at. ///health!o(ket(o% @ Health Care #dvisory $oard intervie/s and analysis

Trading Eo, Premiums for *igh >educti6les

F1000 F1000;F2 F000;F5 F6000G

4# 16

30

$(#

10

!$#

$1# 3

201 201

!"% nrollees Favor *igher >educti6les #nnual eductiBles as Percentae of #ll )ndi'idual Plans-elected on e%ealt& Platform 2017;2015

&verage Pu6lic ?change>educti6les 6y Tier) !"4

Bron7e.

Silver .

=old.

Platinum.

K


35/53


So ;ar< $a(klash #*ainst arro/ et/orks< H:HPs ot ides!read

Sour(e. 8allu!< =e/ly Insured Throu*h 7(han*es 8ive Covera*e 8ood Marksove%+er 1< 201< availa+le at. ///*allu!(o%@ Health Care #dvisory $oard intervie/sand analysis

Ma;ority Satisfied ,ith Coverage

?change nrollees =enerally as *a00yas +thers ,ith *ealth CoverageRatins of %ealt&care $o'erae Quality 2017

&nd Particularly Satisfied ,iththe Cost of Their CoverageRatins of %ealt&care $o'erae $ost 2017

e/ly insured

satisfied /it& costof &ealt& care5

-atisfaction rateamon all insuredindi'iduals

61

=ood or Excellent

+air or Poor

5203

2503

3-#

!(#

#ll Insured

6e/ly-Insured Throu*h 7(han*es

36%!loyers

http://www.gallup.com/http://www.gallup.com/http://www.gallup.com/http://www.gallup.com/


36/53


Cadilla( Ta7 S!urrin* %!loyers to Chan*e $ene'its

RefresherG The Cadillac Ta?

26 2o' all e%!loyers(ould in(ur ta7in 2029

If m0loyers Make /o Changes toCurrent Benefit PlansG

o' all e%!loyers(ould in(ur ta7in 2019

Sour(e. Mer(er< =Survey Predi(ts Health $ene'it Cost In(reases ill d*e U! in 201 Se!te%+er 11< 201< availa+le at.///%er(er(o%@ Han(o(k B< =%!loyer Health Costs Rise Per(ent< Go/est In(rease Sin(e 1FF5 Eaiser Health e/s< Mar(h 22016< availa+le at. ///kaiserhealthne/s(o% @ Mer(er< =Modest Health $ene'it Cost 8ro/th Continues as Consu%eris% Ei(ks intoHi*h 8ear ove%+er 1F< 201< availa+le at. ///%er(er(o%@ Health Care #dvisory $oard interv ie/s and analysis

The Cadillac Ta?

& 0 e7(ise ta7 assessed on a%ount o'e%!loyee health +ene'it e7(eedin*

K10


37/53

"2016 The #dvisory $oard Co%!any & advisory.com Sour(e. Health Care #dvisory $oard intervie/s and analysis

&ctivist m0loyers Investing in a Range of Tools

Four Primary Models for Controlling m0loyee tili7ation

&C+ net,orksG %!loyer (ontra(ts /ith sin*le delivery syste%+ased on !ro%ise o' redu(ed (ost trend

Manage Costs at

Point of Networ

Asse!bly

T&e 3ne;-top -&op


38/53


Gookin* to Co%+ine et/ork #dvanta*es /ith Consu%er #((ounta+ility

Sour(e. Eaiser ;a%ily ;oundation?Health Resear(h J du(ational Trust< =%!loyer Health $ene'its 201 #nnual SurveySe!te%+er 201< availa+le at. ///k''or*@ Health Care #dvisory $oard intervie/s and analysis

m0loyers Moving &,ay From the Traditional *M+

m0loyers Eooking to /arro,er /et,orks

3#

15

%!loyers /ith a hi*h!er'or%an(e or tierednet/ork in their lar*esthealth !lan

F

%!loyer eli%inatedhos!itals or healthsyste%s 'ro% their!lans to redu(e (ostsin 201

Percent of Covered


39/53


Sour(e. #((enture< =Private Health Insuran(e 7(han*e nroll%ent :ou+led 'ro% 201 to 201 #!ril 5< 201< avai la+le at.///a((enture(o%@ To/ers atson< =nroll%ent in Health $ene'its Throu*h To/ers atsonLs 7(han*e Solutions 7!e(ted t o Rea(h #+out12 Million in 201 Mar(h 1F< 201< availa+le at. ///to/ers/atson(o%@ Mer(er< =Mer(er Market!la(e-the 'le7i+le !rivate e7(han*e-!ostsindividual !arti(i!ant and (lient *ains ,(to+er 13< 201< availa+le at. ///%er(er(o%@ Health Care #dvisory $oard interv ie/s and analysis

Private ?change nrollment Continues to =ro,

&nalysts Remain Bullish on Eong-Run

=ro,th Pros0ects

More .i ames Makin t&e (ump

e/er Market Entrants %ittin T&eir -tride

Private ?change nrollment >ou6les in

!"%) But Eags Behind Initial Pro;ectionsProHected Pri'ate Exc&ane Enrollment #monPre;65 Employees and ependents

nroll%ent *ro/th 'or To/ersatsonLs e7(han*e solutions<2010

nroll%ent *ro/th 'or Mer(erLs e7(han*e solutions< 20100

I800k 1:2MJ

I220k 1MJ2017 2015 2016 2014 2018

36

12

22

0

2013Proe(tion

#(tualnroll%ent

201Proe(tion

0Medi(are

http://www.accenture.com/http://www.towerswatson.com/http://www.towerswatson.com/http://www.towerswatson.com/http://www.mercer.com/http://www.mercer.com/http://www.mercer.com/http://www.mercer.com/http://www.towerswatson.com/http://www.accenture.com/


40/53


Pri(e Cuts Continue Una+ated

Sour(e. C$,< =Getter to the Honora+le Bohn $oehner Prov idin* an sti%ate 'or HR 605F< The Re!eal o' ,+a%a(are #(tBuly 2< 2012@ C$,< =Cost sti%ate and Su!!le%ental #nalyses 'or HR 2< the Medi(are #((ess and CHIP Reauthoriation

#(t o' 201@ $ud*et o' the United States 8overn%ent Pro!osed4 ; 2016@ Health Care #dvisory $oard intervie/s andanalysis

14 In!atient Pros!e(tive Pay%ent Syste%24 :is!ro!ortionate Share Hos!ital34 Medi(are #((ess and CHIP Reauthoriation #(t o' 201

/o nd in Sight for In0atient Reim6ursement Cuts

*os0itals Bearing the Brunt of Payment Cuts /e, Pro0osals Continue to merge

K2F$Savin*s 'ro% %ovin* tosite-neutral !ay%ents

K309$Redu(tion in Medi(are+ad de+t !ay%ents

PresidentKs +,2016 .udet Proposal)ncludes -inificant $uts to Pro'iders

K16$Cuts to tea(hin* hos!italsand 8M !ay%ents

K520MCuts to (riti(ala((ess hos!itals

201

2017

2015

2016

2014

2018

201

2020

2021

2022

Reductions to Medicare +ee;for;-er'ice Payments

9J1B:

9J1B:

9J!1B:

9J!(B:

9J$'B:

9J%1B:

9J43B:

9J34B:

9J'4B:

9J(1B:

#C# IPPS1 U!date #dust%ents

#C# :SH2

Pay%ent Cuts

M#CR#3 IPPS U!date #dust%ents

1


41/53


Sour(e. E;;< =Medi(are #dvanta*e ;a(t Sheet Bune 2F< 201< av aila+le at. ///k''or*@ M(Einsey J Co< =Provider-Ged Health Plans. Thee7t ;rontier,r the 1FF0s #ll ,v er #*ainO>< Banuary 201< availa+le at. health(are%(kinsey(o%@ MedPa(< =:o ne/ Medi(are +ene'i(iaries(hoose Medi(are #dvanta*e ri*ht a/ayO> Se!t 1< 201@ Health Care #dvisory $oard intervie/s and analysis

14 Medi(are #dvanta*e

Medicare &dvantage Continues Record =ro,th

".1M134

4.'M314

$"."M04

2025 2015 2005

M& nrollment to /early >ou6le 6y !"!%

Total Enrollment and Percentae of

Total Medicare Population

M& Penetration aries 6y State

Total M# Enrollment as a Percent of

Total Medicare Population 2015

0-10 10-1F 20-2F

states (urrently have!rovider-led !lans intheir %arkets

3Fo' !rovider-led !lanso''er M# (overa*eo!tions

6Fo' ne/ly eli*i+le+ene'i(iaries(hose M# in 2012

2

30-3F 30-3F

2Covera*e 7!ansion

http://www.kff.org/http://www.kff.org/http://www.kff.org/http://www.kff.org/


42/53


8ro/th in Medi(aid enroll%ent ine7!ansion vs non-e7!ansion states<; 201

19 vs

Medicaid ?0ansion PositivelyIm0acting *os0ital Finances

$ene'it o' 7!ansion Clear 'or Hos!itals< $ut ,!!osition Re%ains

Sour(e. Eaiser ;a%ily ;oundation< =Current Status o' St ate Medi(aid 7!ansion :e(isions Mar(h 2< 2016< availa+le at. ///k''or*@ HHS< =Insuran(e7!ansion< Hos!ital Un(o%!ensated Care< and the #''orda+le Care #(t>< Mar(h 23< 201< availa+le at. ///as!ehhs*ov@ P/C Health Resear(h Institute<=The Health Syste% Haves and Have ots o' #C# 7!ansion>< 201< availa+le at. ///!/((o%@ CMS< =Medi(aid J CHIP #!!li(ation< li*i+ili ty< andnroll%ent :ata< Mar(h 2< 2016< availa+le at. ///%edi(aid*ov @ Health Care #dvisory $oard intervie/s and analysis

14 ChildrenLs Health Insuran(e Pro*ra%

Future of Medicaid ?0ansion Eess Clear

$ States and >C *ave &00roved ?0ansion #s of (anuary 2016

ot CurrentlyParti(i!atin*

Parti(i!atin*7!ansion+y aiver

Medicaid &dmissions in(reased21 'or investor-o/ned hos!itals ine7!ansion states

Self-Pay &dmissions de(reased +y5 'or investor-o/ned hos!itals ine7!ansion states

ncom0ensated Care (osts redu(ed +y K +illion in e7!ansion

states in 201

1Met in(rease in Medi(aid< CHIP1 enroll%ent< ,(t 2013 to Ban 2016

3

3

http://www.kff.org/http://www.kff.org/http://www.kff.org/http://www.aspe.hhs.gov/http://www.aspe.hhs.gov/http://www.pwc.com/http://www.pwc.com/http://www.pwc.com/http://www.medicaid.gov/http://www.medicaid.gov/http://www.medicaid.gov/http://www.pwc.com/http://www.aspe.hhs.gov/http://www.kff.org/


43/53


Provider Sele(tion

& Inde!endent Physi(ians

& Patients

Inde!endent Physi(ians


44/53


Referral Choice Criteria >ifferent for PCPs) S0ecialists

Sour(e. Servi(e Gine Strate*y #dvisor i ntervie/s and analysis

The ?tended Service Eine Referral Path,ay

Hos!italPCP Medi(alS!e(ialist

Pro(eduralist

Consu%erInterventions

& To!-not(h s!e(ialty (a!a+ilities and te(hnolo*y

& Su!erior s!e(ialist a((ess

& ,!erations 'o(used on s!e(ialist e''i(ien(y

& Co%!rehensive (are (ontinuu%

& Hi*hest value o' (are

& Su!erior !atient a((ess and e7!erien(e

Traditional >ifferentiators

merging >ifferentiators S o u r c e

s

o f I n f l u e n c e

)alue-$ased

In(entives

Steera*eMe(hanis%s

%er*in* and Traditional :i''erentiators 'or Physi(ians


45/53


Re'errals Hin*e on #((essi+ility and Co%%uni(ation

Sour(e. Ein(hen< ES< et al< =Re'erral o' Patients to S!e(ialists. ;a(tors #''e(tin* Choi(e o' S!e(ialist +yPri%ary Care Physi(ians #nnals o' ;a%ily Medi(ine< May?Bune 200< 2. 2-22@ $arnett< Mi(hael G etal< =Reasons 'or Choi(e o' Re'erral Physi(ian #%on* Pri%ary Care and S!e(ialist Physi(iansBournal o'8eneral Internal Medi(ine< Se!te%+er 16th< 2011@ Servi(e Gine Strate*y #dvisor intervie/s and analysis


46/53


Catalyin* a Shi't in et/ork :e%ands


Market Forces Turning Patients into Consumers

Traditional Market Retail Market

=ro/in numBer of Buyers

1

Proliferation of product options2

)ncreased transparency

3

Reduced s/itc&in costs

=reater consumer cost exposure

Passive e%!loyer<!ri(e-insulated e%!loyee

#(tivist e%!loyer<!ri(e-sensitive individual

$road< o!en net/orks arro/< (usto% net/orks

o !lat'or% 'or a!!les-to-a!!les !lan (o%!arison

Clear !lan (o%!arisonon e7(han*e !lat'or%s

:isru!tive 'or e%!loyersto (han*e +ene'it o!tions

asy 'or individuals tos/it(h !lans annually

Constant e%!loyee!re%iu% (ontri+ution<

lo/ dedu(ti+les

)aria+le individual!re%iu% (ontri+ution<hi*h dedu(ti+les

Characteristics of a Traditional vs. Retail Market

55


47/53


Patient 7!erien(e )ital ;or Se(urin* Pur(haser Choi(e ear ,ver ear


ecision

/et,ork Selection and +ngoing ?0erience

Care

>ecision

Care

>ecision

Care >ecisionClini(al intera(tionsre!resent re!eated

o!!ortunities torein'or(e !atient!re'eren(e throu*hsu!erior e7!erien(e

#nnual net/orksele(tion in 'luidinsuran(e %arket

i%!lies (onsistentreevaluation o'net/ork !er'or%an(e

Patient?0erience

9


48/53


S(o!e and Invest%ent Must 7!and to n(o%!ass ntire 7!erien(e


In0atient Satisfaction Scores Miss Most Interactions

#M$UG#T,R C#R

30


49/53


ConsumersK To0 " Primary Care Clinic &ttri6utes

Prioritiin* Convenien(e and #''orda+ility

Sour(e. 201 Pri%ary Care Consu%er Choi(e Survey< Marketin*and Plannin* Geadershi! Coun(il intervie/s and analysis

&verage tilities for To0 Ten Preferred Primary Care Clinic &ttri6utesn@84

:00

:00

:01

:07

:40

:1

:7

:5

:8

7:11

I' I need la+ tests or 7-rays< I (an *et the% doneat the (lini( instead o' *oin* to another lo(ation

The !rovider is in-net/ork 'or %y insurer

The visit /ill +e 'ree

The (lini( is o!en 2 hours a day<5 days a /eek

I (an *et an a!!oint%ent 'or later today

The !rovider e7!lains !ossi+le (auses o' %y illnessand hel!s %e !lan /ays to stay healthy in the 'uture

a(h ti%e I visit the (lini(< thesa%e !rovider /ill treat %e

I' I need a !res(ri!tion< I (an *et it 'illed at the(lini( instead o' *oin* to another lo(ation

The (lini( is lo(ated near %y ho%e

I (an /alk in /ithout an a!!oint%ent< and IL% *uaranteedto +e seen /ithin 30 %inutes

0


50/53

"2016 The #dvisory $oard Co%!any & advisory.comSour(e. 201 Pri%ary Care Physi(ian Consu%er Goyalty Survey<Market Innovation Center interv ie/s and analysis

Most Patients &re /ot Eoyal to PCP

Percent of Consumers *ighly Eoyalin ach of Three Eoyalty Measures

F

I' your !ri%ary (are %ovedto another (lini( or !ra(ti(e<ho/ likely are you to follo, hi%?her to another (lini( or

!ra(ti(eO

I3n a scale of 0 to 10 /it& 0Bein definitely /ould notfollo/< and 10 Bein definitelyfollo/


51/53


To! Reasons 'or Sel' Re'errals Centered on Re(o%%endation< #''iliation

Sour(e. 201 S!e(ialty Consu%er Choi(e Survey< MarketInnovation Center intervie/s and analysis

S0ecialty Self-Referrals >rive +ver a Third of Business

Percent of Res0ondentsSelf-Referring

n W 12rivers of Self-ReferrersK Choice

Most in'luentialdriver o' (hoi(e

# driver o'(hoi(e

Res0ondents Citing Factor &sG

3

2

Res!ondentsrankin* out-o'-!o(ket (ost as theleadin* reason they

(hose a s!e(ialist

Cost /ot a Ma;or>eciding Factor

2


52/53


Pri(e and Travel Ti%e To! Consu%ersL Sur*i(al Care Priorities

Sour(e. MIC Sur*i(al Care Consu%er Choi(e Survey 2016

14 Relative i%!ortan(e de!i(ts ho/ %u(h di''eren(e ea(hattri+ute (ould %ake in the total utility o' a !rodu(t Thatdi''eren(e is the ran*e in the attri+uteLs utility values 'orthe 'ive 'a(tors e (al(ulate !er(enta*es 'ro% relativeran*es< o+tainin* a set o' attri+ute i%!ortan(e v aluesthat add to 100 !er(ent

24 In(ludes (ost o' (are and travel

Surgical Sho00ers ?tremely Price Sensitive

&verage Relative Im0ortance of Si? Surgical Care &ttri6utes

322

1F93

F21

5262F

Cost o'Sur*ery2

Duality o' Sur*eon

Hos!ital #''iliation

Re'errerLs Re(o%%endation

Go(ation o' ;ollo/-U! )isit

Travel Ti%eto Hos!ital

Cost o' (are is %orei%!ortant than the 'ive other

attri+utes (o%+ined@(o%!rises %ore than hal' o'(onsu%ersL !re'eren(e

Travel ti%e is se(ond%ost i%!ortant and a+outt/i(e as i%!ortant as thene7t %ost i%!ortantattri+ute< re'errerLsre(o%%endation

Hos!ital a''iliation %atters%ore than Auality o' thesur*eon

3


53/53

Consu%ers In(reasin*ly Soli(itin* Pri(in* In'or%ation

K K

*igher >educti6les >riving Increased Price Sensitivity

Many &mericans Eack Cash Flo,to Cover Potential ++P Costs

%ouse&olds it&out Enou& AiNuid #ssetsto Pay eductiBles

Mid;rane deductiBle %i&er;rane deductiBle

02

0

1 2

# sur!risin* !er(enta*e o' !eo!le/ith !rivate insuran(eXsi%!ly donot have the resour(es to !ay theirdedu(ti+les>

re/ #ltman President*aiser +amily +oundation

More Consumers &ttem0tingto Find Pricing Information

6Consu%ers /ho have tried to'ind out ho/ %u(h they /ouldhave to !ay +e'ore *ettin* (are

65

5

Those /ith deducti6les of J%""to J$)""" /ho have soli(ited!ri(in* in'or%ation

Those /ith deducti6les higherthan J$)""" /ho have soli(ited!ri(in* in'or%ation

Documents

health it statistics