Shifting from Volume to Value

Russell Vinik MD Associate Professor of MedicineCMO, University of Utah Health Plans

Spending by Age Group

The Need to Rapidly Bend the Cost CurveU.S. Healthcare Performance

US Administration of Aging, “Why We Need to Bend the Health Care Cost Curve”

PUBLIC PRIVATE

• Affordable Care Act • Accountability for value• Payment reform

• Movement to defined contribution

• High deductible health plans• Consumerism

Employers facing escalating costs in a globally competitive

market & and employees bearing higher cost burden

Government Facing Major Fiscal Challenges

Two related imperatives are Driving Change

Affordable Care Act

Primary intent to improve health insurance markets Access & affordability

Also- promote wellness, support system and quality performance, & curb overall costs.

Declining uninsured % in U.S.

Variable by state (state level decisions on Medicaid expansion)

CMS

Other

Inpatient prospective

payment (IPPS)

Outpatient prospective

payment (OPPS)

Provider Payment

Payer & other Organization Driven

IQR VBP HAC HRRP

OQR

MIPS MU-EP VBM

MU-EH

Rankings MISC.HEDIS

(Measurement &) Accountability for Value

Hos

pita

lCo

mpa

re

Phys

icia

nCo

mpa

re

PQRS

CMS Payment Reform Timelines

BundlesACO’sPCMHs

Limited v. comprehensive population-based payments

‘D’ =incentives & penalties

Forces Driving Increased HDHP Adoption Going Forward

Public exchanges

Private exchanges

Cadillac tax

Large employers shifting to full replacement plans

Continued affordability challenges among small employers

High-Deductible Health Plans Continue to Gain Steam

2008 2013 2014 (Jan-Jun)

5%12% 13%

14%

22%24%

Commercially Insured in HDHPs

w/o HSA with HSA

Sources: CDC/NCHS: National Health Interview Study, 12/14 Early Release; Employee Benefit Research Institute: EBRI Databook on Employee Benefits (Chapter 10). Updated May 2011.

19%

37%34%

Popularity of Bronze and Silver Plans on the Public Exchange Will Further Drive High-Deductible Adoption

Notes: (1) Catastrophic plan. Source: ASPE: Health Insurance Marketplace Enrollment Report. March 1, 2015; HealthPocket, 2015 Obamacare Deductibles Remain High but Don’t Grow Beyond 2014 Levels, 20 Nov, 2014.

Bronze Silver

$5,181

$2,927

$10,545

$6,010

Individual Family

Average Deductible by Metal Level2015 Enrollment Period

National Plan Selection by Metal Level 2015 Enrollment Period

22%

67%7%

3%1%

Bronze

Gold

Platinum

Cat. (1%)1

Silver

BPCIIPPS

OQR

HCAHPS

MU H-IT

PROs

PSIsVBPPPACA

PSN HAC

CGCAHPs

MIPS

P4P

ACOs

MOC PQRS

Change in Healthcare feels like an OOWAA… (Ocean of Words, Abbreviations & Acronyms)

COMPLICATED COMPLEX

McChrystal et al. Team of Teams 2015.

BIG IDEA: From Complicated to COMPLEX

Healthcare Revolutions…BIG IDEA: A VISION FOR REAL CHANGE

From volume to value…BIG IDEA: Patient level MEASUREMENT

Manage What You Measure…

V =Q + S

$VALUE

QUALITY SERVICE

COST

From episode to population…BIG IDEA: Longitudinal Care TEAMS

Med-ical Care Genes

Health Behav-

iors

Social/Soci-etal

Population Health Influences…

TEAM | 19

Will require new ways to organize TEAMS…

Team of Teams: new rules of engagement for a complex worldStanley A. McChrystal, Tantum Collins, David Silverman, Chris Fussell.New York, New York: Portfolio/Penguin 2015

TRAVEL BANKING HEALTHCARE

From Patient to Person…BIG IDEA: Power shift to the CONSUMER

86%OF PATIENTS CONDUCT

HEALTH-RELATED SEARCH BEFORE SCHEDULING

AN APPOINTMENT.1

33%OF AMERICANS USESOCIAL MEDIA TO RESEARCH HEALTH CONDITIONS.1

MORE THAN

41%SAY SOCIAL MEDIA IMPACTS THEIR CHOICE OFHEALTHCARE PROVIDERS.1

Patients are increasingly…EDUCATED & INFORMED BEFORESEEING A DOCTOR

1. Medcitynews/com/2014/03/healthcare-are-dr-google-2014-digital-patient-journeySource: http://www.cdwcommunit.com/perspectives/expert-perspectives/todays-digital-patient/

Patients are increasingly…EMBRACING MOBILE HEALTH

1. Mdlive.com/new/press_05142014b.html2. Alegohealth.com/mhealthh-stats-mobile-apps-devices-solutions/3. Blog.ecgmc.com/2014/04/02/promoting –engagement-through-patient-ortal-

adoption/Source: http://www.cdwcommunit.com/perspectives/expert-perspectives/todays-digital-patient/

82%AMERICANS AGES 18-34 WHO HAVE A DOCTOR PREFER CONSULTATION VIA MOBILE DEVICE.1

52%COMFORTABLE

WITH VIDEOCONSULTS.2

84%OF PATIENTS BELIEVETHEY SHOULD HAVE

FULL ACCESS TO THEIR MEDICAL RECORDS

ONLINE.3

What we need to

execute this?Physician

Patient Focus

Patient

CompetenceCaring

ConvenientQualityValue?

Value Metrics: HEDIS, PQRS, Medicare Stars, Total Cost of Care

ComplianceEfficiency

Payment

Pla

n Fo

cus

Physi

cian

Focu

sThe Cube of Population Health

Plan

Patient Focus

Disease Focus

Plan F

ocus

Total Cost of Care

UU

HP

U BabyBundle

HEDIS

Direct to patient tele-health

Top 50 Conditions

PSS- Pediatric Specialty Services Home

Empower U- Palliative Care

PQRS

“Super Utilizer” High Risk Home

All Heal

th Plans

Building Blocks to Population Health Management

VISION MEASURE

PATIENT TEAM