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Fixing The U.S. Health System State By State

Fixing The U.S. Health System State By State. Stephen C. Schoenbaum, MD, MPH Executive Vice President for Programs April 26, 2007 www.cmwf.org Kentucky Institute of Medicine. Commonwealth Fund’s Commission on a High Performance Health System. Objective:

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Fixing The U.S. Health System State By State

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  1. Fixing The U.S. Health System State By State Stephen C. Schoenbaum, MD, MPH Executive Vice President for Programs April 26, 2007 www.cmwf.org Kentucky Institute of Medicine

  2. Commonwealth Fund’s Commission on a High Performance Health System Objective: • The overarching mission of a high performance health care system is to help everyone, to the extent possible, lead long, healthy, and productive lives • To the Commission, a high performance health system is designed to achieve four core goals • high quality, safe care • access to care for all people • efficient, high value • system capacity to improve

  3. US Scorecard: US Falls Short of Benchmarks on All Dimensions of a High Performance Health System SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

  4. Top Quarter 2nd Quarter 3rd Quarter Bottom Quarter State Health System Performance Summary

  5. Lessons From The Scorecard • Care far from “perfect” • Tremendous variation within the US • Possible to have higher quality and lower cost • We need to address multiple issues simultaneously – e.g., coverage, efficiency, quality

  6. The Discourse Is Changing FROM: • “Americans have the best health care system in the world” • President Bush, State of the Union Speech, 2004 TO: • We need to do better • We spend more on health care than any other country • We need more value for what we are spending

  7. We Know The ProblemsNow We Need Solutions

  8. Keys to Transforming the U.S. Health Care System • Extend health insurance coverage to all • Pursue excellence in provision of safe, effective, and efficient care • Organize the care system to ensure coordinated and accessible care for all • Increase transparency and reward quality and efficiency • Expand the use of information technology and information exchange • Develop the workforce to foster patient-centered and primary care • Encourage leadership and collaboration among public and private stakeholders

  9. 1. Extend Health Insurance Coverage to All

  10. ACCESS: UNIVERSAL PARTICIPATION 1999–2000 2004–2005 NH NH ME WA NH VT ME WA VT ND MT ND MT MN MN OR NY MA WI OR MA NY ID SD WI RI MI ID SD RI WY MI CT PA WY NJ CT IA PA NJ NE IA OH DE IN NE OH NV DE IN IL MD NV WV UT VA IL MD CO DC WV UT VA KS MO KY CA CO DC KS MO KY CA NC NC TN TN OK SC AR OK AZ NM SC AR AZ NM MS GA AL MS GA AL TX LA TX LA FL FL AK AK 23% or more HI HI 19%–22.9% 14%–18.9% Less than 14% Uninsured Non-Elderly Adult Rate Rapidly Deteriorating Data: Two-year averages 1999–2000 and 2004–2005 from the Census Bureau’s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

  11. ACCESS: UNIVERSAL PARTICIPATION 1999–2000 2004–2005 NH ME WA NH VT ME WA VT ND MT ND MT MN MN OR NY MA WI OR MA NY ID SD WI RI MI ID SD RI WY MI CT PA WY NJ CT IA PA NJ NE IA OH DE IN NE OH NV DE IN IL MD NV WV UT VA IL MD CO DC WV UT VA KS MO KY CA CO DC KS MO KY CA NC NC TN TN OK SC AR OK AZ NM SC AR AZ NM MS GA AL MS GA AL TX LA TX LA FL FL AK AK 16% or more HI HI 10%–15.9% 7%–9.9% Less than 7% Percent of Uninsured Children Declined Since Implementation of SCHIP Data: Two-year averages 1999–2000 and 2004–2005 from the Census Bureau’s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

  12. State Action on Employer Coverage In 2006, nearly 30 states considered bills to require employers to offer health insurance or pay in some way to cover the uninsured. So far in 2007, similar plans have been proposed in 14 states. 2006 legislation passed 2007 proposals introduced 2006 legislation failed but 2007 proposals introduced Sources: National Conference on State Legislatures and American Legislative Exchange Council 2006 legislation failed

  13. Massachusetts Health Care Reform • Enacted 4/06 • MassHealth expansion for children up to 300% FPL; adults up to 100% poverty • Individual mandate, with affordability provision; subsidies between 100% and 300% of poverty • Employer mandatory offer, employee mandatory take-up • Employer assessment ($295 if employer doesn’t provide health insurance) • “Connector” to organize affordable insurance offerings through a group pool Source: John Holahan, “The Basics of Massachusetts Health Reform,” Presentation to United Hospital Fund, April 2006.

  14. Update: Massachusetts Health Care Reform • The Commonwealth Connector Authority approved draft regulations on creditable coverage: • Prescription drugs • Coverage of preventive services prior to deductible • Caps on annual deductible and out of pocket costs for hospital and physician services • No limits on benefits per year per sickness • New plans called Commonwealth Choice go on sale May 1 and go into effect July 1, 2007 • Deductibles range from $0 to $2,000 • Phased-in “minimum coverage” requirement, fully in effect January 1, 2009 • Connector Authority currently developing criteria for exempting individuals from requirement

  15. Massachusetts Strategies for Coverage: Everyone “does their part” Government Health Care System • Subsidized insurance • The Connector • Uncompensated Care pool reform • Improved Medicaid reimbursement • Meet quality and performance standards • New levels of “transparency” Expanded Coverage Employers Individuals • Fair Share Assessment • “Free Rider” provisions • Mandatory “cafeteria plans” • Individual Mandate Source: Adapted from Amy Lischko, October 16, 2006. “Massachusetts Health Reform.” NASHP 19th Annual State Health Policy Conference, Pittsburgh, PA.

  16. Targeted State Coverage Innovations

  17. Small Business Programs • Montana: Insure Montana (2-9- employees) • Refundable tax credits ($100-125/employee/month) • Small business purchasing pool (subsidized from increased tobacco tax) • 8000 enrollees in first year • New Mexico: State Coverage Insurance (<50 employees) • Waiver to expand Medicaid eligibility to uninsured working adults <200% FPL • 4400 enrollees, Fall 2006

  18. States Targeting Employees of Small Businesses • Oklahoma: Insure Oklahoma (<50 employees): • Premium assistance pays 60% of premium for low income workers; employer pays 25%; employee pays up to 15%. • Funded from tobacco tax, federal Medicaid match, and employer/employee contributions • 1200 enrollees • New York: Healthy New York (small employers with 30% or more employees earning < $34,000) • State reinsurance keeps premiums affordable • 125,000 enrollees, Fall 2006

  19. CoverTN • Limited-benefit “minimedical” plan launched by Governor Phil Bredesen in March 2007 to offer low-cost insurance to small businesses and uninsured working Tennesseans • Administered by BlueCross Blue Shield; Premiums shared by employer, employee, and the state. Each pay between $34 - $99/month. • Option of two plans, both with no deductible and modest co-pays ($15-$20 for doctor visits; $100 for hospital stays). • Plan A: Covers hospital stays up to $15,000 per year and up to $75 every three months for drugs • Plan B: Covers hospital stays up to $10,000 per year and up to $250 every three months for drugs • Currently enrolled: 1,053 individuals; 89 hospitals; 10,000 physicians; 12,000 businesses pre-qualified

  20. New Jersey Raises Age of Dependent Status for Health Insurance Millions uninsured, adults ages 19–29 • As of 5/2006, NJ requires all state insurers to raise dependent age limit to 30 • Highest age limit in country • Covers uninsured, unmarried adults with no dependents who are either NJ residents or full-time students • Premium capped at 102% of amount paid for dependent’s coverage prior to aging out • 200,000 young adults expected to receive coverage under the law Source: S.R. Collins, C. Schoen, J.L. Kriss, M.M. Doty, B. Mahato, “Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help,” Commonwealth Fund issue brief, May 2006. (Analysis of the March 2001–2005 Current Population Surveys)

  21. Illinois All-Kids • Effective July 1, 2006 • Available to any child uninsured for 12 months or more • Cost to family determined on a sliding scale • Linked to other public programs - FamilyCare & KidCare • Funded by federal and state funds • Children <200% of the federal poverty level funded by federal funds • Children 200%+ of the federal poverty level funded by state savings from the Medicaid Primary Care Case Management Program • All-Kids Training Tour • Public outreach program to highlight new and expanded healthcare programs • Enrollment as of Fall 2006 was 28,600

  22. New Bold State Proposals

  23. California Governor’s Proposal (1/07) • Individual mandate • Shared responsibility • Medi-Cal expansion • All children below 300% poverty • Adults below 100% poverty • Premium subsidies for adults below 250% poverty • Employers must provide health insurance or pay a fee of 4% of wages • Provider fee assessment (2% of physician revenues to 4% of hospital revenues) • Insurance exchange • Guaranteed issue; community rating with age bands • 85% minimum medical loss ratio Source: D. Rowland, “California Health Reform Proposal,” Kaiser Commission on Medicaid and the Uninsured, Presented January 13, 2007.

  24. Extending Coverage is Only One Piece of the Puzzle 3. Organize the Care System to Ensure Coordinated and Accessible Care for All 1. Extend Health Insurance Coverage to All 2. Pursue Excellence in Provision of Safe, Effective, and Efficient Care 7. Encourage Leadership and Collabor- ation Among Public 5. Expand the Use of Information Technology and Exchange 4. Increase Transparency and Reward Quality and Efficiency And Private Stakeholders 6. Develop the Workforce to Foster Patient-Centered and Primary Care

  25. Delaware Health Information Exchange • Delaware Health Information Network • Public-private partnership established in 1997 to assist in the creation of a statewide health information and electronic data interchange network for public and private use. • Functions under the direction of the Delaware Health Care Commission. • In 2006 signed an extendable 6-year contract with technology vendor Medicity, Inc. to create the first statewide health information exchange (Start-up costs =$4 to 5 million). • Interoperable Health Information Exchange • Gives physicians access to secure, fast, and reliable electronic patient information at the time and place of care. • Funded by participating health care organizations, the State of Delaware, and the Federal Agency for Healthcare Research and Quality in the U.S. Department of Health and Human Services.

  26. Community Care of North Carolina Asthma Initiative: Pediatric Asthma Hospitalization Rates (April 2000 – December 2002) • 15 networks, 3500 MDs, >750,000 patients • Receive $2.50 PM/PM from the State • Hire care managers/medical management staff • PCP also get $2.50 PMPM to serve as medical home and to participate in disease management • Care improvement: asthma, diabetes, screening/referral of young children for developmental problems, and more! • Case management: identify and facilitate management of costly patients • Cost (FY2003) - $8.1 Million; Savings (per Mercer analysis) $60M compared to FY2002 In patient admission rate per 1000 member months Source: L. Allen Dobson, MD, presentation to ERISA Industry Committee, Washington, DC, March 12, 2007

  27. Building Quality Into RIte CareHigher Quality and Improved Cost Trends Cumulative Health Insurance Cost Trend Comparison Percent • Quality targets and $ incentives • Improved access, medical home • One third reduction in hospital and ER • Tripled primary care doctors • Doubled clinic visits • Significant improvements in prenatal care, birth spacing, lead paint, infant mortality, preventive care Source: Silow-Carroll, Building Quality into RIte Care, Commonwealth Fund, 2003.Tricia Leddy, Outcome Update, Presentation at Princeton Conference, May 20, 2005; updated.

  28. Prescription for Pennsylvania (1/07) • Affordable basic health insurance for all • Promote non-emergency settings for non-emergency care • Improve quality by eliminating hospital-acquired infections, medical errors • Pay-for-performance • Long-term care: promote home/community services • Enhance pain-management, palliative care, and hospice care • Promote wellness and sound nutrition in the schools and by making workplaces, restaurants, and bars smoke-free

  29. Components of Comprehensive Health Care Reform Plans

  30. Ways States Can Promote a High Performance Health System • Extend coverage – ideally to all • Reduce cost shifting by adequate funding of public programs • Simplify and streamline public program eligibility and re-determination • Promote safer care • Reporting, analysis, technical assistance • Promote more effective, efficient, patient-centered, timely, and coordinated care • Public reporting • Payment policies – “value-based purchasing” • Assure competent professionals • Licensure, maintenance of competence, discipline • Promote the use of health information technology • State-wide information exchanges, capital loans, technical assistance • Promote wellness and healthy living

  31. In Sum: • Efforts at the state level to expand access, improve quality and efficiency are gaining momentum • States are learning from each other • States are informing the national debate

  32. What About Kentucky? DISCUSSION

  33. Visit the Fundwww.cmwf.org

  34. Acknowledgements Karen Davis, President The Commonwealth Fund Cathy Schoen, Sr. Vice President Research & Evaluation Anne Gauthier, Senior Policy Director Commission on a High Performance Health System Elizabeth Sturla, Executive Assistant Rachel Nuzum, Program Officer State Innovations Visit the Fund at:www.cmwf.org

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