Do We Really Have a Is The Healthcare System In Irons Problem? - - PDF document

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Do We Really Have a Is The Healthcare System In Irons Problem? - - PDF document

Question Confronting Healthcare Executives Should We Upend Our Restructuring The Care Delivery Existing Delivery System Model To System: Will Limited Growth In Lower Costs or Continue Business As Revenues Force A Change? Usual?


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Restructuring The Care Delivery System: Will Limited Growth In Revenues Force A Change? Stuart H. Altman

Chaikin Professor of Health Policy Heller School for Social Policy and Management Brandeis University

Question Confronting Healthcare Executives‐‐‐”Should We Upend Our Existing Delivery System Model To Lower Costs or Continue Business As Usual”?

Will Limits On Future Resources Force The System To Change

Is The Healthcare System “In Irons’

Do We Really Have a Problem?

Altman and His Cronies Have Been Talking About The Coming of The Bogey Man For Years

So‐‐‐What’s Happening? Yes‐‐Healthcare Spending Growth Has Slowed But Will It Continue?

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Average Annual Percent Change in National Health Expenditures, 1960‐2012

13.1% 11.0% 8.4% 5.5% 5.8% 6.4% 7.0% 8.5% 9.5% 8.4% 7.1%6.8% 6.6% 6.2% 4.7% 3.8% 3.9% 3.9% 3.7% 3.8%

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

1970 1980 1990 93 97 98 99 2000 1 2 3 4 5 6 7 8 9 10 2011 2012 2013 Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2010; file nhe2010.zip).

Is The Decline In Spending Growth The Result Of:‐‐‐‐

A Slow Down In Economic Growth Or Structural Factors Within The Healthcare System

Medicare Actuaries Think Limited Growth Will Return

As a Result of An Expanding Economy and Aging Medicare Recipients

Growth In Yearly Healthcare Spending Actual (2012‐2014) and Projected (2015‐2019)

4.80% 6.20% Annual Growth in Spending 2012‐2014 2015‐2019

Most Growth From Medicare and Medicaid Spending Increases!

Even For Medicare Most of Growth The Result Of More Care for Older Patients

Growth in Health Care Spending By Payer:

Actual 2012‐2014, Projections 2015‐2019

4.8% 6.0% 4.6% 0.3% 2.7% 4.5% 3.8% 4.5% 0.5% 3.4% 7.0% 0.8% 3.1% 2.6% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0%

Total Health Consumption Expenditures Private Health Insurance Medicare Medicaid Total Health Consumption Expenditures Private Health Insurance Medicare Medicaid

Average Annual % Increase

Source of Funds

Growth in Enrollment Growth in Spending per Enrollee Total Health Consumption Expenditure Growth

5.1% 3.7% 9.7% 5.3% 6.9% 7.1%

2012 ‐ 2014 2015 ‐ 2019

Source: Office of The Actuary, CMA , September 2014.
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Does It Matter?

The Altman/Reinhardt Thesis I’m a bit Older!

In The Past Hospital Spending Driven More By Cost of Care

(Reimbursement Model) In The Future Cost of Care Likely To Be Driven More By Spending Limits (Payment Model)

WHY‐‐‐

In The Past‐‐‐Most Hospitals Able to Make‐Up Shortfalls From Lower Government Payments and Uncompensated Care By Higher Payments From Pvt. Patients

91.40% 94.70% 134.50% 60.00% 70.00% 80.00% 90.00% 100.00% 110.00% 120.00% 130.00% 140.00% 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Hospital Payment‐to‐Cost Ratios

Medicare Medicaid* Private Payer

Private Insurance Payments Used to Pay for Lower Government Payments

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But What About The Future?

Government Sponsored Payments Will Become A Greater Force in Healthcare System

Medicare and Medicaid Enrollments Will Grow Disproportionately‐‐‐

6% 57% 71% 10 20 30 40 50 60 70 80 Private Medicare Medicaid Percent Change in Enrollment

CMS, National Health Expenditure Projections, 2012 to 2022, January 2013.

Growth in Enrollment by Payer Source, 2006 - 2022

As a Result Government Payments Will Dominate The Healthcare System!

CMS, National Health Expenditure Projections, 2012 to 2022, January 2013.

Total Health Insurance Payments by Payer Source 2006 versus 2022 (Percent of Total)

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Can Healthcare Providers Continue To Counted on Higher Private Insurance Payments To Make Up for Shortfalls In Government Payments?

UNLIKELY!

85.00% 80.00% 162.50% 60.00% 80.00% 100.00% 120.00% 140.00% 160.00% 180.00%

Hospital Payment‐to‐Cost Ratios

Medicare Medicaid* Private Payer

Private Payments Needs To Grow Substantially To Maintain Hospital Margins

Even Actuaries Estimate No Change In Growth of Private Insurance Payments

Growth in Health Care Spending By Payer:

Actual 2012‐2014, Projections 2015‐2019

4.8% 6.0% 4.6% 0.3% 2.7% 4.5% 3.8% 4.5% 0.5% 3.4% 7.0% 0.8% 3.1% 2.6% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0%

Total Health Consumption Expenditures Private Health Insurance Medicare Medicaid Total Health Consumption Expenditures Private Health Insurance Medicare Medicaid

Average Annual % Increase

Source of Funds

Growth in Enrollment Growth in Spending per Enrollee Total Health Consumption Expenditure Growth

5.1% 3.7% 9.7% 5.3% 6.9% 7.1%

2012 ‐ 2014 2015 ‐ 2019

Source: Office of The Actuary, CMA , September 2014.

Will Expansion of Medicaid and Private Insurance Bail Out The System?

Depends: Where You Live and Whether Non‐Medicaid Expansion States Change Course

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Other Good News

Slower Medicare Spending Growth Could Lessen Need to Further Cut Medicare Payment Rates

But Reductions In Hospital Payment Growth Legislated In ACA Likely To Continue

What About Payments To Physicians?

The Saga of Controlling Medicare Spending for Physician Services

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A Few Congressional Staffers in 1997 Thought‐‐‐

Medicare Should Limit Its Growth In Spending for Physician Services to The Growth In The Countries Real GDP!

What Is The Medicare Physician Spending Target

Sustainable Growth Rate (SGR)

  • Input Costs for Physician Services 2.0%
  • Real GDP per capita 1.9
  • Fee‐for‐Service Enrollment ‐0.2
  • Changes due to law or regulation ‐1.5
  • Sustainable Growth Rate 2.2%

So What Happened‐‐‐‐

Actual Spending Growing Faster Than SGR 2000‐2004

  • Growth In Volume of Services 5.5%

Types of Services

  • Evaluation and Management 3.6%
  • Imaging 10.3
  • Major procedures 3.8
  • Other procedures 6.4
  • Test 8.2

Since 2001, actual spending for physician services has exceeded target

Note: Estimates shown are preliminary Source: Office of the Actuary 2008.

Because of legal limits on how much physician fees could be cut in one year and past deficit between target and actual spending‐‐‐ Deficits Put OFF‐‐‐

So‐‐‐Physician fees were scheduled to be cut by 18.9% 2013

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So What Can Hospitals and Physicians Expect In Terms

  • f Revenue Growth

My Best Shot

Expected Hospital Revenue Growth

  • Medicaid

– Depends Where Located

  • Medicaid Expansion States

– Continued Growth In Demand For Services

  • Non-Medicaid Expansion

– Less Growth in Demand, Lower Growth in Revenue

– All Bets Off If Serious Cut Back In ACA

Expected Hospital Revenue Growth

  • Medicare

– Growth In Patient Demand But Limited Growth in Per Patient Rates – Significant Changes In Program Put Off

  • Existing Cuts Will Continue
  • Outside Chance The DRG System Will Incorporate

Physician Payments and Post-Acute Care

– Some Likelihood That SGR Will Be Revised But No Big Inc. in Phy. Payments

Expected Hospital Revenue Growth

  • Pvt. Insurance

– Non-Exchange

  • Reduced Demand
  • Limited Growth in Payt.
  • Higher Patient Cost Sharing

– Govt. Exchange

  • Expanded Demand
  • More Use of Tiered Network
  • Much Higher Patient Cost Sharing

Sorry‐‐‐But Even If SGR

Repealed Growth In Medicare and Private Insurance Physician Rate Will Be Limited

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So ---What To Do!

Prudent Dictates---Need To Increase Efforts To Develop More Efficient (Lower Cost) Delivery System

Rob Mechanic and I Will Discuss Possible Options (Depending On Your Market Place) in Our Breakout Session

  • n Tuesday