How Health Reform is Changing Patient Care, Healthcare Jobs and the Structure and Financing of the Health System.

Mary MacDonaldDirector, AFT Healthcare

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U.S. Healthcare Spending

• 2011: $2,700,000,000,000

• 2020: $4,600,000,000,000

Office of the Actuary, Centers for Medicare and Medicaid Services

U.S. HEALTHCARE SYSTEM vs. Comparable Countries

• Average annual expenditure per person:U.S. $7,538 Comparable countries $2,995.

• Average hosp admission cost:U.S. $16,708.

Comparable countries $5,949.• The U.S. Health System in Perspective: A Comparison of Twelve Industrialized

Nations, The Commonwealth Fund, July 2011.

•

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Five Year Survival Rates for Certain Cancers by Country

CAN* GER* NZ OECD Median

SWE UK US*0

102030405060708090

10087

83 85 84 8681

89

6963

68 66 68

5964

63 62 62 62 63

54

65

Breast Cancer Cervical Cancer Colorectal Cancer

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Who’s Coordinating Care?

Oncologist

Endocrinologist

Primary

Care

DieticianRadiologist

Patient

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Waste and Unnecessary Expenditures: Over $750,000,000 annually.

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The Problem in One Chart http://www.washingtonpost.com/blogs/wonkblog/wp/2012/09/07/we-spend-750-billion-on-unnecessary-health-care-two-charts-explain-why/http://www.washingtonpost.com/blogs/wonkblog/wp/2012/09/07/we-spend-750-billion-on-unnecessary-health-care-two-charts-explain-why/

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How Does ACA Propose to Fix Flaws in Delivery System?

• Restore emphasis on preventive and primary care.

• Primary care practices that are accountable for overall coordination of care.

• Create structures that promote care coordination and support payment reform.

• Reimbursement based on outcomes, not volume.

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Patient-Centered Medical Homes

• Teams of providers who are responsible for overall coordination of care for pt.

• Regular communication with patients and families.

• Commitment to evidence-based medicine.

• Electronic health records.• Best for chronic, complex patients.• If certified, can bill for coordination.

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Patient Centered Medical Homes: Results

• Fewer hospital admissions• Less use of specialists• Less Emergency Room usage• Lower costs• Better Care.

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Accountable Care Organizations: New Centralized Structures

• Accountable Care Organizations – Hospitals, primary care providers, specialists and others who work together in one corporate structure and accept collective accountability for the cost and quality of care delivered to patients.

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Montefiore Health System

• Montefiore Hospital, Children’s Hospital• Medical Group: 2139 physicians,

primary and specialty.• 2 Patient Centered Medical Homes• School Health Centers• Care Management Organization• Insurance

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Risk/Reward

• Fee for Service• Bundled Payments

•Capitation

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How do we change the system?

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Cuts by Medicare (and others…)

• 2008 – “Never Events”• 2012 – High 30-Day Readmission Rates

for AMI, heart failure, pneumonia.• 2012 – Value Based Purchasing• 2015 – Disproportionate Share payments

cut.• 2015 – Hospital Acquired Infections – top

quartile.

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New Money

• Shared Savings for ACOs• H.I.T. payments• Value Based Purchasing.

– 1 (rising to 2 %) deducted from Medicare reimbursement but some percentage may be returned depending on facility’s score.

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Value Based Purchasing

• Seventeen “process” measures… (i.e. “Did AMI patients get aspirin on arrival?” “Did they get smoking cessation counseling?”

• Three “outcome” measures – 30 day mortality rate for AMI, Heart Failure, Pneumonia.

• Patient Satisfaction Surveys – 30% of total scores.

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Value Based Purchasing:Process Measures

• AMI–1: Aspirin at Arrival.• AMI–2 : Aspirin Prescribed at Discharge.• AMI–3 : ACE/ARB Inhibitor.• AMI–4 : Adult Smoking Cessation Advice/Counseling.• AMI–5 : Beta Blocker Prescribed at Discharge.• AMI–7a : Fibrinolytic Therapy Received Within 30 Minutes of

Hospital Arrival.• AMI–8a : Primary PCI Received Within 90 Minutes of Hospital

Arrival. • HF–1: Discharge Instructions.• HF–2 : Evaluation of LVS Function.• HF–3 : ACEI or ARB for LVSD.• HF–4 :Adult Smoking Cessation Advice/Counseling

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Value Based Purchasing:Outcome Measures

• MORT–30–AMI: Acute Myocardial Infarction (AMI) 30-Day Mortality Rate.

• MORT–30–HF: Heart Failure (HF) 30-Day Mortality Rate.

• MORT–30–PN: Pneumonia (PN) 30-Day Mortality Rate.

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Value-Based Purchasing: Patient Satisfaction

• During this stay, how often did the nurses treat you with courtesy and respect?

• How often did nurses listen carefully to you?• How often did nurses explain things to you in

a way you could understand? • How often did physicians treat you with

courtesy and respect?• How often did physicians listen carefully to

you?• How often did physicians explain things to you

in a way you could understand?

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• After you pressed the call button, how often did you get help as soon as you wanted it?

• Did you need help from nurses or other staff in getting to the bathroom or using a bedpan?

• How often did you get help getting to the bathroom…as soon as you wanted it?

• How often were your room and bathroom kept clean?

• How often was the area around your room quiet at night?

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• Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?

• Would you recommend this hospital to your friends and family?

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Consultants:

• “You can speak to patients using language that they will be able to recognize when taking the survey. It’s almost like an open book test.”

• “Jane is coming on next. She’s a great nurse. She works this unit all the time.”

• “Is there anything else you need? I have the time.”

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Bargaining Pay for Performance

• If score on “communications w/doctors increases by 5%, 10% or 15%, house staff officers share $50,000, $100,000 or $150,000. In addition, employer funds “best practices” work.

• Four divisions targeted. If goals met in one division, RNs get $200 bonus. If all four, RNs get $250.

• Employer agrees to provide 1% salary increase to base rate of each RN if scores on specific Press Ganey questions improve.

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Questions for Unions…

• Union role in costing-cutting/quality improvement activities?

• New forms of compensation?• How to follow the work?• How to build/preserve power?

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• “…as we look to reform our health care system, our nation is not taking advantage of all that nurses have to offer. We are squandering opportunities to learn from nurses and implement their ideas.”

Risa Lavizzo-Mourey, president and CEO, Robert Wood Johnson Foundation.