Kayla Sutton Managing director, economic outlook Healthcare’s Economic Outlook.
-
Upload
chester-wilkins -
Category
Documents
-
view
218 -
download
0
Transcript of Kayla Sutton Managing director, economic outlook Healthcare’s Economic Outlook.
Kayla SuttonManaging director, economic outlook
Healthcare’s Economic Outlook
2 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Imperative to bend cost curve
Advanced data analytics
Comparative effectivenessresearch
Utilization of productsand services
Employer health benefits/insurance exchanges
Consolidation amonghealth systems
Uncompensated care
Health IT requirements
New care delivery models
Reimbursement cuts
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0%6.8%
7.5%
10.8%
16.5%
16.8%
20.5%
24.3%
28.0%
68.8%
Spring 2012 Fall 2012 Spring 2013 Fall 2013
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
3 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Healthcare cost drivers
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
Health
care
legis
lation
Labo
r cos
ts
Misa
lignm
ent o
f qua
lity a
nd p
aym
ent i
ncen
tives
Overu
tiliza
tion
Lack
of c
linica
l coo
rdina
tion
of c
are
Patien
t dem
and
Health
info
rmat
ion te
chno
logy
Pharm
aceu
ticals
Unjust
ified
varia
tion
in ca
re
Med
ical d
evice
s
New c
linica
l tec
hnolo
gy/e
quipm
ent
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Fall 2013
Spring 2013
Fall 2012
Spring 2012
4 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Market response from ACA
Provider consolidation
Payer consolidation and information technology acquisitions
Physician groups creating ACOs
Private payer, federal and state payment reforms
New collaborations and partnerships
Changes in employer and employee coverage practices
4Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
5 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Patient forecasting
5.0%
22.3%
32.7%
32.7%
7.2%
Inpatient forecast
Increase by more than 5%Increase by up to 5%No changeDecrease by up to 5%Decrease by more than 5%
13.2%
47.8%24.6%
10.7%
3.6%
Outpatient forecast
Increase by more than 5%Increase by up to 5%No changeDecrease by up to 5%Decrease by more than 5%
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
6 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Creating or adopting ACOs
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%26.6%
7.2%
21.0%
11.5% 10.6%
23.1%21.9%
14.3%
18.0%
9.7% 9.7%
26.5%
Fall 2013Spring 2013
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
7 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Potential ACO Impact
1. Reduced utilization and costs due to incentives
2. Greater demand for proven effectiveness and value analysis of new products
3. Suppliers need to demonstrate value through cost, quality and experience
4. Value will be measured not just at the site of delivery but across the continuum of care
5. Purchasing
6. Supply chain innovation (by-product)
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
8 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Partnerships for population health management
Other
External hospitals, health systems or non-acute providers at a national level
Public payors (Medicare, Medicaid)
External hospitals, health systems or non-acute providers at a local level
Private payors (commercial)
Large local employers
Local public health or health departments
Health and wellness-focused community groups
Physician and provider leadership within your organization
0.0% 20.0% 40.0% 60.0% 80.0%
3.0%
11.0%
39.0%
39.4%
46.6%
46.6%
51.3%
52.5%
74.2%
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
9 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Resource dedication for population health
Lifest
yle/w
ellness
coach
ing
Home h
ealth
Transit
ional a
nd/or e
nd-of-l
ife c
are
Patient-c
entere
d medica
l hom
es
Partnerin
g with
payo
rs
Patient r
isk s
tratifi
catio
n
Virtual c
are/te
lem
edicine
Inte
grate
d clin
ical, s
upply ch
ain a
nd financia
l data
Patient r
egistrie
s0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
66.7%
56.1% 54.5% 51.2%
40.2% 39.0% 38.2% 38.2%31.7%
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
10 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Approaches to using data
Inte
gratin
g clin
ical a
nd cla
ims
data
Predict
ive a
nalytics
Using a
n inte
grate
d data
solu
tion to
reduce
silo
s
Inte
gratin
g supply
chain
and c
linica
l data
Oth
er0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0% 63.8%
44.8% 43.7%36.2%
1.7%
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
11 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Factors with the greatest influence on supply chain decisions
Other
Commodity prices
Medical device prices
Drug shortages
Comparative effectiveness/value analysis research
Implementing healthcare IT
Integrating the supply chainacross the continuum of care
Reductions in overutilization/variation in care
Cost savings' goals
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%
2.2%
3.9%
7.8%
8.4%
8.9%
7.8%
12.0%
21.8%
27.1%
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
12 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Medicare Breakeven
$- $20,000 $40,000 $60,000 $80,000 $100,000 $120,000 $140,000 $160,000 $180,000 0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
140.0%
160.0%
180.0%
200.0%
Average cost per case
Per
cen
t o
f co
st
cove
red
by
CM
S p
aym
ent
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
13 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Willingness to try non-branded PPI
19.3%
48.1%
29.7%
2.7% 0.3%
Definitely wouldProbably wouldMight or might notProbably would notDefinitely would not
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
14 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Transradial intervention (TRI) versus transfemoral intervention (TFI) for PCI procedures
In U.S., 10-11% of PCI done using TRI; 50-70% in Europe
Using Premier data, researchers showed benefits from TRI, including:
• Higher patient satisfaction• Increased comfort• Early ambulation
Benefits from TRI allow for safer shift to same-day discharge
Clinical innovation in percutaneous coronary intervention (PCI)
15 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
PCI shift to outpatient care
2009 2010 2011 20120%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Percent of PCI Cases Coded as Inpatient or Outpatient
Inpatient Outpatient
16 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Trends impacting supply chains
TrendsFall2013
Spring2013
Fall2012
Increased physician-health system engagement across clinical and supply chain operations
24.8% 29.6% 38.4%
Supply chain integration to align with clinical care, revenue capture and IT across facility/health system
20.1% 10.7% 6.3%
Focus on waste management (e.g., resource utilization,as a means to reduce supply cost)
13.9% 21.4% 17.3%
Comparative effectiveness/value analysis research N/A
10.3% n/a n/a
Centralized purchasing N/A 15.0% n/a n/a
Use of new supply chain metrics/processes
N/A 5.0% n/a n/a
Population health management and care coordination across the continuum
5.6% 7.8% 4.8%
Location and product identification standardization (e.g., GLN and GTIN)
5.3% 1.5% 2.7%
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
17 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Standardization receiving most resources
IT investments – non-EHR-specific
Data standardization
Comparative effectiveness/value analysis research
Reducing costs for commoditiesproducts
Reducing costs for physicianpreference products
Building relationships withphysicians and clinicians
IT investments – EHR-specific
Product standardization
0.0% 10.0% 20.0% 30.0% 40.0% 50.0%
Fall 2012Spring 2013Fall 2013
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities
18 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Device purchases from multiple vendors
Reliance on line-item versus system pricing
Substantial price difference for devices•Tiered pricing
Little association between volume ordered and pricing of devices
Cardiac rhythm management (CRM) Collaborative
19 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Number of vendors by facility
8%17%
39%
33%
3%
1 Vendor2 Vendors3 Vendors4 Vendors5 Vendors
20 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
3 facilities with a cath lab
12 physicians performing CRM implantation (5 of whom employed by health system• Physician champion • Open communication with physicians• Cost & utilization review once per month• Vendor code of conduct:
»Vendor rep with largest volume allowed in lab once per week
»All other vendors allowed in lab once per month
CRM case study
21 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Program to assist smaller facilities in building greater supply chain and operational efficiencies
Improvement in operational efficiency and supply-related revenue capture
Decrease in medical-surgical supply expenses
Facility 1: • 30-bed skilled nursing facility• Decrease in 32% of matched items• 3.27% reduction in annual supply expense
Facility 2: • 75-bed skilled nursing facility • Price decrease in 29% of supply items• 4.89% reduction in total supply expense
E-procurement case studies
22 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Centralized purchasing
46.5%
41.8%
11.7%Yes - we have the capabil-ity and have fully imple-mented centralized pur-chasing across acute and alternate sites
Yes - we have the capabil-ity, but have not fully im-plemented centralized purchasing across acute and alternate sites
No - we do not have the capability for centralized purchasing across acute and alternate sites
Source: Premier’s fall 2013 Economic Outlook, Population health: Unlocking the value of healthier communities22
23 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
BARRIERS
Incentives and Barriers to Clinical Integration
Source: Premier healthcare alliance spring 2013 member survey
INCENTIVES► Outcomes-based
measurements (74%)
► Bonuses contingent on achievement of quality outcomes (68%)
► Penalties for readmissions and infections (33%)
► Lack of willingness on part of physicians (29%)
► Difficulties in implementation of cross- continuum EHR (21%)
► Lack of budget to create integration (15%)
► Need for greater incentives to encourage participation (15%)
24 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Supply Mix Index
25 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Premier Hospital - CY11
MSDRGFacility Ave.
Cost per Case Facility Case
Count Premier Top
Quartile
Member Variance to 1st Quartile
Potential Savings
Opportunity 227CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC $ 25,711 136 $ 25,152 $ 559 $ 76,008
Tota
l Cos
t
247PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC $ 11,650 504 $ 9,125 $ 2,526 $ 1,272,891 460SPINAL FUSION EXCEPT CERVICAL W/O MCC $ 22,654 89 $ 18,899 $ 3,755 $ 334,208 470MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC $ 11,571 581 $ 12,558 $ (987) -
227CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC $ 20,447 136 $ 16,634 $ 3,813 $ 518,579
Supp
ly C
ost
247PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC $ 5,747 504 $ 3,560 $ 2,187 $ 1,102,006 460SPINAL FUSION EXCEPT CERVICAL W/O MCC $ 13,499 89 $ 9,976 $ 3,523 $ 313,519 470MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC $ 4,940 581 $ 5,500 $ (560) -227CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC $ 344 136 $ 161 $ 183 $ 24,920
Phar
mac
y Co
st247PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC $ 582 504 $ 631 $ (49) -460SPINAL FUSION EXCEPT CERVICAL W/O MCC $ 723 89 $ 426 $ 297 $ 26,458 470MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC $ 507 581 $ 339 $ 168 $ 97,347
Targeting cost opportunity with clinical data
Premier Regional - CY11
MSDRGFacility Ave.
Cost per Case Facility Case
Count Premier Top
Quartile
Member Variance to 1st Quartile
Potential Savings
Opportunity 227CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC $ 25,780 149 $ 25,152 $ 628 $ 93,565
Tota
l Cos
t
247PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC $ 11,934 611 $ 9,125 $ 2,810 $ 1,716,656 460SPINAL FUSION EXCEPT CERVICAL W/O MCC $ 28,479 548 $ 18,899 $ 9,580 $ 5,250,060 470MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC $ 16,122 198 $ 12,558 $ 3,564 $ 705,760 227CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC $ 18,942 149 $ 16,634 $ 2,308 $ 343,910
Supp
ly C
ost
247PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC $ 4,196 611 $ 3,560 $ 635 $ 388,211 460SPINAL FUSION EXCEPT CERVICAL W/O MCC $ 16,271 548 $ 9,976 $ 6,294 $ 3,449,331 470MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC $ 6,136 198 $ 5,500 $ 636 $ 125,861 227CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC $ 439 149 $ 161 $ 278 $ 41,434
Phar
mac
y Co
st247PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC $ 863 611 $ 631 $ 233 $ 142,225 460SPINAL FUSION EXCEPT CERVICAL W/O MCC $ 842 548 $ 426 $ 417 $ 228,461 470MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC $ 612 198 $ 339 $ 273 $ 54,027
Premier Memorial - CY11
MSDRGFacility Ave.
Cost per Case Facility Case
Count Premier Top
Quartile
Member Variance to 1st Quartile
Potential Savings
Opportunity 227CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC $ 34,900 10 $ 25,152 $ 9,748 $ 97,478
Tota
l Cos
t
247PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC $ 13,701 166 $ 9,125 $ 4,576 $ 759,647
460SPINAL FUSION EXCEPT CERVICAL W/O MCC $ 27,723 343 $ 18,899 $ 8,825 $ 3,026,817 470MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC $ 13,989 1,023 $ 12,558 $ 1,431 $ 1,464,219 227CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC $ 27,798 10 $ 16,634 $ 11,165 $ 111,645
Supp
ly C
ost
247PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC $ 7,006 166 $ 3,560 $ 3,446 $ 572,043 460SPINAL FUSION EXCEPT CERVICAL W/O MCC $ 16,984 343 $ 9,976 $ 7,007 $ 2,403,494 470MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC $ 6,922 1,023 $ 5,500 $ 1,422 $ 1,454,665 227CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC $ 345 10 $ 161 $ 184 $ 1,839
Phar
mac
y Co
st247PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC $ 2,524 166 $ 631 $ 1,893 $ 314,214 460SPINAL FUSION EXCEPT CERVICAL W/O MCC $ 672 343 $ 426 $ 246 $ 84,498 470MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC $ 407 1,023 $ 339 $ 68 $ 69,700
Premier Medical Center - CY11
MSDRGFacility Ave.
Cost per Case Facility Case
Count Premier Top
Quartile
Member Variance to 1st Quartile
Potential Savings
Opportunity 227CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC $ 25,275 68 $ 25,152 $ 123 $ 8,392
Tota
l Cos
t
247PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC $ 14,225 360 $ 9,125 $ 5,100 $ 1,836,080 460SPINAL FUSION EXCEPT CERVICAL W/O MCC $ 23,618 213 $ 18,899 $ 4,719 $ 1,005,125 470MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC $ 13,626 215 $ 12,558 $ 1,068 $ 229,576 227CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC $ 11,620 68 $ 16,634 $ (5,013) -
Supp
ly C
ost
247PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC $ 3,926 360 $ 3,560 $ 366 $ 131,634 460SPINAL FUSION EXCEPT CERVICAL W/O MCC $ 12,569 213 $ 9,976 $ 2,593 $ 552,324 470MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC $ 4,332 215 $ 5,500 $ (1,168) -227CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH W/O MCC $ 458 68 $ 161 $ 297 $ 20,197
Phar
mac
y Co
st247PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC $ 1,269 360 $ 631 $ 639 $ 229,936 460SPINAL FUSION EXCEPT CERVICAL W/O MCC $ 644 213 $ 426 $ 218 $ 46,446 470MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC $ 488 215 $ 339 $ 149 $ 31,934
4 Premier member hospitals identified over
$17m in savings opportunities in 4 high cost / high volume MS-
DRGs
26 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Capital budget forecasts
Incr
eased b
y 30%
or m
ore
Incr
eased b
y 10%
to 2
9%
Incr
eased b
y 1%
to 9
%
No Change
Decrease
d by
1% to
9%
Decrease
d by
10% to
29%
Decrease
d by
30% o
r more
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
Fall 2013Spring 2013 Fall 2012 Spring 2012Fall 2011
27 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Areas of capital investment
Other
Laboratory equipment
Other clinical equipment
Imaging equipment
Surgical suites/equipment
Infrastructure (e.g., construction)
IT and telecommunications
0.0% 10.0% 20.0% 30.0% 40.0% 50.0%
Fall 2011Spring 2012Fall 2012Spring 2013Fall 2013
28 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Inflation estimates
2006 2007 2008 2009 2010 2011 2012 2013 2014
-1.0%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
CPI - U, Medical care CPI, and IPPS marketbasket rates (2006- 2013)
CPI-U Medical care CPIMedicare marketbasket - inpatient hospital
An
nu
al p
erce
nt
chan
ge
29 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
TRJ/CRB index 2008-2013
1/3/
2008
2/28
/200
8
4/24
/200
8
6/19
/200
8
8/14
/200
8
10/9
/200
8
12/4
/200
8
1/29
/200
9
3/26
/200
9
5/21
/200
9
7/16
/200
9
9/10
/200
9
11/5
/200
9
12/3
1/20
09
2/25
/201
0
4/22
/201
0
6/17
/201
0
8/12
/201
0
10/7
/201
0
12/2
/201
0
1/27
/201
1
3/24
/201
1
5/19
/201
1
7/14
/201
1
9/8/
2011
11/3
/201
1
12/2
9/20
11
2/23
/201
2
4/19
/201
2
6/14
/201
2
8/9/
2012
10/4
/201
2
11/2
9/20
12
1/24
/201
3
3/21
/201
3
5/16
/201
3
7/11
/201
30
50
100
150
200
250
300
350
400
450
500
Currently 38% below 2008 peak and 42% above 2009 floor
30 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
U.S. monetary policy/quantitative easing
Strength of U.S. dollar compared to other currencies
Resiliency of European Union
Demand from China and emerging markets
Suppliers identified energy, labor and plastic resins as the top cost drivers of raw materials
Major factors impacting 2014 commodity prices
31 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Commodities highlights
Commodity Last monthchange
Last yearchange
What to Watch
Copper -1.00% -14.00% 678,225 metric tons of surplus; decreasing demand for metals
Cotton -2.88% 14.55% Rise in global demand and decreased production in US due to drought expected to increase prices
Natural Gas -1.91% 2.42% Report on June 6th showed largest inventory gain in four years; winter weather expected to raise prices in 2014
Oil -5.83% 11.43% Increasing global demand combined with increase in non-OPEC fuels production; China second-largest consumer of oil
32 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Food price volatility
33 PROPRIETARY & CONFIDENTIAL – © 2013 PREMIER INC.
Questions?
Contact:
www.premierinc.com/economicoutlook