Download The Coming Age Wave - Chicago Health Executive Forum

The Coming Age Wave:
Perspectives of a LTC Geriatrician
Peter Jaggard, MD CMD
Vice President of Medical Affairs
Presbyterian Homes, IL
The Coming Age Wave:
US Population 65+ (in millions)
80
70
60
50
40
30
20
10
0
1980
2000
2020
2030
The Coming Age Wave:
Health Workforce Projections
JOB
2008
RN
2.6 million
Aide, orderly
1.5 million
Home health aide
922,000
Personal home aides 817,000
LPN
754,000
PT
186,000
Physicians
661,000
PA
75,000
2018
3.2 million
1.7 million
1.4 million
1.2 million
909,000
242,000
806,000
104,000
American Medical News, 11/7/11, p. 5.
The Coming Age Wave:
US National Health Expenditures
• 2009: $2.5 Trillion
• 2019: $4.6 Trillion (before health reform)
6.3% annual growth
• 2019: $4.3 Trillion (after health reform)
5.7% annual growth
Cutler et.al., The Impact of Health Reform on Health System Spending,
(Washington and New York), Center for American Progress and The
Commonwealth Fund, May 2010.
Cited by Glenn Steele , MD at the McEachern Symposium, Kellogg
School of Management, 5/11/11
$2.5 Trillion Health Bill (2009):
Where It Came From
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•
•
•
•
•
•
•
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32%
20%
12%
10%
5%
4%
3%
7%
6%
private health insurance
Medicare
out of pocket
Medicaid Federal
Medicaid state and local
VA, DOD, CHIP
Government Public Health
other third party payers and programs
investment
$2.5 Trillion Health Bill (2009):
Where It Went
• 31% Hospital Care
• 20% Physicians and Clinics
• 10% Prescription Drugs
• 7% Dental Services, other Professionals
• 7% Govt. admin., net cost health insurance
• 6% Investment
• 6% Nursing facilities, CCRCs
• 5% other health, residential, personal care
• 3% Home Health Care
• 3% Government Public Health Activities
• 3% other medical products – DME, etc.
Medicare and Health Reform:
A Look Back and Down the Road
• 2010: 47.5 Mill beneficiaries
• 2010: $523 Billion expenditures
• Affordable Care Act: $500 Bill in cuts over
10 years (nearly 10% of Medicare budget)
Medicare Now: 2011 Cuts for NFs
• 11% cut for post-acute NF services due to
$4 Billion cost overrun last year
• NFs receive about 20% of revenue from
post-acute care
• Reductions may force some NFs out of
Medicare business, if it is a money loser
Medicare 2012: Cuts for MDs?
• 29.5% physician reimbursement cut set for 2012
• This coming due because of Sustainable Growth
Rate formula which has been “fixed” annually by
Congress for years
• SGR projected cuts were used during health
reform debate for overly optimistic projections of
cost savings
• Lack of action may force many MDs out of
Medicare, reducing patient access to PCP
The Coming Age Wave:
Concerns of a Geriatrician
• Who will take care of frail older adults?
• How will their care be paid for?
• Will quality of care be sacrificed for cost
savings?
Health Care for the Coming Age Wave:
The “Triple Aim” of Reform
• Lower Cost
• Improve Quality of Individual Care
• Increase Access and thereby Improve
Health of Population
The Coming Age Wave:
Are ACOs the Answer?
ACOs offer solutions through variety of strategies:
• Hospital-physician integrated networks
• Shared savings model
• Health information technology
• Clinical decision support
• Health information exchanges
• Disease management
• Care coordination
• Use of physician extenders (APN, PA)
What Does the Experience of the 1990s Reveal
about the Proposed Components of ACOs?
• Little or no evidence of effectiveness
• Need a more evidence-based approach
• Revisit assumptions on which strategic changes
are made
• Rather than focus on structure, focus on
processes to bring people into interaction
who need it
Lawton Burns, PhD., presentation at McEachern
Symposium, Kellogg School of Management, 5/11/11
Where are Achievable Savings?
• Accountable Care Organizations looked at
as a mechanism by which to control costs
of care for episodes of illness
• “The savings generated by ACOs, in many
cases, are expected to result from reduced
inpatient admissions.” (CMS) – from Henry
Allen, Senior Attorney for Advocacy, AMA
Reducing NF Hospitalizations as a
Potential Medicare Cost-Saver
• 8.5% of all Medicare hospitalizations are from
NFs
• 40% of these occur within 90 days of NF admit
• Nearly 1/5 of Medicare hospital discharges are
readmitted within 30 days; 27% of these are for
CHF, 21% for pneumonia
• From 1984 to 2009, rehospitalization rate at 60
days had increased from 22.5% to 31%
The INTERACT Project: A Working Solution to
Reducing Transfers from LTC – Acute Care
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INTERventions to Reduce Acute Care Transfers
Multi-site, ongoing research in LTC
Measures and tracks hospitalization rate at NF
QI tool to assess avoidable hospitalizations
QI tools to assist nursing staff in early
identification, assessment, communication, and
documentation of change of condition
INTERACT II Results
• NHs in Massachusetts, NY, Florida
• 6-month study period compared to previous year
6-month period
• 24% reduction in hospitalizations for 17 NHs
rated as “engaged” in INTERACT process
• 6% reduction in hospitalizations in 8 NHs rated
as “not engaged”
• 3% reduction in 11 NHs used as a comparison
NF Hospitalizations:
Presbyterian Home McGaw Center
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NF average census 170; 27% subacute
Staff physicians rounding 3-4 X weekly
Full-time APN
Hospitalization rate 2.07/1000 pt-days (cp
with rate of approx 4 in published study)
• Med A 30-day rehospitalization 9.9%
(Chicago area average 17%)
Whose Care Costs Medicare the Most?
• 20% of Medicare population accounts for
2/3 of Medicare expenditures
• Spending for beneficiaries with 5 or more
chronic conditions as a percentage of
Medicare spending has risen from 52%
(1984) to 76% (2002).
Buckets for Cost Savings
• Big: Lifestyle modifications for young and
middle aged adults
• Medium: Higher quality, more costeffective care strategies
• Smaller: administrative efficiency
Comorbidity, Trajectories of
Decline, and Transitional Care
• Multiple illness = more acute episodes of care
• Acute on Chronic diseases = various trajectories
of functional decline; more transitions of care
• Transitions of care are increasingly more
complex, fragmented, and dangerous for older
adults (Home-hospital-SNF-home care-etc.)
Looming Challenges
• In the face of the coming age wave, Medicare
cuts, and limited resources, how will we care for
older adults with complex needs?
• Will we manage the data/IT wave, or will it
dictate care?
• Will health care organizations keep their focus
on their core mission and values, the care of and
respect for the patient? Or will that be lost
behind a wave of new bureaucracies,
information systems, and data gathering?
“Who is my Neighbor?” - A Story
Seeing, Caring and Transitioning Those in Need
• A complex patient
• A caring spirit
• Hands-on treatment
• Providing continuity of care through a difficult
transition for the patient, even at some cost to
the provider
A Few Suggestions
• Develop systems of care that improve quality by
filling gaps in transitions of care for older adults
• Help patients define realistic goals of care and
execute advance care planning
• Develop collaborative inter-institutional
professional relationships along the continuum
(Hospital-SNF-Home Care-Hospice)
• Use IT systems and data wisely; EMR systems
need active human input and management
• EMRs are not a panacea; med errors still
happen
A Few Suggestions
• Develop clinical protocols that will help older
adults reduce hospitalizations
• Emphasize team care at all sites of care to
maximize care, function, and independence of
older adults
• Develop or review your organization’s mission
and values
• Renew your commitment to honor, respect, and
care for each person in your care as you help
them navigate the changing waves of healthcare