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Rough Waters Ahead: Navigating Health Reform, the Future of Health Care and Telemedicine's Expanding Role
1. Rough Waters Ahead:
Navigating Health Reform,
the Future of Health Care, and
Telemedicine’s Expanding Role
John F. Duval
Virginia Commonwealth University Health System
March 18, 2013
2. Agenda
• Quick overview of the Affordable
Care Act
• What’s popular, what’s controversial
• The promise and key disconnects
– Costs
– Workforce adequacy
– The States: Medicaid Expansion and
Insurance Exchanges
• Stay tuned
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–
–
–
What we don’t know
Critical disconnects
What is happening in spite of reform
Telemedicine’s expanding role
1
3. What is good about
the health care
delivery system?
4. John’s List
•
•
•
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•
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Robust medical community, well represented by specialties
Strong & dedicated allied health workforce
Best education system in the world across all disciplines
Cutting edge technologies & pharmaceuticals
Strong research basis
Social safety net
Modern physical plant
Improving transparency & accountability
Improving quality & safety
Major economic engine, frequently largest employer
3
5. What is not good
about the
health care
delivery system?
6. John’s List
•
•
•
•
•
•
•
•
•
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Current costs and growth rate are economically not sustainable
≈ 50 million uninsured
Racial / economic / geographic disparities in access to care
Unnecessary variations in amount / quality of care provided and some care
is not evidence based
Quality and safety accountability improving, but still too opaque
Economic incentives between provider and insurer communities not
aligned
Regulatory structure / licensure laws result in inefficient use of workforce
Sickness as opposed to wellness focused
High administrative overhead is wasteful
Education costs of healthcare workforce are borne by providers and
government payors
5
7. Patient Protection and Affordable Care Act (PPACA):
Signed into Law March 23, 2010
• Most comprehensive change in healthcare finance since
1964 Medicare & Medicaid legislation
• Reforms the actuarial financing model for health services
in the United States
• Improves access to care for most citizens and reduces the
number of uninsured
• Reins in unpopular insurance industry practices
• Increases quality and safety of health care
• Improves transparency of health and insurance
information
• Creates Health Insurance Exchanges in each state
• Provides option for Medicaid Expansion in each state
• And much, much more
6
8. PPACA: What is Popular?
• Extends insurance coverage to 32 million people
• Allows parents to cover children up to the age of 26 under their
private insurance plans
• Eliminates lifetime dollar limits on benefits imposed by most
medical plans
• Prevents medical plans from denying insurance and benefits based
on preexisting conditions
• Limits the amount insurers spend on administrative costs versus
medical costs (Medical Loss Ratio)
• Provides more transparency with publically reported metrics
related to quality, safety, and patient outcomes
7
9. PPACA: What is Controversial?
• Mandates individuals have health insurance by 2014 or pay a penalty
• Expands Medicaid coverage to residents with incomes up to 133% of the
federal poverty level (FPL)
– Federal government will cover all costs for this group starting in 2014 and
will phase down to 90% by 2020
• Role of the States
– Health Insurance Exchanges
– Medicaid Expansion
• Requires some employers with 50+ employees who do not offer health
insurance to pay a penalty
• Significantly reduces Medicaid and Medicare Disproportionate Share Hospital
(DSH) allocations
• New taxes on Individuals, health insurance sector, and manufacturers of
pharmaceuticals and medical devices
8
10. PPACA: What the Law Doesn’t Cover
• PPACA does not adequately address important issues facing
the health delivery system including:
– Impending physician and nursing shortages
– Rapidly escalating costs and their cause within our hospitals and
health systems
– Large variations in medical practice observed across the nation
– Financing of graduate medical education / other workforce
issues
– Foreign national population
– Costs of those who opt out
9
13. Murphy’s Law of health care
legislation:
“If it can cost more than the
highest available official
estimate, it probably will.”
Senate Joint Economic Commission
12
14. Will They Be Right?
• Coverage expansions
cost $938 billion over
10 years
• Federal deficit reduced
by $124 billion over 10
years
Source: Kaiser Family Foundation, 2011
13
15. A Lesson from History…
Program (Estimate Year)
Original estimate Actual cost
Medicare Part A (1965)
$9b/1990
$67b/1990
All of Medicare (1967)
$12b/1990
$110b/1990
ESRD program (1972)
$100m/1974 $229m/1974
Medicaid DSH (1987)
Mcare Home Care (1988)
< $1b/1992
$17b/1992
$4b/1993
$10b/1993
Source: Senate Joint Economic Committee, 7/31/09
14
19. Health Care Labor Force
• Projected shortages BEFORE health care reform
• Reform makes some efforts to begin addressing
shortages
BUT
• The law covers 32 million new patients nationally and
approximately 1 million in Virginia
• That may not add up…
18
20. Will There Be Enough Doctors?
• Pockets of physician shortages now
• 40% of practicing physicians ≥ age 55
• In Virginia, a recent survey showed one-third
were ≥ age 55 and 10% ≥ age 65
• How many more will we need?
– E.g., currently 6,830 geriatricians nationally
• That is only 1 for every 1,900 seniors ≥ age 75
• IOM indicates 36,000 needed by 2030
Sources: Alliance for Health Reform, 2011; Virginia DHP, 2009; Institute of Medicine, 2008
19
21. What About Other Health Professionals?
• 33% of nursing workforce ≥ age 50
– More than half of these plan to retire within 10
years
• Will an improved economy
reduce supply?
• Nursing shortage projected
to grow to 260,000 RNs by 2025
Source: Alliance for Health Reform, 2011
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22. What other health professionals may be needed?
•
•
•
•
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•
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Case Managers/Social Workers
Physical/occupational therapists
Pharmacists
Medical technologists
Clinical psychologists
Dieticians
Rehabilitation counselors
Medical coders
Health information technicians
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27. Policy Issues for State Medicaid Expansion
Opt In
• Long-term cost
• Long-term support (Workforce, etc.)
• Long-term benefits of reduced uninsured population
Opt Out
•
•
•
•
Cost of larger uninsured population
Federal leverage – What sticks still remain?
Lost dollars to state
Tax exportation
26
28. Stay Tuned
•
•
•
•
What we don’t know
Critical disconnects
What is happening in spite of reform
Telemedicine’s expanding role
27
31. He Wasn’t Discussing Reform, But…
“There are things we
know that we know.
There are known
unknowns. That is to say
there are things that we
now know we don't
know. But there are also
unknown unknowns.
There are things we do
not know we don't
know.” D. Rumsfeld
30
32. Critical Disconnects
•
•
•
•
•
•
•
•
Cost estimates?
Economic impact
Access to providers
Graduate medical / other education
Implementation unknowns
Payment alignment with delivery goals
Tort reform
Medicaid/Medicare requirements /
provider cuts / Disproportionate Share
Hospital payments
• Undocumented foreign nationals
• Personal responsibility
• And more…
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33. Ongoing efforts, even before
(in spite of) reform
•
•
•
•
•
•
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Quality improvement
Increased safety
Greater efficiency
More transparency
Coordinated care
Healthier populations
Integrated providers
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35. How can we use telemedicine to
address critical disconnects?
• Combating the rising cost of care
– Reduces emergency transport costs from rural communities to urban areas
– Decreases ED admissions and readmissions through remote telemonitoring
• Providing high-quality care
– Decreases mortality and length of stay with Tele-ICU coverage
– Initiates more timely treatment with ED-ED consults via telemedicine
• Meeting care demands
– Provides rural and underserved communities expanded access to specialists and subspecialists
• Overcoming provider shortages
– Expands reach of providers who prefer to live in larger cities by giving them remote access to
rural patients
– Creates additional capacity for traveling physicians by removing barriers of time and distance
• Achieving patient satisfaction
– Improves patient satisfaction by providing care in a timely fashion
– Keeps care local – only the most serious cases should be packed and shipped to tertiary centers
Source: Telemedicine: An Essential Technology for Reformed Healthcare
(Computer Sciences Corporation, 2011)
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36. The Potential of Telemedicine
• Emergency Medical Services
– TeleECG on ambulances transmitted to cardiologists via
smartphones or other devices
– Immediate treatment started in transit before patient hits ED
• Telesurgery using robot surgical systems
– MD Anderson received a $1M contribution from AT&T to seed
its venture into remote surgical care for cancer patients
– If successful, surgical cases would occur in rural and
underserved Texas communities rather than Houston
35
37. VCUHS Telemedicine Strategic Plan
Mission Statement & Vision
Mission Statement:
VCUHS Telemedicine supports the mission of the Health System by offering
confidential, timely and cost-effective medical services to patients; removing
distance barriers throughout the Commonwealth of Virginia; providing
superior, compassionate and innovative patient care.
Vision:
Integrate Telemedicine as a part of VCUHS’ strategy to respond to Affordable
Care Act mandates and grow its relationships with community and regional
providers, hospitals and community health centers.
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38. Goals of VCUHS Telemedicine Program
• Develop and grow relationships with all correctional
facilities in order to provide access and decreases costs
• Utilize telemedicine in under-served and rural areas to
reduce health care disparities
• Leverage the clinical, educational and outreach efforts
of our Centers of Excellence to provide specialty
expertise across the Commonwealth
• Develop innovative models of care using telemedicine
that keep care local and provide care for complex
patients in their homes
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41. VCUHS Telemedicine Expands to Meet Needs
of Outlying Communities: Post-2010
Correctional:
Before 2010
Community Based:
Growth since 2010
Pending Contracts/Negotiations
Updated 1/1/2014
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42. VCUHS Telemedicine provides increased access
to specialists in South Hill, Virginia
• VCUHS utilizes telemedicine to expand access to patients
at Community Memorial Healthcenter:
• Clinical Telepsychiatry Services – Inpatient and Long Term Care
• ICU Intensivist support
• Virginia Tobacco Commission Grant expands Patient Access
• Two new wireless telemedicine units and MCU bridge
• Multidisciplinary tumor conferences, clinical research and
Telemed consults
• Massey Cancer Center case conference review and provider
collaboration – Southern Virginia
41
43. VCUHS is working with several outlying community providers
to launch ED-ED Pediatric Telemedicine
Goal: Improve access and quality by providing telemedicine consults to pediatric patients
admitted to Virginia community hospital Emergency Departments
Objectives:
– Provide physician based pediatric critical care in terms of stabilization and
intervention for children in need of transfer to CHoR
– Provide visual report for nursing hand-off
– Physician based screening for pediatric “puzzlers” (i.e., skin rash, lab finding, etc.)
– Assist with ER disposition plan for subspecialty inpatient/outpatient follow-up
care
– Expand telemedicine collaboration to other specialties and services
– Develop a successful ED to ED model for state-wide roll out at other referring
hospitals
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44. Independence at Home Demonstration
• In 2012, Virginia Commonwealth University applied for a consortium site to
demonstrate the value of the Independence at Home clinical model
– Partnered with MedStar Washington Hospital Center and the University of
Pennsylvania
– Based on VCU House Calls program that has provided in-home primary care for
more than 5,000 home-bound patients over the past 25 years
• Tests a payment incentive and service delivery model that utilizes physician and
nurse practitioner directed home-based primary care teams
• The Consortium will utilize remote diagnostics and telemonitoring as part of
the IAH program
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–
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Pulse oximetry
I-STAT devices
iCard IPhone EKGs
EKG harnesses for laptops
In-home telemedicine
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45. Telemedicine’s Expanding Role
• Many challenges are coming our way:
–
–
–
–
Health reform implementation
Provider shortages, especially in rural and under-served areas
Aging of the Baby Boomers
Addition of previously uninsured population
• New strategies/models for providing access and quality care are essential
• Telemedicine is a maturing tool that will help stretch our workforce and
ensure all patients have access to needed care
– Offers opportunity to redeploy and reengineer workforce in ways that were
previously not attainable
– Holds promise for dramatically improving access and reducing health inequities in
rural and economically distressed areas
• It’s not a cure-all, but will help us as we figure out how to avoid this….
44
Hinweis der Redaktion
Let me be clear up front. We needed health care reform in this country. No question about it. Where I work and throughout the field in Virginia, we have been working hard to improve quality, make care safer, and reduce costs. Really, we’ve been trying to increase value in health care while also increasing community health.And the new health care reform law has promise in these areas. But will promise clash with reality?
Lots of reasons for this:Underestimated the level of demand for the proposed new benefits, perhaps due to insufficient data or a lack of experience administering those sort of benefits. On Medicare specifically, estimators could not have been expected to factor in future program expansions. And then, of course, the political process is sometimes brought to bear as well.
The Congressional Budget Office, a non-partisan scorekeeper responsible for estimating the cost of legislation, took their best shot at estimating what might happen with health care reform as it passed. Of course, they are bound by the same limitations described in the last two slides. What does that tell us about the odds that their estimates of the largest piece of social legislation in at least a generation, a controversial bill that stoked the flames of political passion throughout the belief spectrum, will prove to be accurate?
According to the U.S. Senate Joint Economic Commission, “experts’” history in accurately estimating the cost of health care programs is ridiculously bad. This table shows:The program establishedThe year the estimate was done (basically near program inception)The original estimated annual cost by a certain dateThe actual cost at that date. Medicare Part A is the hospital insurance portion of Medicare, which is the national insurance program for the elderly and disabled.ESRD is the kidney disease portion of Medicare.Medicaid DSH is for providers that treat a disproportionate share of the Medicaid population, to help motivate them to continue treating these patients despite payments that fail to cover the cost of care.As you can see, occasionally we have been off by half, and sometimes by factors of 10 or even 17. We appear to be pretty consistent in our ability to underestimate the cost of new health care programs.
Time will demonstrate the outcome of the experts’ cost estimates and health care reform’s impact on the economy and actual care in the US, but history and current economic trends give us plenty of reasons to be concerned.The health care reform law presents numerous other potential disconnects from reality, too. I want to take a few moments to highlight several of them.
It reminds me of an old Peanuts cartoon where, upon hearing that in life you win some and lose some, Charlie Brown responded, “That would be nice.”
Daunting demographics of an aging patient population and graying workforce created projected provider shortages BEFORE health care reform. Despite some nominal efforts in health care reform to address these problems, 32 million newly-covered patients exacerbate that situation. Adding more patients to an already inadequate workforce may not add up to improved access to care
There are not enough physicians now. Geriatricians, who specialize in patients age 75 and up, make an interesting example since baby boomers have just begun turning 65. The Institute of Medicine estimates we will need 36,000 of them by 2030, nearly six times the number we have today. It is a daunting task to educate so many new providers. But lower payments to these specialists lead medical students to select higher paying, procedure-oriented specialties.
Although the supply of nurses has fluctuated with changes in the economy (weaker financials forcing some nurses to delay retirement or to reenter the workforce), demand continues to grow. With health care reform’s focus on care coordination, who will guide patients in their needed care?Health care reform significantly expanded coverage. That’s not enough. Simply having an insurance card does not equal access to care. Having providers located somewhat nearby who are available to see you in a timely fashion are critical components of that equation.If we are ever going to come close to meeting patient demand, we need to be thinking about other policy changes to ensure that all providers are able to practice to the top of their training levels to meet patient needs and that payment policies incentivize the right mix of providers.
Of course, the supporting cast for patient care goes far beyond doctors and nurses. What role will these other providers play in caring for patients? Will there be enough of them, and will they be able to supplement the traditional physician and nursing roles in other ways? And our needs for behind-the-scenes players, like the people who complete the administrative processes and make sure the equipment and technology are working, will continue to grow as well.
Access to providers represents an even broader disconnect between health care reform and reality.
Another disconnect includes all of the question marks remaining in this large, complex law.
Health care reform is a huge, complex, politically controversial law. And much of the detail wasn’t even fleshed out. Who knows how many times the phrase, “The Secretary shall…” appears in the law? (Slide animation will phase in 1045 after you hit the advance button).Those are areas, of course, where Congress deferred the details to the administrative agency. Add to that the following phrases, which also appear many times: “the Secretary may…;” “the Secretary determines…;” and “the Secretary has the authority to….”With so much administrative latitude and details “To Be Determined,” in many areas it is not clear how health care reform will interact with reality. A recent example, the proposed regulations for one particular new payment and delivery model called Accountable Care Organizations, are more than 400 pages long and highly complex. That’s only one variation on what will be numerous types of payment and delivery reform. Will every proposed implementation piece be as cumbersome? Will such regulation promote or hinder innovation and improvement?
There is a significant amount about health care reform that we still don’t know.
So we’ve talked about some critical disconnects where the health care reform law missed the reality boat:Cost estimates may be offEntitlement growth could impact the economy in ways that necessitate changesEmployers may behave differently than assumedThere may be inadequate providers to care for patients and reform did not do enough to incentivize more providersAnd there is much we do not know about what implementation will bring.
So as I said in the beginning of this presentation – we needed health care reform. And even without the law, the health care field has been working to improve itself.In Virginia, we were already very low cost relative to our sister states, with relatively high quality. And we have been very focused on improving quality and safety of care. I could give you an entire presentation on our efforts to reduce infections one might incur while in the hospital. You’ve seen a great deal of technological advancements that improve efficiency. Greater transparency related to quality of care and efforts to be more transparent on pricing, despite our convoluted health financing system. We are doing much more to coordinate care and keep people healthy. We are encouraging active lifestyles and different provider types are doing more to work together for the good of the patient. But we still have more to do, and key questions revolve around how the mandates, incentives, and barriers included in the health care reform law will interact with the efforts that were already underway and the realities that currently exist.