Advisory Council presentation July 2007 (2)...Dr Fineberg, President of IOM, National Governor’s Association Meeting, July 2007 What accounts for growth in health care spending ?

Rising Health Care Costs, Rising Health Care Costs, Prevention & Primary Care, and Prevention & Primary Care, and

Personal ResponsibilityPersonal Responsibility

Marcia Nielsen, Ph.D., MPHMarcia Nielsen, Ph.D., MPHExecutive DirectorExecutive Director

July Advisory Council MeetingsJuly Advisory Council Meetings

ObjectivesObjectives

To explore evidence regarding rising costs of To explore evidence regarding rising costs of health care, chronic disease, and health behaviorhealth care, chronic disease, and health behaviorTo explore the evidence regarding coordination To explore the evidence regarding coordination of care, primary care, a medical homeof care, primary care, a medical homeTo discuss personal responsibility related to To discuss personal responsibility related to health behaviors, cost effective use of health health behaviors, cost effective use of health care services and health literacy, and care services and health literacy, and contribution to the cost of health insurance. contribution to the cost of health insurance.

Rising health care costs Rising health care costs and the burden of chronic and the burden of chronic

disease disease

Institute of MedicineInstitute of Medicine’’s Top 10 s Top 10 Concerns re: the US Health SystemConcerns re: the US Health SystemThe number of uninsuredThe number of uninsuredThe rising costs of care and increases in health The rising costs of care and increases in health care expensescare expensesDeficient quality and safetyDeficient quality and safetyInadequate evidence about value performanceInadequate evidence about value performance, , cost of intervention and insufficient reliance on cost of intervention and insufficient reliance on available evidenceavailable evidenceDysfunctional competition, Dysfunctional competition, perverse incentivesperverse incentives, , inefficiency and wasteinefficiency and waste

Dr Fineberg, President of IOM, National Governor’s Association Meeting, July 2007

Institute of MedicineInstitute of Medicine’’s Top 10 s Top 10 Concerns re: the US Health SystemConcerns re: the US Health System

Insufficient use of Health Information Insufficient use of Health Information TechnologyTechnologyUnderinvestment in preventionUnderinvestment in preventionWorkforce shortages, low morale, and Workforce shortages, low morale, and mismatches to current and future needsmismatches to current and future needsDisparities in access and outcomesDisparities in access and outcomesLow health literacy and poor accommodations Low health literacy and poor accommodations to patientsto patients

Building a better Building a better health systemhealth system

““30 to 40% of every dollar spent in the 30 to 40% of every dollar spent in the US on health care is spent on overuse, US on health care is spent on overuse,

underuseunderuse, misuse, duplication, etc, misuse, duplication, etc””


What accounts for growth inhealth care spending ?

Secretary Bremby, KHPA Board Retreat, 2007

0%10%20%30%40%50%60%70%80%90%

100%

U.S. Population Health Expenditures

Health Care Costs Concentrated in Sick Few—Sickest 10 Percent Account for 64 Percent of Expenses

1%5%

10%

49%

64%

24%

Source: The Commonwealth Fund. Data from S. H. Zuvekas and J. W. Cohen, “Prescription Drugs and the Changing Concentration of Health Care Expenditures,” Health Affairs, Jan./Feb. 2007 26(1):249–57.

50%

97%

$36,280

$12,046

$6,992

$715

Distribution of health expenditures for the U.S. population,by magnitude of expenditure, 2003

Expenditure threshold (2003 dollars)

Health Expenditure Growth 2000–2005for Selected Categories of Expenditures

12.0

8.6 8.0 7.96.1

10.7

0

5

10

15

20

Total Hospital care Physician &clinical services

Nursing home &home health

Prescriptiondrugs

Prog. admin. &net cost of

private healthinsurance

Average annual percent growth in health expenditures, 2000–2005

Source: A. Catlin et al., “National Health Spending in 2005: The Slowdown Continues,”Health Affairs, Jan./Feb. 2007 26(1):142–53.

Health Care Expenditure per Capita by Source of Funding in 2004

$803

$472 $313$582 $396 $389

$359

$2,572

$483 $342 $354

$2727$2,210 $2,475

$1,894$2,350

$1,940 $2,176 $1,917 $1,832 $1,611

$239

$238

$148$906$444

$113$28$370

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

UnitedStates

Canada France Netherlands Germany Australia UnitedKingdom

OECDMedian

Japan NewZealand

Private Spending

Out-of-Pocket Spending

Public Spending

a b

a2003b2002 (Out-of-Pocket)

aa

Source: The Commonwealth Fund, calculated from OECD Health Data 2006.

Adjusted for Differences in Cost of Living

Prevention, Health Prevention, Health Behavior, Personal Behavior, Personal

ResponsibilityResponsibility

Health Factors

Environment22%

How We Live -

Behavior51%

Medical Care10%

Genetic Make-Up

17%

Source: USDHEW, PHS, CDC. “Ten Leading Causes of Death in US 1975.”Atlanta, GA, Bureau of State Services, Health Analysis & Planning

for Preventive Services, p 35, 1978

* National Center for Health Statistics. Mortality Report. Hyattsville, MD: US Department of Health and Human Services; 2002† Adapted from McGinnis Foege, updated by Mokdad et. al.

Actual Causes of Death†

Tobacco

Poor diet/lack of exercise

Alcohol

Infectious agents

Pollutants/toxins

Firearms

Sexual behavior

Motor vehicles

Illicit drug use

Causes of Death United States, 2000

Leading Causes of Death*

Percentage (of all deaths)

Heart Disease

Cancer

Chronic lowerrespiratory disease

Unintentional Injuries

Pneumonia/influenza

Diabetes

Alzheimer’s disease

Kidney Disease

Stroke

Percentage (of all deaths)0 5 10 15 20 25 30 35 0 5 10 15 20

19961991

2003

Obesity Trends* Among U.S. AdultsBRFSS, 1991, 1996, 2003

(*BMI ≥30, or about 30 lbs overweight for 5’4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Prevalence of Diabetes in AdultsPrevalence of Diabetes in AdultsUnited States, BRFSS: 2000United States, BRFSS: 2000

<4% 4–6% >6%

YRBS National Surveys, 1991–2001

Centers for Disease Control & Prevention

Percentage of U.S. High School Students Who Did Not Attend

Physical Education Classes Daily

Coordination of care and Coordination of care and a primary care medical a primary care medical

homehome

Environment

Family

School

Worksite

Community

Chronic Care Model

Medical System

Information Systems

Decision Support

Delivery System Design

Self Management Support

PatientSelf-Management

Source: The Commonwealth Fund 2006 Quality of Care Survey

Adults with a Medical Home Are More Likelyto Report Checking Their Blood Pressure Regularly

and Keeping It in Control

2942

25

1510

17

56 48 58

0

25

50

75

100

Total Medical home Regular source of care, nota medical home

Does not check BPChecks BP, not controlledChecks BP, controlled

Percent of adults 18–64with high blood pressure

Source: Commonwealth Fund 2006 Health Care Quality Survey.

Note: Medical home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running on time.


55

74

52*

38*

0

25

50

75

100

Total Medical home Regular source ofcare, not a medical

home

No regular source ofcare/ER


The Majority of Adults with a Medical HomeAlways Get the Care They Need

Percent of adults 18–64 reporting always getting care they need when they need it

Note: Medical home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running on time.* Compared with medical home, differences remain statistically significant after adjusting for income or insurance.


8065

73 69

39* 34*

0

25

50

75

100

Insured all year Any time uninsured

Medical home

Regular source of care, not a medical homeNo regular source of care/ER

Percent of obese or overweight adults 18–64 whowere counseled on diet and exercise by doctor

Adults with a Medical Home Have Higher Ratesof Counseling on Diet and Exercise Even When Uninsured


Note: Medical home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running on time.* Compared with medical home, differences are statistically significant.

THECOMMONWEALTH

FUND

Following Treatment Regimens for Chronic Diseases

Percent of privately insured adults 21–64 with chronic conditionswho strongly/somewhat agree that they follow their treatment regimens very carefully

67646259

88

7584

63

4951

89

51

657370

0

25

50

75

100

Allergies Arthritis Depression HighCholesterol

Hypertensionor Stroke

Comprehensive HDHP CDHP

Comprehensive = health plan with no deductible or <$1,000 (individual), <$2,000 (family).HDHP = high-deductible health plan with deductible $1,000+ (individual), $2,000+ (family), no account.CDHP = consumer-driven health plan with deductible $1,000+ (individual), $2,000+ (family), with account.*Difference between HDHP/CDHP and Comprehensive is statistically significant at p ≤ 0.05 or better.

(n=89) (n=74)

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2006.

THECOMMONWEALTH

FUND

69

1215

21

26

0

25

50

GER NZ UK AUS CAN US

23

41

2420

29

23

36

White Black Hispanic Aboveaverageincome

Belowaverageincome

Insured Uninsured

International comparison United States, by race/ethnicity,income, and insurance status

Went to ER for Condition That Could Have Been Treatedby Regular Doctor, Among Sicker Adults, 2005

Percent of adults who went to ER in past two years for condition that could have been treatedby regular doctor if available

GER=Germany; NZ=New Zealand; UK=United Kingdom; AUS=Australia; CAN=Canada; US=United States.Data: Analysis of 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults;Schoen et al. 2005a.

EQUITY: COORDINATED AND EFFICIENT CARE

THECOMMONWEALTH

FUND

Adults Without Insurance Are Less Likelyto Be Able to Manage Chronic Conditions

18 16

58

27

59

35

0

25

50

75

Skipped doses or did not fill prescription forchronic condition because of cost

Visited ER, hospital, or both for chroniccondition

Insured all year Insured now, time uninsured in past year Uninsured now

Percent of adults ages 19–64 with at least one chronic condition*

Source: S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, Findings from the Commonwealth Fund Biennial Health Insurance Survey (New York: The Commonwealth Fund, Apr. 2006).

*Hypertension, high blood pressure, or stroke; heart attack or heart disease; diabetes; asthma, emphysema, or lung disease.

Kansas specific data on Kansas specific data on health behaviorhealth behavior and and

chronic diseasechronic disease

Risk Factors for Coronary Artery Disease & Risk Factors for Coronary Artery Disease & Stroke in KansasStroke in Kansas

Tobacco Smoking Tobacco Smoking -- 2003 2003 20.4% of adult Kansans currently 20.4% of adult Kansans currently smoked cigarettes.smoked cigarettes.1 in 5 high school students and 6.0% of 1 in 5 high school students and 6.0% of middle school students reported middle school students reported smoking cigarettes.smoking cigarettes.

Source: 2003 Kansas Behavioral Risk Factor Surveillance System. 2002 Kansas Youth Tobacco Survey. Office of Health Promotion, KDHE.


Physical Inactivity Physical Inactivity -- 2003 2003 25.9% of adult Kansans reported that they did 25.9% of adult Kansans reported that they did not participate in any leisure time physical not participate in any leisure time physical activity.activity.

Low Fruit and Vegetable Consumption Low Fruit and Vegetable Consumption -- 20032003Only 1 in 5 adult Kansans attained the goal of Only 1 in 5 adult Kansans attained the goal of eating at least 5 fruits and vegetables per day.eating at least 5 fruits and vegetables per day.

Source: 2003 Kansas Behavioral Risk Factor Surveillance System.


Overweight & Obesity Overweight & Obesity -- 2003 2003 60.5% of adult Kansans were 60.5% of adult Kansans were overweight or obese.overweight or obese.22.6% of adult Kansans were obese in 22.6% of adult Kansans were obese in 2003 compared to 13.0% in 1992.2003 compared to 13.0% in 1992.The highest prevalence of obesity was The highest prevalence of obesity was seen among nonseen among non--Hispanic blacks Hispanic blacks (32.8%).(32.8%).

Overweight or obese body mass index ≥ 25.0 kg/m2 Obese body mass index ≥ 30.0 kg/m2

Source: 2003 Kansas Behavioral Risk Factor Surveillance System. Office of Health Promotion, KHDE

Childhood Overweight and Obesity Childhood Overweight and Obesity Statistics in KansasStatistics in Kansas

In 1999In 1999--2000, 15% of 62000, 15% of 6--19 year old children & teens 19 year old children & teens were overweight. were overweight.

Over 10% of preOver 10% of pre--schoolschool--aged children (ages 2 aged children (ages 2 --5) are overweight5) are overweight (up from 7% in 1994). (up from 7% in 1994).

Another Another 15% of children and teens are 15% of children and teens are considered at riskconsidered at risk for becoming overweight for becoming overweight

Childhood obesity has Childhood obesity has increased 36%increased 36% in the past in the past 20 years20 years

Source: Kansas Department of Health & Environment

Office of Health Promotion


High Blood Cholesterol High Blood Cholesterol -- 2003 2003 Almost oneAlmost one--third (29.4%) of adult Kansans third (29.4%) of adult Kansans who had ever been tested for serum who had ever been tested for serum cholesterol levels were told by their health cholesterol levels were told by their health care provider that they have high serum care provider that they have high serum cholesterol levels. cholesterol levels. Prevalence was higher for whites as compared Prevalence was higher for whites as compared to blacks (30.5% and 25.1%, respectively).to blacks (30.5% and 25.1%, respectively).


High Blood Pressure High Blood Pressure -- 20032003Almost 1/4Almost 1/4thth (23.3%) of adult Kansans had (23.3%) of adult Kansans had high blood pressure.high blood pressure.Prevalence of high blood pressure increases Prevalence of high blood pressure increases with increasing age. 50% of adults aged 65 with increasing age. 50% of adults aged 65 and older had hypertension.and older had hypertension.NonNon--Hispanic blacks had the highest Hispanic blacks had the highest prevalence (29.2%) of hypertension.prevalence (29.2%) of hypertension.

Source: 2003 Kansas Behavioral Risk Factor Surveillance System.


Diabetes Diabetes -- 2003 2003 6.0% of adult Kansans had been 6.0% of adult Kansans had been diagnosed with diabetes.diagnosed with diabetes.Prevalence of diabetes increases with Prevalence of diabetes increases with increasing age. 14.5% of adults aged 65 increasing age. 14.5% of adults aged 65 and older had diabetes.and older had diabetes.The highest prevalence of diabetes was The highest prevalence of diabetes was seen in nonseen in non--Hispanic blacks (10.1%). Hispanic blacks (10.1%).

BRFSS Trends Data: KansasBRFSS Trends Data: KansasAdult Percent Overweight By BMIAdult Percent Overweight By BMI

BMI 25BMI 25--29.929.9

34.8% 34.5%

33.8% 34.1%

34.5%

39.2%

37.1% 37.2%

37.9%

35.4%

37.4%

31.0%32.0%33.0%34.0%35.0%36.0%37.0%38.0%39.0%40.0%

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Source: Kansas Department of Health & Environment

Behavioral Risk Factor Surveillance System

BRFSS Trends Data: KansasBRFSS Trends Data: KansasAdult Percent Obese: By BMIAdult Percent Obese: By BMI

BMI BMI >> 3030

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Kansas Department of Health & Environment

Behavioral Risk Factor Surveillance System

Adults in Kansas Reporting No Leisure Time Adults in Kansas Reporting No Leisure Time Physical ActivityPhysical Activity

28.90%

38.30%

34.50%30.90%

36.40%38.30%

30.40%26.70%

22.50%

0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%

1992 1993 1994 1995 1996 1998 2000 2001 2002

Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Behavioral Risk Factor Surveillance System Trends Data: Kansas

Current Cigarette Smokers in Kansas 1992 Current Cigarette Smokers in Kansas 1992 -- 20032003

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%Pe

rcen

tage

of A

dult

Popu

latio

n

Kansas 22.4 20.3 21.8 22.0 22.1 21.0 21.1 21.0 21.0 22.2 22.1 20.4National 22.2 22.6 22.7 22.4 23.4 23.2 22.9 22.6 23.2 22.8 23.0

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Source: 1992-2003 Behavioral Risk Factor Surveillance System , Office of Health Promotion, Kansas Department of Health and Environment

National data : 1992-2003 Behavioral Risk Factor Surveillance System , Centers for Disease Control and Prevention.

Prevalence of cigarette use among adults in Kansas has remained relatively unchanged. This trend is similar to the trend in the United States.

Prevalence of cigarette us in Kansas is highest among individuals of low education (36.4% for less than high school) and low income (28.6% for < $15,000 annual household income)

Tobacco Use in Kansas Tobacco Use in Kansas –– Key IndicatorsKey Indicators

• Youth rates have declined in the recent past, leveling out at approximately the adult prevalence rate. Youth rates are used to measure youth access and initiation.

• Adult quit attempts in the past 12 months by adult Kansas smokers have remained consistently in the 40-50% range since 2000. Cessation attempts are used to gauge community norm changes as well as short/intermediate term outcome objectives.

Source: 2000-2003 Behavioral Risk Factor Surveillance System , Office of Health Promotion, Kansas Department of Health and Environment

2000 and 2002 Kansas Youth Tobacco Survey, Office of Health Promotion, Kansas Department of Health of Environment

RecommendationsRecommendations

Getting Value for Money: Health System TransformationGetting Value for Money: Health System Transformation

•• Transparency; public information on clinical quality, patientTransparency; public information on clinical quality, patient--centered care, centered care, and efficiency by provider; insurance premiums, medical outlays,and efficiency by provider; insurance premiums, medical outlays, and and provider payment ratesprovider payment rates

•• Payment systems that reward quality and efficiency; transition tPayment systems that reward quality and efficiency; transition to population o population and care episode payment systemand care episode payment system

•• PatientPatient--centered medical home; Integrated delivery systems and centered medical home; Integrated delivery systems and accountable physician group practicesaccountable physician group practices

•• Adoption of health information technology; creation of stateAdoption of health information technology; creation of state--based health based health insurance exchangeinsurance exchange

•• National Institute of Clinical Excellence; invest in comparativeNational Institute of Clinical Excellence; invest in comparative costcost--effectiveness research; evidenceeffectiveness research; evidence--based decisionbased decision--makingmaking

•• Investment in high performance primary care workforceInvestment in high performance primary care workforce

•• Health services research and technical assistance to spread bestHealth services research and technical assistance to spread best practicespractices

•• PublicPublic--private collaboration; national aims; uniform policies; simplifiprivate collaboration; national aims; uniform policies; simplification; cation; purchasing powerpurchasing power

Source: The Commonwealth Fund

18 16 17

4943

516

10

7585

0

20

40

60

80

100

Proportion of under-65population that has no

health insurance

Total cost of healthcare as a percentage

of GDP

Proportion ofhouseholds spending

>10% of income onOOP costs and

premiums*

Proportion ofrecommended

preventive care adultsreceive

Proportion ofrecommended

preventive carechildren receive

Current Goal

Percent

Transformation Is PossibleTransformation Is Possible

Source: Commonwealth Fund Health Care Opinion Leaders Survey, Jan. 2007.

"What you would see as both an achievable anda desirable goal or target for policy action within the next 10 years?"

Note: Goal percentages represent median responses.* Or 5% of household income for low-income households; OOP = “out-of-pocket”.

Health Care Opinion Leaders: Health Care Opinion Leaders: Views on Controlling Rising Health Care CostsViews on Controlling Rising Health Care Costs

50%

51%

54%

54%

57%

61%

65%

66%

70%

75%

Consolidate purchasing power by public, privateinsurers working together to moderate rising costs of

Have all payers, including private insurers, Medicare,and Medicaid, adopt common payment methods or rates

Establish a public/private mechanism to produce,disseminate information of effectiveness, best practices

Reduce administrative costs of insurers, providers

Allow Medicare to negotiate drug prices

Reward providers who are more efficient and providehigher quality care

Increase the use of disease and care managementstrategies for the chronically ill

Increased and more effective use of IT

Use evidence-based guidelines to determine if a test,procedure should be done

Reduce inappropriate medical care

“How effective do you think each of these approaches would beto control rising costs and improve the quality of care?”

Percent saying “extremely/very effective”

Note: Based on a list of 19 options.Source: The Commonwealth Fund Health Care Opinion Leaders Survey, Jan. 2007.

Elements of State Based ReformsElements of State Based Reforms

Extract as much from the federal government as Extract as much from the federal government as you canyou canBuild on existing private and public schemesBuild on existing private and public schemesExtend participation by employers through Extend participation by employers through incentives and requirements incentives and requirements Facilitate insurance marketsFacilitate insurance marketsApply income related fees, deductibles, and Apply income related fees, deductibles, and copayscopays


Elements of State Based ReformsElements of State Based Reforms

Define basic coverageDefine basic coverageEncourage disease prevention and health Encourage disease prevention and health promotionpromotionCorrect for adverse insurance selectionCorrect for adverse insurance selectionPromote quality improvements, efficient disease Promote quality improvements, efficient disease management, and use of evidencemanagement, and use of evidence

Documents

Advisory Council presentation July 2007 (2)...Dr Fineberg, President of IOM, National Governor’s Association Meeting, July 2007 What accounts for growth in health care spending ?