National Commission for Quality Long Term Care Testimony of George Taler, MD Director, Long Term...

National Commission for Quality Long Term Care

Testimony ofGeorge Taler, MD

Director, Long Term CareWashington Hospital Center

Washington, DC

Past President, American Academy of Home Care Physicians

Summary

• Primary Care & Geriatric Medicine

• A different approach to the health care challenges of an aging population

• Restructuring health care delivery and health care financing

Woo B. N Engl J Med 2006;355:864-866

Median Compensation for Selected Medical Specialties

Bodenheimer T. N Engl J Med 2006;355:861-864

Bodenheimer T. N Engl J Med 2006;355:861-864

Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates

Bodenheimer T. N Engl J Med 2006;355:861-864

Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists

National Medical AssociationGallup Poll of Membership, 2003

Maryland Academy of Family Physicians2005 Practice and Income Survey

• 663 Active Members (private practice: 66%)

• Median annual income: $103,400– 37% no change since 2001– 41% decrease since 2001

• In response:– 16% have increased hours or # of patients/wk– 44% have decreased hours in clinical practice– 35% plan to retire, relocate or change careers

Geriatricians Have GreatestCareer Satisfaction

Changes in Medicare Payments to Physicians 1999-2012

Concentration of Total Annual Medicare Expenditures Among Beneficiaries, 2001

Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.

Perc

ent

High-Cost Medicare Beneficiary Spending

Medicare Spending

% of Total

Mean

Top Quartile

85% $24,800

Second Quartile

11% $3,290

Bottom Half

4% $550

Total 100% $7,310

Medicare Spending

% of Total

Mean

Top 5 % 43.1% $63,030

Top 6-10 % 18.4% $26,900

Top 11-25% 23.5% $11,430

Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.

Note: Spending reported in 2005 dollars

Yes, but…

Just because you have a bad year, does your bad luck persist and for how long?

Expenditure History of the Top 25% of Medicare Beneficiaries, 1997

Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.

Distribution of High-Cost Months, 1997-2001

Source: Congressional Budget Office based on data from the Centers for Medicare and Medicaid Services.

Concentration of Total Cumulative Medicare Expenditures Among Beneficiaries, 1997-2001

Targeting the High-Cost User

• Diagnostic characteristics

• Functional characteristics

• Resource utilization history

Prevalence of Chronic Conditions

Beneficiary Group(Spending pattern)

All Low Cost High Cost(Non-persistent) (Persistent)

Coronary Artery Disease 28.2% 19.1% 50.0% 53.7%

COPD 19.6% 13.9% 28.9% 37.5%

Congestive Heart Failure 18.5% 10.1% 33.0% 44.3%

Diabetes 16.7% 12.6% 23.5% 29.5%

Cognitive Impariment 8.8% 5.7% 13.9% 18.7%

Asthma 3.9% 2.9% 4.5% 7.3%

ESRD 2.3% 0.7% 4.2% 7.9%

Mean number of conditions 1.0 0.7 1.6 2.0

Notes: COPD=Chronic Obstructive Pulmonary Disease, ESRD=End Stage Renal Disease. Data from a 5 percent random sample of fee-for-service (FFS) beneficiaries between 1989 and 1997. Source: CBO preliminary analysis.

Number of Chronic Conditions Predicts High-Cost Status

Notes: The 7 conditions considered were: CHF, CAD, COPD, ESRD, Asthma, Diabetes, and Cognitive impairment. Source: CBO preliminary analysis.

Beneficiary Group(Spending pattern)

Low Cost High Cost(Non-persistent) (Persistent)

0 of the 7 conditions 89.5% 4.4% 6.1%

1 condition 71.5% 11.1% 17.3%

2 conditions 53.3% 15.0% 31.7%

3 conditions 34.5% 16.1% 49.4%

4 conditions 20.2% 13.8% 66.0%

5 conditions 10.8% 9.9% 79.3%

6 conditions 5.4% 6.0% 88.7%

7 conditions 0.0% 0.0% 100.0%

Spending for People with Chronic Illnesses and Activity Limitations

$2,890$3,830

$5,650

$7,800

$11,890

$13,420

$7,560

$5,650

$4,060

$2,550$1,500

$680

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

0 1 2 3 4 5+

Number of Chronic Conditions

Avg

. An

nu

al H

ealt

h C

are

Exp

ense

s P

er

Per

son

No Activity Limitation

With Activity Limitation

Sources: Partnership For Solutions, “Chronic Conditions: Making the Case for Ongoing Care,” December 2002; MEPS, 1998.

Service Organization Structure & Process Criteria

• Make the HOME the center of health care delivery and social supports

• Re-establish the Doctor-Patient relationship

• Continuity of care across all settings and over the natural history of illness

• Coordinate Medical, Social and Housing services

• Match patient goals and processes of care

Life Care Coordination Fees• Layered fee for non-covered services

– Comprehensive Geriatric Assessment– Team meetings– Care coordination– Enhanced urgent care services– On-call services– Gap-filling fund

• Renewable contingent on performance– Adherence to evidence-based guideline targets– Patient and caregiver satisfaction targets– Reduced costs

“Whose Ox Gets Gored?”

• Sponsoring Hospitals– Cover “margin” expectations– Rate incentives for supporting innovation

• SNF/ICF– Escalated payments for greater complexity– Decreased payments for custodial care– Incentives for community-based referrals

The “Ask”: How You Can Help

• Advocacy for a focused, population-based health care delivery system transformation

• Development of population target criteria

• Development of new financing mechanisms

• Special interdisciplinary training programs

• Development of a public-private partnership towards common goals and incentives

“You can judge a civilizationby the care it takes of its oldand sick people. I wantAmerica to pass this test well.”

Rep Claude D. Pepper