CHALLENGES, OPPORTUNITIES, AND UNKNOWNS FOR THE 2020 … · 2019. 5. 3. · CHALLENGES, OPPORTUNITIES, AND UNKNOWNS FOR THE 2020 PHYSICIAN Joe Thompson, MD, MPH President and CEO,

CHALLENGES, OPPORTUNITIES, AND UNKNOWNS FOR THE 2020 PHYSICIANJoe Thompson, MD, MPHPresident and CEO, ACHIProfessor, UAMS Colleges of Medicine and Public Health

05.03.19

OUR MISSION, VISION & VALUES

ACHI’s values are trust, innovation, initiative, and commitment.VALUES

VISION

MISSIONACHI’s mission is to be a catalyst for improving the health of

Arkansans through evidence-based research, public issue advocacy,and collaborative program development.

ACHI’s vision is to be a trusted health policy leader committedto innovations that improve the health of Arkansans.

Cost of Diabetes, Obesity Care Requires Cutbacks in Other AreasMedical Grads Exceed Available Residency Slots, Flood PCP Market

Patient EMRs Hacked!Baptist, SVI, Mercy, UAMS Data BreachedCMS Changes Physician Fee Schedule;2 payment levels for two-thirds of visitsRoutine Primary Care Offered Online by Walmart, Amazon, CVSACA Amendment Leaves 300,000 Arkansans w/o Medicaid CoverageMeasles Epidemic Overwhelms Primary Care Clinics StatewideCongress Passes, President Signs Medicare for All BillYouth Vape Use Reaches 40%; Superintendents Blame FlavorsArkansas Suffers Third Rural Hospital Closure in Six Months

HEALTH CARE’S IRON TRIANGLE

AccessCost

Quality

HEALTHCARE SPENDING IN HIGH-INCOME COUNTRIES (1980-2016)

Source: OECD 2017 Online Health Database, http://www.oecd.org/els/health-systems/health-data.htm

Healthcare Spending as a Percentage of GDP

PROJECTED FEDERAL SPENDING, 2016–2027

Source: Congressional Budget Office

(Bill

ions

)

AVG. HEALTH INSURANCE PREMIUMS 1999–2018

ARKANSAS: PRE-ACA LANDSCAPE

oConsistently ranked low on national health indicatorsoInsurance premiums doubled in 10 years resulting in growing

numbers of uninsured o25% of working-age Arkansans uninsuredoMore than 50% of Arkansas’s adult population living with at

least one chronic diseaseoIncreasingly fragmented healthcare system hard for citizens to

navigate

U.S. Census Bureau. Published 2012.

Percent: 20.0 - 22.422.5 - 24.925.0 - 29.930.0 - 34.9 35.0+

ARKANSAS UNINSURED BY COUNTY IN 2010(19-64 YEARS OLD)

Source: New York Times, October 30, 2015

PERCENTAGE UNINSURED, BY COUNTY (2015)

OBAMACARE RATES RISING% change 2017

2017 premium increase for lowest-cost silver plan

Source: McKinsey Center for U.S. Health System Reform

COMPETITION HAS FALLEN IN THE U.S.Number of insurance carriers in Obamacare markets

Source: McKinsey Center for U.S. Health System Reform

STATE AVERAGE CHANGE IN PREMIUMS VS. CHANGE IN ENROLLMENT, 2016–2017

Source: Summary Report on Permanent Risk Adjustment Transfers for the 2017 Benefit Year, CMS, July 9, 2018

RURAL HOSPITAL CLOSURES SINCE 2010

39 rural hospital closures in surrounding states since Jan. 2010

Source: University of North Carolina, Rural Health Research Program. “Rural Hospital Closures Map.”

PRIMARY CARE APPOINTMENT AVAILABILITY FOR MEDICAID PATIENTS

Source: Basseyn, Simon; Saloner, Brendan; Kenney, Genevieve M.; Wissoker, Douglas; Polsky, Daniel; Rhodes, Karin V. Medical Care54(9):878-883, September 2016

Comparing Traditional and Premium Assistance Plans

Arkansas Iowa

ARKANSAS INDIVIDUAL MARKETPLACE HEALTH INSURANCE PREMIUMS

Source: Adapted from Kaiser Family Foundation analysis of Healthcare.gov data, Marketplace Average Benchmark Premiums, KFF, Accessed October 2018

FEDERAL ACTIONoChanges to individual mandate

oHardship exemptions extended (Apr. 2018)o Individual IRS penalty reduced to $0 (Jan. 2019)

oChanges to health plansoPurchase of insurance across state lines enabled (Oct. 2017)oFormation of association health plans eased (Jan. 2018)oDefinition of limited-duration plans eased (Feb. 2018)

oElimination of cost-sharing reduction payments (Oct. 2017)oReduced navigator funding (July 2018)oU.S. Justice Dept. signals intent to not defend ACA (March 2019)

FEDERAL STEPS ADVANCING WORK REQUIREMENToU.S. Supplemental Nutrition Assistance Program: Explicit option for

states to impose work requirements as condition of eligibilityoCBO estimated cuts to SNAP participation by 1 million over 10 years

oCMS Director Verma: “Use existing Section 1115 demonstration authority to review and approve meritorious innovations that build on the human dignity that comes with training, employment and independence.” (1/11/18)

oHUD Secretary Carson: “Our welfare system should be a pathway to self-sufficiency by focusing on work and stable families, giving hope to their dreams and a foundation for their success.” (4/25/18)

ARKANSAS WORK REQUIREMENT

WORK REQUIREMENT TIMELINE: KEY DATES

1

May 4, 2017Work and community engagement requirement for Arkansas Works enrollees passed by Arkansas General Assembly.

2

March 5, 2018Centers for Medicare &

Medicaid Services approves waiver amendments, including

work requirement.

3

June 1, 2018Work requirement reporting begins for new enrollees ages 30-49 (100% FPL and below).

4

September 1, 2018First terminations occur due to non-compliance with work

reporting requirements.

5

January 1, 2019Work requirement applies to all enrollees ages 19-49 (up to 138% FPL).

6

March 27, 2019D.C. district judge’s ruling halts Arkansas’s work and

community engagement requirement for Medicaid.

ENROLLEES NOT MEETING WORK REQUIREMENT IN 2018 (PER REPORTING PERIOD)

7,041 6,531 6,174 7,748 2,600 2,429 - - -- - - 5,426 5,076 4,841 6,002 1,936 - - -

4,353

4,109

3,815

4,655

1,232

DecemberNovemberOctoberSeptemberAugustJulyJune 2018

18,164 total

throughDec.

1-month non-compliance

2-months non-compliance

Closed: 3-months non-compliance

Compiled from ARWorks Reports, June–Dec. 2018, Ark Dept of Human Services. https://humanservices.arkansas.gov/newsroom/toolkits

ARKANSAS WORKS—DECEMBER 2018 ‘CHURN’

oTotal cases closed in December: 15,981

oOnly 1,232 of those closed due to not meeting work requirement

Source: Arkansas Works Program, December 2018 Report, Arkansas Department of Human Services.

ARKANSAS UNEMPLOYMENT BY COUNTY

Source: Labor force data by county, not seasonally adjusted, Feb. 2017–March 2018, Local Area Unemployment Statistics (LAUS) from Bureau of Labor Statistics (BLS). https://www.bls.gov/lau/

2.6 8.6

NATIONAL FRAMEWORK FOR ALTERNATIVE PAYMENT MODELS (APM) Population-Based Payment

Category 1 Category 2 Category 3 Category 4Fee for Service — No Link

to Quality and ValueFee for Service — Link to

Quality and ValueA

Foundational Payments for Infrastructure & Operations

BPay for Reporting

CRewards for Performance

DRewards and Penalties for

Performance

APMs Built on Fee-for-Service Architecture

AAPMs with Upside

Gain-sharingB

APMs with Upside Gain-sharing/

Downside Risk

Population-Based PaymentA

Condition-Specific Population-Based Payment

BComprehensive Population-

Based Payment

*Qualifying APM conversion factor**Non-qualifying APM conversion factor

MACRA AND QUALITY PAYMENT PROGRAM (QPP) TIMELINE

MEDICAL HOME: ROLLOUT TIMELINE

Wave 3178 PracticesWave 2

123 Practices

Wave 1

Comprehensive Primary Care Initiative (CPC)69 Practices

Start of wave:

October 2012

2014

135 Practices

2015 2016 2018

Wave 4

Wave 6

195 Practices with 182 in CPC+ Initiative

2017

Wave 5207 Practices

Multi-Payer PCMH Coverage Strategy

MEDICAID PCMH SHARED SAVINGS SUMMARYo2014 Performance

o$8.8M distributed to 30 eligible PCMHs

o2015 Performanceo$12.8M distributed to 53 eligible PCMHs

o2016 Performanceo$2.1M distributed to 14 eligible PCMHs

o2017 PerformanceoReport pending

CHOOSING WISELY BACKGROUND

oAn initiative of the American Board of Internal Medicine (ABIM) Foundation

oRecommendations developed by provider specialty societies

oBased on specialty societies’ recommendations for tests and treatments that may be unnecessary

oSince 2012, over 80 provider groups have published more than 550 recommendations

Source: Choosing Wisely Initiative Website, “About” Section.

FINDINGS WITHIN STATE/SCHOOL EMPLOYEES PLAN

oOf the 42 common low-value services assessed, 8 measures account for 69% of low-value services

oThe top 8 low-value services (based on cost) represent 85% ($13 million) of the total low-value dollars

oAmong EBD members enrolled in 2017, 91,051 had at least one of the 42 low-value services

TOP 8 LOW-VALUE SERVICES WITHIN EBD (2017)Low-Value Service

EBD Members with a Low-

Value Service

Number of Low-ValueServices

Low-Value Total Dollars

1. Baseline lab studies in patients without significant systemic disease undergoing low-risk surgery

9,118 13,060 $4,028,766

2. Annual electrocardiograms (EKGs) for low-risk patients without symptoms

9,643 10,274 $1,612,932

3. Routine imaging tests for patients without signs or symptoms of significant eye disease

8,187 12,875 $1,236,098

4. Unnecessary cervical cancer screenings for low-risk women 7,676 7,762 $740,322

5. Coronary angiography in patients without cardiac symptoms, unless high-risk markers present

202 205 $372,219

6. Imaging for uncomplicated headache 557 584 $258,925

7. Population-based screening for Vitamin D deficiency 2,925 3,050 $193,703

8. Oral antibiotics for patients with upper URI or ear infections 24,853 32,503 $186,219

ANNUAL EKGS AND OTHER CARDIAC SCREENINGS

Providers

- 135 providers

2017 provider variation of low-value services

ARKANSAS MEDICAL MARIJUANA: KEY DATES

1

November 2016Arkansas voters approve a medical marijuana initiative, Amendment 98.

2

January 2017Arkansas General Assembly

passes amendments related to the implementation of the Medical

Marijuana Amendment of 2016.

3

June 2017State of Arkansas begins accepting applications from individuals to register for medical marijuana use.

4

July 2018Arkansas Medical Marijuana

Commission awards licenses to 5 cannabis cultivation companies.

5

January 2019Arkansas Medical Marijuana Commission approves 32 dispensaries to be licensed to sell in the state.

6

May 2019Medical marijuana

availability anticipated to begin this month.

MEDICAL MARIJUANA: PATIENT QUALIFICATIONSoIn order to qualify for a registry card to legally purchase medical

marijuana, you must meet the following qualifications:oBe 18 years or older, or a minor patient with parental consent

oBe diagnosed with a qualifying medical condition

oHave an official written certification from a physician

oBe an Arkansas resident with proof of residency

oMembers of Arkansas National Guard and U.S. Military are prohibited from obtaining a registry ID card

Source: Arkansas Department of Health

MEDICAL MARIJUANA: PHYSICIAN CERTIFICATE

Source: Arkansas Department of Health

AR MEDICAL MARIJUANA DISPENSARY ZONES

oEight geographic zones throughout the state

oNo more than 4 dispensary locations per zone

oDispensary license valid only for the designated zone and cannot be used in another geographic zone

1 23

4

56

78

Source: Arkansas Medical Marijuana Commission

Total Number of Qualifying Patients Statewide:

541,673**As of March 2017. Does not include patients with certain conditions.

ARKANSAS MEDICAL MARIJUANA: POTENTIAL QUALIFYING PATIENTS

PERCENTAGE OF BENEFICIARIES WHO RECEIVE HIGH-DOSE OPIOIDS, ADULTS 19–64 (2016)

Adult Commercial Adult Medicaid

0 4.394

HEALTH CARE’S IRON TRIANGLE

AccessCost

Quality

OUR PRIORITIESHealthy Systems

Healthy Communities

Healthy Choices

SMOKING DISPARITY IN THE U.S.

Source: Tobacco Nation: The Deadly State of Smoking Disparity in the U.S., www.truthinitiative.org

SMOKING DISPARITY IN THE U.S.

Source: Tobacco Nation: The Deadly State of Smoking Disparity in the U.S., www.truthinitiative.org

TOBACCO USE BY YOUTH IS RISING

Source: Tobacco Product Use Among Middle and High School Students —United States, 2011-2018. Morbidity and Mortality Weekly Report (MMWR), February 2019.

HIGH SCHOOL E-CIGARETTE USERS ARE USING THEM MORE OFTEN

Source: Tobacco Product Use Among Middle and High School Students — United States, 2011-2018. Morbidity and Mortality Weekly Report (MMWR), February 2019.

CDC’s Division of Diabetes Translation. United States Diabetes Surveillance System available at http://www.cdc.gov/diabetes/data

Obesity (BMI≥30 kg/m2) Diabetes

<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%

Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults

1994



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


1995



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


1996



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


1997



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


1998



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


1999



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2000



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2001



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2002



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2003



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2004



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2005



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2006



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2007



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2008



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2009



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2010



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2011



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2012



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2013



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2014



<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

18.0%–21.9%<14.0%Missing Data

14.0%–17.9%22.0%–25.9% ≥26.0%


2015

Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults

Obesity (BMI ≥30 kg/m2)

Diabetes

1994

1994

2000

2000

No Data <14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9% > 26.0%

No Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% >9.0%

CDC’s Division of Diabetes Translation. United States Surveillance System available at http://www.cdc.gov/diabetes/data

2015

2015

ADULT OBESITY RATE BY STATE (2017)

Source: Trust for America’s Health: https://stateofobesity.org/adult-obesity/

OBESITY PREVALENCE IN OECD COUNTRIES;TOP & BOTTOM RANKING U.S. STATES

Source: America’s Health Rankings, United Health Foundation “A call to action for individuals and their communities—Annual Report 2017.”

Healthy Active Arkansas 10-Year Plan• Overarching goal: Increase the percentage of

adults, adolescents, and children at a healthy weight

• Reducing BMI of Arkansans by only 5% will:- Prevent thousands of cases of diabetes, stroke,

coronary heart disease, hypertension, and cancer

- Lead to savings of more than $2B in 10 years

OUR PRIORITIESHealthy Systems

Healthy Communities

Healthy Choices

ACHI.net@ACHI_net

@ARCenterForHealthImprovement

@ACHI_net @JoeThompsonMD

Documents

CHALLENGES, OPPORTUNITIES, AND UNKNOWNS FOR THE 2020 … · 2019. 5. 3. · CHALLENGES, OPPORTUNITIES, AND UNKNOWNS FOR THE 2020 PHYSICIAN Joe Thompson, MD, MPH President and CEO,