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State of Healthcare in
Kansas and MissouriJanuary 24, 2019
Thomas L. Bell
President
Kansas Hospital Association
Herb B. Kuhn
President and CEO
Missouri Hospital Association
The Value of Kansas and Missouri Hospitals
Agenda
Overall Trends in Health Care
Trends in Health Policy – Federal Level
Trends in Health Policy – Kansas and Missouri
Looking Around the Corner:
Emerging Issues in Health Care
2
The Value of Kansas and Missouri Hospitals
Source: CNBC, Dec. 4, 2017.
“It’s the perfect time to bring [CVS
and Aetna] together to create a new
healthcare platform that can be
easier to use, less expensive for
consumers, and create a new front
door to healthcare in our country.”
—LARRY MERLO, CEO, CVS
HEALTH
Traditionally, Health Care Change Has
Been Incremental.
But New Entrants Are Thinking Big.
9
The Value of Kansas and Missouri Hospitals
From CVS’s 2018 Q1 Earnings Report
Describing its Preliminary Strategy with Aetna
Transaction creates opportunity to rethink and reinvent U.S. health care
We have begun to identify populations and intervention tools for first programs
Primary patient populations:
– Those with one of five chronic diseases: diabetes, hypertension, hyperlipidemia, asthma, depression
– Patients undergoing transition in care
– Broader focus on managing high-risk patients
Initial tools in four major categories:
– Interventions in stores
– Activities in patients’ homes
– New digital tools and capabilities
– Data and advanced analytics
This combination will create an innovative, new health care platform that will be easier to use, less
expensive for consumers, and integrated broadly within the marketplace to deliver superior,
coordinated care
Source: CVS Health: First Quarter 2018 Earnings Conference Call. Presentation, May 2, 2018.
10
The Value of Kansas and Missouri Hospitals
The Competitive Landscape
Early entrant
Approved
In Conversation
Constant
Speculation
Action and Speculation
Powerful outpatient footprint
Aggressive strategic plan
Walmart: 5,000 stores, especially in rural America;
140 million in-store and online customers per week
Humana: 14 million members
Joint venture with Berkshire
Hathaway and JPMorgan Chase
Announced employee clinics;
CEO Tim Cook says health care is a
“big area for Apple’s future”
11
The Value of Kansas and Missouri Hospitals
• 115 announced hospital
transactions in 2017
(compared with 74 in
2010)
• 16 transactions involved
organizations with
revenues between
$500 million and
$1 billion (compared
with 2 in 2010)
Dec. 4, 2017
Dec. 7, 2017
• 10th largest U.S. health system
• 27 hospitals
• 3 million patients per year
• Largest U.S. hospital system
• 140 hospitals
• 700 care sites in 28 states
$200 Billion $240 Billion $540 Billion
Getting Bigger, but Relatively
Speaking, Not Big
12
The Value of Kansas and Missouri Hospitals
Vulnerability: Digital
Sources: Salesforce: 2016 State of the Connected Patient,; Rock Health: “50 Things We Now Know about Digital Health Consumers,” Jan. 9, 2017; Ripton, J.T.: “Five Ways Millennials Are Changing the Healthcare
Industry,” Becker’s Hospital Review, March 1, 2017; Koren, D.: “What Millennials Want When It Comes to Healthcare.” Media Post, Dec. 23, 2016; Kaufman Hall: 2017 State of Consumerism in Healthcare. August 2017.
However, hospitals are still largely analog
• Only 14% offer digital tools and
information to enable consumer
engagement
• Only 23% offer a range of
virtual/telehealth access points
• Only 20% have an online price
estimation tool
• Only 43% provide messaging between
patients and providers
Millennials especially are
demanding digital health care
• 71% want to book appointments
with mobile apps
• 74% would prefer to see a doctor
virtually
• 75% look at online reviews before
selecting a physician
• 42% have used synchronous video
telemedicine
13
The Value of Kansas and Missouri Hospitals
Vulnerability: Access
Contemporary access is still a work in progress for traditional health
systems
• 89% offer no access or limited access through retail clinics
• 77% offer no access or limited access through virtual visits
• 52% offer no access or limited access through urgent care centers
• A key value proposition for CVS, Optum, and others is conveniently
located and operated facilities and 24/7 access to virtual care — this is the
expectation of today’s health care consumer
Source: Kaufman Hall: 2017 State of Consumerism in Healthcare. August 2017.
14
The Value of Kansas and Missouri Hospitals
Vulnerability: Convenience
Health care consumer interactions are among the least convenient of any
industry
• Health care consumers face inconvenience in appointment scheduling,
communication with providers, wait times, wayfinding, repetitive
paperwork, confusing billing, and lack of digital options
• Companies like Amazon take experiences that consumers don’t even
perceive as problematic and transform them into something actionable,
appealing, and engaging
• These companies are never satisfied with the level of convenience and
engagement for consumers
Source: Kaufman Hall: 2017 State of Consumerism in Healthcare. August 2017.
15
The Value of Kansas and Missouri Hospitals
What These Observations Show About the
Business of Health Care
Far more resources are needed to be a leader in health care
A huge investment of financial and intellectual capital is needed to
transform health care
A new level of competition is entering health care
New entrants are large, highly capable, and highly competitive
companies
Becoming a commodity is a real—and a really bad—possibility
Any organization—provider, insurer, pharmacy—that focuses on a
single business line is in danger of being commoditized
16
The Value of Kansas and Missouri Hospitals
Current Kansas Hospital
Operating Margins
18
LOSS GAIN
Percent of hospitals operating at a loss/gain
Based on 2017 AHA Data
The Value of Kansas and Missouri Hospitals
Holy Grail of Health PolicymakingFind a model that aligns the interests of health care providers and patients.
Healthy Consumer
Continued Health Preventable Condition
No Hospitalization Acute Care Episode
High Cost and Successful Outcome
Efficient and Successful Outcome
Complications, Infections,
Readmissions
20
The Value of Kansas and Missouri Hospitals
A Strategic Journey
Integration
PopulationHealth
Fee-For-Service
Fragmentation
Current Model
Fee-for-ServiceIllness and cureVolume incentiveFragmentation
New Model
Population HealthIntegrationValue-base payments
Accountability
21
The Value of Kansas and Missouri Hospitals
The Challenge of Managing in Two Worlds
Pay for value
Accountable care
Coordinated care across
the continuum
Global payment
Right care, right setting,
right time
Triple Aim metrics
Fostering wellness
Payer partners
Fully wired systems
Pay for volume
Fragmented care
Fee-for-Service
Treating sickness
Adversarial payors
Little HIT
Lack of outcome
based metrics
Duplication and
waste
Source: Premier, Inc.22
The Value of Kansas and Missouri Hospitals
Third year of Trump Administration
Several cabinet positions changing
Health care positions stable, but changes at OMB
House
Democratic control
New leaders on key health committees
Senate
Slight improvement in GOP control
Some changes on key health committees
Supreme Court
More conservative
23
The Value of Kansas and Missouri Hospitals
Alex Azar – HHS Secretary
“One of my top 4 priorities … will be to use the
power of Medicare and Medicaid to drive
transformation of our healthcare system from a
procedure-based system that pays for sickness to
a value-based system that pays for quality and
outcomes.”
Four Priorities:
1. Private insurance market competition (Medicare Advantage, other plans)
2. Increase drug market competition
3. Move to value-based payment models
4. Increase price and quality transparency
24
The Value of Kansas and Missouri Hospitals
Cost AnalysisRecent study from George Mason University
$32.6 trillion over 10 years
Starts at 10.7 percent of GDP and moves to 12.7 percent of GDP
“Doubling all currently projected federal individual and corporate income tax
collections would be insufficient to finance the added federal costs of the plan.”
Health care providers asked to do the heavy lifting
Medicare hospital payment rates are 62 percent of private insurance
Medicare physician payment rates 75 percent of private insurance
MedPAC shares that hospital Medicare margins were -9.6 percent in 2016
Health care providers will be reimbursed at rates that are 40 percent lower than those
currently paid by private insurance
“Perhaps some facilities and physicians would be able to generate heretofore
unachieved cost savings that would enable their continued functioning without
significant disruption. However, at least some undoubtedly would not, hereby
reducing the supply of healthcare services at the same time Medicare for all
increases healthcare demand.”
27
The Value of Kansas and Missouri Hospitals
Estimated Ideology of House Democratic Candidates
28Source: Washington Post, May 16, 2018
The Value of Kansas and Missouri Hospitals
Baby Boomers’ Aging Contributes to Rapid
Population Aging
Source: U.S. Census Bureau, 2010 Census, 2012 National Population Projections and MedPAC.
31
The Value of Kansas and Missouri Hospitals
2.0
2.5
3.0
3.5
4.0
4.5
5.0
1970 1990 2010 2030 2050
Workers per HI beneficiary
Projected
0
20
40
60
80
100
1970 1990 2010 2030 2050
Medicare enrollment (in millions)
Projected
Historical
Historical
Note: HI (Hospital Insurance, otherwise known as Medicare Part A).Source: Boards of Trustees 2014 and MedPAC.
Medicare Enrollment Projected to Grow Rapidly
Workers per HI Beneficiary Projected to Decline
32
How Spending Growth is Impacted by the “Silver Tsunami”
21
23 3 3
9
6
6
1
43
0
2
4
6
8
10
12
1980s 1990s 2000s 2010-2014 Trustees CBO
Ave
rag
e a
nn
ua
l ch
an
ge
(in
pe
rce
nt)
Enrollment Spending per beneficiary
Historical Projections, 2015-2025
7
8
4
76
11
Note: CBO (Congressional Budget Office), Trustees (Boards of Trustees of the Medicare Trust Funds). Values are rounded to the nearest one.Source: 2015 annual report of the Boards of Trustees of the Medicare Trust Funds and CBO report Updated Budget Projections: 2015 to 2025, released March 2015.
Spending
33
The Value of Kansas and Missouri Hospitals
340B Drug Discount Program
The 340B Drug Pricing Program is a critical program to
Kansas and Missouri hospitals.
77 Kansas hospitals have signed up to participate
69 Missouri hospitals have signed up to participate
ACTIVITY ON MULTIPLE FRONTS
1) Addressing the Final OPPS Rule
– Reduced payments for 340B drugs from ASP+6% to
ASP-22.5%
– Exemptions for CAHs, rural Sole Community
Hospitals, Children’s Hospitals, and Cancer Hospitals
2) Lawsuit - Original lawsuit filed on Dec. 21stt
– Court ruled in favor of HHS
– Lost Appeal…Suit Refiled
3) Congressional Hearings and Bills
4) President’s Blueprint for Reducing Drug Pricing
– Feedback provided on 340B program
34
The Value of Kansas and Missouri Hospitals
Actions being take by Trump Administration and
Congress to Reduce or slow the increase in drug prices
Administration
Dept. of Justice expanding investigation of possible generic drug-price fixing
HHS releases series of memoranda, white papers, tweets and official
statements on topics related to containment of drug prices
New policy – use of step therapy for Medicare Advantage plans ad
prohibition of pharmacy gag clauses
Proposed policy – change Medicare Part B prices, pegging them to an
“international price index” as a means to align the U.S. with other countries
Congress
Senator Sanders/Representative Cummings – legislate international price
index for Medicare Part B drugs; permit Medicare to negotiate Medicare Part
D prices; permit U.S. residents to purchase medicines directly from Canada
and other countries
38
“For decades, other countries have rigged the system so that American patients are charge much more – and in some cases, much, much more – for the exact same drug. In other words, Americans pay more, so that other countries can pay less.” President Donald Trump
The Value of Kansas and Missouri Hospitals
Unique Alignment among Democrats,
Republicans and Stakeholders
The beginning of 2019 ushered in new price increases for nearly 300
medications. Pharmaceutical companies are boosting their prices just as the
new Congress is setting its agenda. These 2019 changes have once again raised
the ire of Democrats and Republicans.
Republicans and Democrats committed to hold hearings on the issue – drug
company CEOs to be hauled before Congress
Same goals, different ideas? Sec. Azar meets with Republicans and
Democrats. After meeting with House Oversight Chairman Elijah
Cummings, there were hopeful feelings of common ground. “We are
headed for the same goals, but not necessarily the exact same legislation,”
Cummings said.
A new survey from the American Hospital Association says that price hikes
and continuous shortages of basic medicines continue to add pressure,
leading to staff reductions and delay in investments.
The Value of Kansas and Missouri Hospitals
Current Status of State Medicaid
Expansion Decisions
Source: Status of State Medicaid Expansion Decisions. KFF State Health Facts
The Value of Kansas and Missouri Hospitals
Medicaid Expansion Ballot Initiatives
Result % “Yes” % “No”
Idaho Approved 61 39
Montana Defeated 45 55
Nebraska Approved 53 47
Utah Approved 53 47
42
The Value of Kansas and Missouri Hospitals
Medicaid: Culprit for Budget Woes
“It's one of the largest budget items in the
state of Missouri. And when you start
talking $300 or 400 million every year, you
can't sustain that.” -Governor Mike Parson
“If we do nothing to shore up and to
improve the sustainability of our Medicaid
program, it will continue to strain nearly
every other area of the state budget.”
-Medicaid Director Todd Richardson
43
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2003
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016.46
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2004
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016.47
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2005
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016.48
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2006
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016.49
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2007
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016. 50
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2008
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016. 51
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2009
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016. 52
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2010
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016.53
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2011
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016.54
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2012
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016. 55
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2013
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016. 56
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2014
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016. 57
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2015
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016. 58
The Value of Kansas and Missouri Hospitals
States with More DRUG-INDUCED Than
Motor Vehicle-Related Deaths
2016
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Washington DC
Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC
WONDER Online Database, released December, 2017. Data are from the Multiple Cause of Death Files, 1999-2016. 59
The Value of Kansas and Missouri Hospitals
Opioids and Substance Use Disorders
KHA/KMS Committee on Opioid Use
Focused on provider led initiatives to address opioid and substance use disorders
Committee comprised of representatives from KHA and KMS
Governor’s Task Force on Substance Use Disorders
Focused on developing policy recommendations for the Governor and the 2019 Legislature
Committee comprised of a variety of stakeholder groups
K-TRACS
Kansas Perinatal Quality Collaborative
Kansas Partnership for Pain Management
Project ECHO
KHA/KMS Joint Committee on Opioid Use
BlueCross BlueShield of Kansas
Governor's Substance Use Disorder Task Force
61
The Value of Kansas and Missouri Hospitals
Missouri Government Action
Senate Bill 501, signed into law
Grants immunity from arrest, prosecution or other penalties for certain drug-related
crimes if seeking medical assistance for a drug or alcohol overdose
Permits the director of the Missouri Department of Health and Senior Services or
physician designee to issue a statewide standing order for Naloxone
Revises standards for medication-assisted treatment of substance abuse
Allows the Board of Pharmacy to allocate funds for drug “take-back” programs
Executive Order 17-18: “Multi-phase PDMP”
Retrospective data mining for prescribing variance from pharmacy benefit manager
organizations and dispensers and through use of technology and software
2018 Legislation
Prescription drug monitoring program – no bill proposed
Needle exchange programs
Expanded take-back programs
Governor’s Budget
Fund Executive Order 17-18
Expand community treatment services to support medication-assisted treatment
Multi-agency prescriber letter initiative
Targets Medicaid prescribers
62
The Value of Kansas and Missouri Hospitals
Rural Emergency Medical Center LegislationH.R. 5678
HIGHLIGHTS OF THE LEGISLATION
• Establishes a new rural facility designation under the
Medicare program: Rural Emergency Medical Center
(REMC)
• Allows CAHs and prospective payment system hospitals
with 50 or fewer beds to convert to a 24/7 emergency
department.
• REMCs would provide 24/7 emergency care and other
outpatient services (e.g., observation, diagnostic and
telehealth).
• Post-acute care could be provided in a separately licensed
SNF unit
• REMC reimbursement would be the combination of the
Medicare OPPS rate for services and a fixed facility fee
payment.
• REMCs would be required to provide transportation to an
inpatient hospital, when needed.66
The Value of Kansas and Missouri Hospitals
Why An Alternative Model for Kansas?
Kansas 2013 Acute Patient Data
18 hospitals </= 1
15 more </= 2
19 more </= 3
13 more </= 5
Others 5+
Kansas 2013 Swing Bed Patient Data
All hospitals: Highest ADC = 10
Hospitals <5 acute ADC: Highest SB ADC = 5
</= 1
</= 2
</= 3
</= 5
5+
67
The Value of Kansas and Missouri Hospitals
Principles for a Sustainable
Rural Health System
Improve Health
Provide Access
Encourage Collaboration
High Quality
Promote Efficiency and Value
Embrace Technology
Financed Fairly to Address Population Health
68
The Value of Kansas and Missouri Hospitals
Governor’s Rural Health Summit
Presentations addressed a variety of rural health topics.
Don Babb was the keynote speaker, describing the evolution of Citizens Memorial Hospital.
Governor Parson hosted a Rural Health Summit in Bolivar on December 3.
69
The Value of Kansas and Missouri Hospitals
MHA Rural Health Initiative
MHA Rural Health initiative focuses on 10 policy issues taken from the Governor’s Rural Health Summit.
The 10 issues and related policy proposals are posted on MHA’s website.
Weekly promotions highlight an issue and its policy proposals, targeting a broad coalition and social media.
70
The Value of Kansas and Missouri Hospitals
MHA Rural Health Initiative
Extensive outreach with Reimagine Rural Health
Initiative
Distributed to more than 800 lawmakers and
opinion leaders across Missouri ― many from
nonhealth care groups (agriculture, banking, etc.)
Extensive use of social media
Op-eds and letters to the editor
Meetings with state legislators
71