THE AMERICAN HEALTH CARE PARADOX Friday, October 24 th Blue Cross - PowerPoint PPT Presentation

THE AMERICAN HEALTH CARE PARADOX Friday, October 24 th Blue Cross Blue Shield Foundation of Massachusetts LAUREN A. TAYLOR, MPH Co-Author, The American Health Care Paradox Presidential Scholar, Harvard Divinity School 1

Outline for Today 1. Define the US health care paradox 2. Present some data on international health spending patterns 3. Present some new data on domestic health spending patterns 4. Discuss challenges in financing health 2

Then there’s the problem of rising cost. We spend one and a half times more per person on health care than any other country, but we aren’t any healthier for it. President Obama Joint Session of Congress 3 September 9, 2009

Health Expenditures as a % of GDP, 2009* 20 18 16 14 12 10 8 6 4 2 0 4 *Turkey is missing data for 2009

US HEALTH RANKINGS Maternal Life Low Birth Mortality Expectancy Weight Rank: 25 th among Rank: 26 th among Rank: 28th among OECD countries OECD countries OECD countries Guam Iran Finland #169 #136 #42 Turks and Croatia Hungary Caicos 5

Particularly perplexing when we imagine HEALTHCARE = HEALTH 6

What Determines Health? Healthcare Genetics Social, Environmental, Behavioral Factors 20% 60% 20% 7 McGinnis et al, 2002

High cost conditions Evidence suggests that social, behavioral and environmental factors are responsible for… 70% of colon cancer cases 70% of stroke cases 80% of heart disease cases 90% of adult-onset diabetes cases 8 TAHCP, 2013

Social Services employment supportive nutritional other social housing programs support & services that & rent subsidies family exclude assistance health benefits 9

Health Expenditures as a % of GDP, 2009* 20 18 16 14 12 Percent of GDP 10 8 6 4 2 0 10 *Turkey is missing data for 2009

Total Expenditures as a % GDP, 2009* 40.00 Social Service Expenditure, %GDP 35.00 Health Expenditure, %GDP 30.00 25.00 Percent of GDP 20.00 15.00 10.00 5.00 0.00 11 *Switzerland and Turkey are missing data for 2009

Ratio of Social to Health Expenditures, 2009* 2.50 Ratio of Social to Health Spending 2.00 1.50 1.00 0.50 0.00 12 *Switzerland and Turkey are missing data for 2009

DOES IT MATTER? METHOD: Multivariable regression using OECD pooled data from 1995-2007 on 29 countries and 5 health outcomes. FINDING: The ratio of social to health spending was significantly associated with better health outcomes: less infant mortality, premature death, fewer low birth weight infants, and longer life expectancy. NOTE: This remained true even when the US was excluded from the analysis. 13 Bradley et al, 2011

Inadequate attention to and investment in services that address the broader determinants of health is the unnamed culprit behind why the United States spends so much on health care but continues to lag behind in health outcomes. 14

Can the same be said within US? State spending Mean Range MA in 2009 %GSP Health service 18.2% 13.0% - 26.6% 19.25% spending Social service 11.0% 7.8% - 15.5% 12.86% spending 15

Ratio of social-to-health care spending* HIGHEST QUINTILE MEDIAN QUINTILE LOWEST QUIINTILE 16 *Medicare and Medicaid spending

Ratio social-to-health Percent of population that spending is obese HIGHEST QUINTILE LOWEST QUINTILE MEDIAN QUINTILE MEDIAN QUINTILE LOWEST QUIINTILE HIGHEST QUIINTILE 17

Ratio social-to-health Post neonatal mortality rate spending per 100,000 live births HIGHEST QUINTILE LOWEST QUINTILE MEDIAN QUINTILE MEDIAN QUINTILE LOWEST QUIINTILE HIGHEST QUIINTILE 18

Affordable Care Act (2010) 19

The Promise of Population Health Built Environment Nutrition Healthcare Population Individual Health Health Education Housing Patient

Getting Getting How Well How Well Patients Patients Access to Access to Timely Care, Timely Care, Your Doctors Your Doctors Rating of Rating of Specialists Specialists Appointment Communicate Doctor Appts and Communicate Doctor Information s and $ $ $ $ Information ACO Measures Health Health Shared Shared Risk Risk ASC ASC Promotion Promotion Decision Decision Standardized, Standardized, Admissions, Admissions, and and Making Making All Condition All Condition COPD or COPD or Education Education Readmissions Readmissions Asthma Asthma $ $ $ $ & Incentives ASC ASC Percent of Percent of Medication Medication Falls; Falls; Admissions, Admissions, PCPs who PCPs who Reconcilia- Reconciliatio Screening for Screening for Heart Failure Heart Failure Qualified for Qualified for n tion Fall Risk Fall Risk EHR Incentive EHR Incentive $ $ $ $ Depression Depression Colorectal Colorectal Mammog Mammograp Influenza Influenza Pneumon- Pneumonicoc Adult Weight Adult Weight Tobacco Use Tobacco Use Screening Screening Cancer Cancer Screening hy Screening Immunization Immunization al icocal Screening Screening Assessment Assessment Screening Screening Vaccination Vaccination and Follow- and Follow- and Cessation and Cessation up up $ $ $ $ $ $ $ Percent of Percent of Proportion of Proportion of Homoglobin Homoglobin Low Density Low Density Tobacco Non- Tobacco Non- Aspirin Use Aspirin Use Blood Blood Adults Who Adults Who Beneficiaries Beneficiaries A1c Control A1c Control Lipoprotein Lipoprotein Use Use Pressure Pressure with diabetes with diabetes Had Blood Had Blood whose HIbA1c whose HIbA1c Pressure Pressure $ $ $ $ $ $ $ in poor control in poor control Screened in Screened in Last 2 years Last 2 years Drug therapy Drug therapy Percent of Percent of Percent of Percent of Percent of Percent of ACE Inhibitor ACE Inhibitor Health Health Status Beta blocker Beta blocker beneficiaries with beneficiaries with beneficiaries beneficiaries for ARB for ARB for lowering for lowering beneficiaries beneficiaries Status/Functi + therapy for therapy for IVD with complete IVD with complete with IVD who with IVD who Therapy for Therapy for LOL LOL whose BP < whose BP < onal Status Functional lipid profile and lipid profile and LVSD LVSD use Aspirin or use Aspirin or Patients with Patients with Cholesterol Cholesterol 140/90 140/90 LDL control < LDL control < Status $ $ $ $ $ $ other other CAD and CAD and 100mg/dl 100mg/dl antithrombotic antithrombotic Diabetes Diabetes 21

What Happened to This Model? Genetics Social, Environmental, Behavioral Factors Healthcare 60% 20% 20% Initial Vision of What ACO Would Be Responsible For 22

What Happened to This Model? Genetics Social, Environmental, Behavioral Factors Healthcare 20% 60% 20% But Who Is Accountable for This? What We Paid ACOs to Be Responsible For 23

Looking Forward What do we mean by health? Who needs to be at the table, on the board, in the meeting? How are we going to systematically share resources to get the job done? 24

Thank you! 25