Kenneth E. Thorpe, Ph.D. Emory University The Carter Center Health Care Reform: Challenges And Opportunities for Behavioral Health November 5,

Intertwined issues — Value for health spending — Cost containment — Health security Policy options — Care coordination inside and outside the traditional health system — Prevention — Payment reforms Evidence Reform prospects 2

 No care coordination in FFS Medicare  95% of spending in Medicare linked to chronically ill patients  Six chronic conditions (diabetes, others) account for 40% of rise in Medicare spending— mainly conditions requiring drug and ambulatory care  High rates of preventable hospital admissions and readmissions  A third of the rise in spending traced to the doubling of obesity 3

 Long-term savings  Lifetime health spending for obese seniors is 15%-40% than for normal-weight peers with no chronic disease  Near-term savings  RCTs show savings potential of >$10 billion/year in Medicare with existing care management protocols 4

 Siloed care that does not integrate mental health, acute care, and chronic disease prevention, treatment, and management  Fragmentation  40% primary care docs in groups <4  More than ½ of people with serious chronic conditions see >3 different physicians yearly  Separation of prevention and treatment  Outdated payment and delivery system designed largely for acutely ill not chronically ill patients. 5

 Prevention  Health risk appraisal and personalized care plan added to Medicare  No cost sharing for USPSTF “disease detection” screenings  Care management-system reform  ACOs – accountable care organizations  Medical home pilots  Payment reforms 6

 Prevention and care management  Identify key functions in successful models that improve quality and reduce costs, such as:  Coordinated care across providers and settings  Transitional care  Patient support, especially for medication adherence  Community-based care and support  Key: scaling and replication  Federal investment ($30B) 7

CHTs PCP 8 Physical Activity DPP Tobacco Cessation WHP Community Prevention Hospital HEALTH INFORMATION TECHNOLOGY Outcome Metrics, Evaluation Bundled Payments Specialists

 Targeting the right patients  Medication and testing adherence  Transitional care programs  Close integration with the coordinating provider practice  Ability to link with and refer to effective community- based interventions  Real-time evaluation and information on clinical markers with feedback 9

 Medicare demos  Integrated practices achieve better outcomes and savings  Savings up to 5% possible in current system  Penn transitional care RCTs  56% reduction in readmissions; 65% fewer hospital days  Average costs $4,845 lower  YMCA-DPP  11 lbs (~5%) weight loss; 58%  diabetes  Improved control of other CVD risk factors 10

 Trust for America’s Health community- based interventions  Short-term ROI 1:1  Longer-term ROI ~6:1  Value of HIT  Improved care coordination and administrative processes  Properly implemented and widely adopted, annual savings from efficiency alone could be $77 billion or more  Health and safety benefits could double savings 11

 Medication adherence  Adherence generally low: 50%-65% for common chronic conditions such as hypertension and diabetes  Nonadherence is costly: ~$100 billion/year for hospitalizations alone  Proven strategies: patient education; improved dosing schedules; additional open clinic hours; improved communication between providers and patients  Adherence ROI: 7:1 for diabetes, 5.1:1 for hyperlipidemia, 3.98:1 for hypertension; overall healthcare spending 15% lower for CHF 12

 Community-based prevention  $10/person/year could yield more than $16 billion in medical cost savings annually within 5 years  Coordinated care  Meta-analysis of chronic disease management studies showed 36%-45% drop in readmissions; 35%-45% drop in total hospital costs; ROIs from 1.4 to 32.7; Medicare savings from reduced CHF readmissions of $424 million per year 13

 Coordinated care  Interventions for diabetes resulted in $685- $950 drop in per patient per year costs; 9% drop in all-cause hospitalizations; 71% drop in ER/hospital utilization; 21% fewer total claims  Transitional care  $25 billion investment in CHTs over 10 years could produce savings of $100 billion over the same period 14

 Prevention is not a single intervention  Interventions must be evidence-based  Growing body of research shows what works  Integrated prevention is based in both the community and the health system  Primary, secondary, and tertiary prevention are all essential  Payment reform is critical  Incent prevention through payment revisions 15

 State-level efforts pave the way  Private sector is also innovating  Senate bill released October 26  House bill introduced October 29 16

 Expand the capacity of two independent, advisory task forces — the U.S. Preventive Services Task Force (USPSTF) and the Task Force on Community Preventive Services (TFCPS) — to undertake rigorous, systematic reviews of existing science  Invest in prevention research to expand the evidence base  Eliminate cost‐sharing on recommended preventive services delivered by Medicare, Medicaid, and public option insurance (or Health Insurance Exchange)  Deliver community preventive services  Invest in state, territorial, and local public health infrastructure  Provide grants to implement TFCPS‐recommended services 17

 Establish Prevention and Wellness Trust funded at $2.4 Billion in FY2010 and rising to $3.5 Billion in FY2014:  $30 million in each of FY to fund the activities of the Clinical and Community Preventive Services Task Force.  $100 million in FY 2010 for prevention and wellness research and rising to $300 million in FY2014.  $1.1 billion in FY 2010 for community-based prevention and wellness services and rising to $1.6 billion in FY2014.  $800 million in FY2010 for core public health infrastructure and activities for state and local health departments rising to $1.3 Billion in FY2014.  $350 million in each of FY for core public health infrastructure and activities for CDC. 18

 Mandates national public-private partnership for a prevention and health promotion outreach and education campaign  “Community Transformation” grants for implementation, evaluation, and dissemination of proven evidence-based community preventive health activities to reduce chronic disease rates, address health disparities, and develop a stronger evidence base of effective prevention  “Healthy Aging, Living Well” program to improve the health of the pre-Medicare-eligible population to help control chronic disease and reduce Medicare costs.  Pilot programs would evaluate chronic disease risk factors, conduct evidence-based public health interventions, and ensure that individuals identified with or at risk for chronic disease receive clinical treatment to reduce risk  Community Health Teams 19

 Medicare pilots to test bundled payments  Value-based purchasing in Medicare to pay hospitals based on performance – focus on preventable readmissions  Care coordination – especially for “duals” – patients eligible for both Medicare and Medicaid  Comparative effectiveness research: focus on clinical services 20

HouseSenate 1 Pass bills out of committee 2 Combine committee bills Introduce on floor 3 Pass a bill in each chamber 4 Combine House and Senate bills in Conference Committee 5 Floor vote on combined bill 6 President Obama signs into law 21