Health care shifts

Tuesday, July 01, 2014 12:38 PM

Kate Alfano, CMS contributing writer

Five trends affecting the work of physicians in Colorado

Health care has been rapidly evolving for the past decade; as such it’s often difficult to predict the next iteration. Michele Lueck, president and CEO of the Colorado Health Institute, (CHI), does this, though, using her organization’s extensive research to present five trends that will affect the work of Colorado physicians over the next two years.

These trends relate to affordability, physician workforce, the pressure to control costs, innovation and integration, and the rise of consumer-available health care data.

Affordability depends on where you live.

Health policy experts understand that the cost of health insurance varies widely based on a patient’s location but with the Affordable Care Act, (ACA), and the rise of its state health care exchanges, consumers can now easily compare their insurance costs to those of their peers in other cities and regions. It was revealed that the Colorado mountain resort region has the highest health costs in the country.

“Here’s the fundamental problem,” Lueck said, pointing to a matrix of costs. “If a single 38-year-old nonsmoker lived in Denver or Weld counties, he could buy a plan for around $227. In Pitkin County where Aspen is, it would cost somewhere between $471 and $650 for the exact same plan with the exact same benefits. We see this huge variation of health insurance premiums within the state. That’s a fundamental policy issue that the governor and his team are working hard to figure out.”

Additionally, CHI surveys Coloradans every other year on their perception of health care. The current average monthly price paid for single insurance premiums through Connect for Health Colorado is $376. In their most recent survey CHI asked Coloradans how much they were willing to pay for health insurance. Nearly 30 percent said “zero,” that they weren’t willing to pay anything; 8.5 percent said between $1 and $25, nearly 25 percent said between $26 and $75, and nearly 20 percent said $76 to $150. Only a fraction – a little less than 20 percent – said they would pay more than $150.

What this means for physicians, she said, is that patients who come into a physician’s office or clinic and who have paid for health insurance already think they’ve paid a lot to see you and they may be confused about additional copays and deductibles.

There are plenty of providers for the commercially insured. There are fewer for the most vulnerable.

The influx of nearly one million newly insured individuals through the ACA in addition to existing patient population raises questions about workforce adequacy. CHI conducted a study to project into which programs or markets the 900,000 who were uninsured before Jan. 1, 2014 would go. They projected that 130,000 would go into Medicaid or CHP+; 220,000 would purchase individual coverage; 160,000 would be picked up by employer-sponsored plans; and 360,000 would opt to remain uninsured.

A separate CHI study revealed that the state needs 120 more clinicians to take care of the newly insured – already a difficult task. But the bigger issue is in the distribution of physicians around the state. Lueck showed areas of low demand and high demand, as well as primary care “hot spots” where there aren’t enough physicians to take care of either the general or Medicaid population.

While ideas for optimizing workforce abound, she admitted that they don’t know exactly how they’re going to take care of all of the Coloradans who are newly insured and the current patient population. “I would suggest to you that we really need your leadership and insight about how we’re going to accommodate the new populations coming into the ACA.”

Cost control means you (and others).

Lueck was quick to point out that this statement is not a judgment; it’s an acknowledgment that physicians are seeing pressure on the systems to control costs that will carry down to the practice level. The most recent example is the establishment of the Colorado Commission on Affordable Health Care Costs, which will study the drivers of health care costs over the next few years and propose solutions to control them.

Physicians are familiar with the line graph depicting health care costs: Workers’ earnings and inflation are rising slightly at the bottom of the graph while health insurance premiums are increasing at a much more rapid rate. “When they talk about bending the cost curve, this is what they’re talking about,” she said.

The good news is the rate of increase in health insurance premiums has slowed slightly – only growing by 3.9 percent between 2009 and 2011 – but inflation grew at 2.9 percent over the same period, and Lueck suggested more needs to be done to address this.

Expect to be asked to innovate and integrate.

Practices are already seeing multiple initiatives coming down from the federal and state government around innovation and integration, for better or for worse. The state is currently pursuing federal funds to integrate behavioral health and primary care in recognition that half of behavioral health disorders are treated in primary care and that nearly half of appointments for psychotropics are with primary care providers.

Lueck recommended that CMS stay engaged in the State Innovation Model. “I encourage that for a few reasons. One of them is that when you start thinking about integration, it gets fuzzy about the outcomes you should measure and it would be important for you to weigh in on that in a meaningful way. It’s also important to think about how this model might be aligned for all payers. By definition this innovation grant has to be multi-payer but it’s important to think about how much administrative burden that’s going to put on your practice.” It’s also important to consider how to invest in practices so the effort isn’t pushed out as an unfunded mandate, she said.

“On a micro level, I would suggest to you that innovation and integration is expected or at least there are a lot of policy pressures being put on your practices in order to change and adapt to these new ideas and new situations. I also think that’s happening on a macro level if we go up to the hospital level. I wanted to suggest that that’s another facet of the work we’re thinking about at CHI that really impacts how you might think about your practices and how those practices are evolving.”

Your patients are becoming savvy shoppers.

Finally, Lueck shared the idea that patients are becoming more savvy shoppers as more are moving from receiving a defined benefit for health insurance – where an employer chooses a health insurance product for employees – to a defined contribution – where an employer gives an employee a stipend to buy a plan and the employee must cover any cost above that stipend. “When that happens, people become more invested, more aware of what they’re buying. That’s factor number one.”

The second factor is the rising number of patients with high-deductible health plans, which also require more patient buy-in. And the third factor is heightened transparency of information for consumers at both the federal and state levels. This includes the recent data release that revealed what Medicare paid individual physicians in 2012.

“I think all of this information is very dangerous to consumers,” Lueck said. “It doesn’t mean that they won’t use it; they’ll use it a lot.” But consumers won’t know how to process the data. “Right now there’s a whole host of information out there that’s just information and data and there’s going to be a lot of need and a lot of demand to help figure that out.”