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Health Care Reform Memo: November 26, 2012

Deloitte Center for Health Solutions publication

The health care reform memos are issued on a weekly basis, highlighting news from the previous week's activities in the administration and implications for the C-suite and various stakeholder groups.

My take: branding: an essential aspect of the health care industry

From Paul Keckley, Executive Director, Deloitte Center for Health Solutions

I love college sports: men’s and women’s, any season, any sport, you name it and I love it. And right now, it’s a special time—my Buckeyes finished 12-0, my Commodores 8-4 and Bowl eligible, and hoops are around the corner.

But I am also a little confused these days: how can the “Southeastern Conference” include Texas A&M and Missouri—are they “southeastern”? How is the “Big Ten” actually 12 teams, or possibly 14 if Maryland and Rutgers join? And how can the Big East include USF and Notre Dame in basketball, but only USF in football—last I checked, Notre Dame was having a pretty good year on the gridiron too!

It probably boils down to two simple things: brands matter, and teams go where brands lead to more money. College sports, after all, is a business, and institutions like Ohio State, Vanderbilt, and Notre Dame guard jealously their brands. It’s understandable.

Health care is no different. It’s about patient care and complex science, but it’s also about dollars and cents. It’s a $2.8 trillion industry in the U.S. alone, and every sector in the industry needs revenue growth because demand for health goods and services is increasing exponentially and medical inflation and labor costs add 3 percent per year to costs of operation. And in health care, a strong brand can often lead to more revenue.

But branding in health care can be just as puzzling as college athletic conference affiliations. Our surveys indicate consumers, for the most part, are confused about the U.S. system’s performance and seemingly lost in our branding wars. Consider, there are 700 “Top 100 U.S. Hospitals,” Blue Cross plans that don’t have Blue Cross in their names, and “medical centers” that have fewer than 100 beds. We call lots of folks in health care “doctor” these days, including many without formal training, and the name game in prescription drugs requires a thesaurus embedded in a mobile app to stay abreast.

Seems to me everything about the future of health care points to the importance of branding, but with a substantially different twist. Historically, our brands were built on impressions by first-hand users (patients, members, clinical trial subjects, et al) or word of mouth. In some sectors, advertising helped bolster brands—hospitals, drug companies, and insurance plans invested strategically to win hearts and minds of their customers, and differentiate to the extent possible from competitors. But that’s changing.

Consumers have more skin in the game now than ever before. They’re able to compare prices and outcomes for simple medical treatments. And they can access their own medical records to compare their signs, symptoms, risk factors, and co-morbidities to clinical algorithms and better understand where to get the appropriate care, and how much that care will cost.

They’re able to log on to independent websites and compare insurance plans head-to-head, download applications that let them know about a generic substitute in lieu of the prescribed drug, and search for a clinician who uses diagnostic techniques they prefer.

And all this while the industry is consolidating and integrating: going big or getting out is table stakes in most sectors as consolidation takes on many shapes and sizes—plans and plans, hospitals and hospitals, hospitals and physicians, plans and physicians, pharma and biotech, bio-pharma and companion diagnostics, device and pharma, over-the-counter and prescription, and so on.

No industry is as pervasive in its impact financially and personally as health care, and none has been as insulated from consumerism as this one. Branding matters in most industries because a trusted brand conveys quality and value to its customers. Branding in health care has not kept pace. Little wonder most consumers are not convinced of our value. By two to one, most U.S. adults think the U.S. health care system is expensive, wasteful, and often ineffective. But it will change. The forces of the market lead to two simple facts: consumerism in health care is not a fad. Consumers’ increased role as the direct purchasers of goods and services is certain, and their appetite for demonstrated value from the health system just as real.

The value proposition for our industry must be re-thought: does Joe Six Pack associate what’s expected with what’s delivered, or what’s paid vs. what costs truly are? Do non-traditional competitors pose big threats to incumbents sometimes prone to focus on traditional competitors only? Is the issue for-profit or not-for-profit ownership status, or how profit is made and operating surpluses used? I don’t suspect retail pharmacy primary care clinics needed permission to enter markets. Dramatic adoption of distance medicine, alternative health, self-care diagnostics, online social networks, probiotics, substitutionary medicine, and many others validate that the pursuit for value is now impacting our industry.

Our customers are consumers, not just patients; employers, not just group accounts; government professionals, not just bureaucrats. In some ways, they see the future better than we do, they’re pursuing brands that bring value and they’ve long since slain our sacred cows…

  • All health care is local.
  • Everything that’s done is necessary.
  • Quality can’t be measured.
  • And costs don’t matter.

So I plan to watch the Big Ten even though it’s actually 12, and the Southeastern Conference even though it’s now also southwest. I am able to live with the branding of these conferences because their value propositions to their customers—advertisers, fans, players, and coaches—seems solid.

Branding in our industry is a whole new ball game.

Paul Keckely

Paul Keckley, Ph.D., Executive Director, Deloitte Center for Health Solutions

Implementation update

HHS provides guidance on EHB, premium pricing, and wellness programs

As anticipated, the U.S. Department of Health and Human Services (HHS) is providing a steady stream of guidance pursuant to the implementation of the Affordable Care Act (ACA). Tuesday, three proposed rules were issued for comment. Insurers, employers, consumer groups, and the public have 30 days to weigh in on the essential health benefits (EHBs) (119 pages) and premium pricing rules (131 pages), and until January 25 for the wellness rule (81 pages).

Essential health benefits

Insurance plans sold to individuals who buy their own coverage and to employers—except those that self-insure—must include a core package of services referred as EHBs covering ten categories including emergency services; hospitalization; pediatric services, including oral and vision care; mental health; and others. The proposed rule reaffirms earlier guidance that states can choose the exact package of benefits that insurers must provide, based largely on what is already offered in the most popular plans currently sold in their states. One notable change from earlier guidance issued last December: the original guidance about prescription drug coverage required one class of drugs be covered for each major diagnostic category (i.e., depression, heart disease, asthma, et al). The proposed rule says that the minimum standard should be the number of drugs per category in the state’s chosen benchmark plan or one drug, whichever is greater.

Premium pricing

Consistent with prior reports, the proposed rule allows insurers to vary their rates based on age, tobacco use, family size, and geography (where a person lives), but disallows higher premiums for sicker people and any differential based on sex (premiums for women were traditionally higher than for men since on average women have higher utilization). The proposed rule allows insurers to charge tobacco users 50 percent more than non-users, but offers an exemption to those who participate in smoking cessation programs.

The proposed rule also clarifies how insurers may increase premiums as a person ages: the ACA limits premiums for older people to no more than three times what younger people are charged, thus lowering rates for older adults, but increasing rates for younger enrollees. The rule prohibits premium rate variation for individuals under age 21, and as adults age, allows insurers to charge slightly more annually until a person reaches age 64. Above age 64, all enrollees in the plan would pay the same rate.

Note: the proposal differs from the standard business practices whereby many insurers now set “age bands,” generally in five- or ten-year increments. The proposal also gives more flexibility to states and insurers to vary annual deductibles, co-pays, and other elements of the policies—so long as the policies’ overall coverage meets a minimum actuarial value requirement, or the average percentage the plan pays toward a typical consumer’s estimated annual medical costs. Rates must be based on defined geographic areas within the state. A state can have up to seven zones, and may have one rating for the whole state, define zones by grouping counties, base its zones on areas that share the first three digits of a ZIP code, or group by metropolitan statistical areas (MSAs) and non-MSAs. Each state will be responsible for setting its premium oversight to the zoning method it chooses. Note: there are 3,068 counties, 455 three-digit ZIP codes, and 367 MSAs in the U.S.

Wellness programs

The ACA allows employers to provide discounts on health insurance to employees who achieve certain medical or fitness goals targeting areas such as weight loss, cholesterol level management, or blood pressure control. The proposed rule raises the maximum permissible reward, discount, or penalty from 20 percent to 30 percent of the cost of the health coverage, and increases the maximum reward to 50 percent for programs to reduce tobacco use. The proposed rule adds a provision wherein the wellness programs must offer alternatives for employees whose health conditions make it “unreasonably difficult” or for whom “it is medically inadvisable” to meet the specified health-related standard, and it requires that discounts or other rewards be available to workers annually.

My take: with last Friday’s deadline extension to December 14 for states to submit their health insurance exchange (HIX) blueprints, and these three proposed rules, the implementation of the ACA is in full swing. Additional guidance is expected soon—among the several anticipated: how the 2.3 percent tax on medical devices will work; how the medical loss ratio (MLR) will be calculated; how the federal government will operate HIXs in states that do not choose to operate their own; how states can opt out of the expanded Medicaid program created by the law given the Supreme Court’s ruling June 28; how the federal government will allocate reduced disproportionate care funds for hospitals treating uninsured individuals; and a final rule on how contraception coverage will be provided to employees of religious universities, hospitals, and religiously-affiliated businesses that object. Stay tuned. The Supreme Court’s ruling as well as the re-election of President Obama and party control in the U.S. House and Senate remaining the same affirmed that the implementation of ACA will continue. Its next chapter will be about implementation and industry response.

PCORI board adopts methodology strategy for CER

Last Monday, the Patient-Centered Outcomes Research Institute's (PCORI) Board of Governors approved a 30-page draft of the research methods it will use in the development of comparative effectiveness research (CER). Tuesday, it announced plans to award $12 million for up to 14 contracts for studies that will address knowledge gaps and advance the field of comparative clinical effectiveness research. Application materials can be downloaded from the “Funding Opportunities” section of PCORI’s website. The online application system is now open and letters of intent are due January 15, 2013. PCORI expects to announce research awards in the spring of 2013.

My take: PCORI might be the least understood and most fundamentally transformative element of the ACA. Its role is three-fold: filling gaps in evidence about treatments, developing appropriate methodologies to compare and contrast approaches based on objective criteria, and disseminating its comparative effectiveness studies to industry stakeholders and end-users—consumers.

Court challenge to contraception requirement denied

The U.S. District Court for the Western District of Oklahoma denied a request from the Christian owners of the Hobby Lobby Inc. stores that they be exempted because of their religious beliefs. Judge Joe L. Heaton, a President George W. Bush appointee, said Hobby Lobby, as a secular company, does not have rights to the free exercise of religion. The owners, the judge said, are “unlikely to prevail” because the administration's regulations “are neutral laws of general applicability which are rationally related to a legitimate governmental objective.” The Becket Fund for Religious Liberty, representing the owners, is appealing the decision to the 10th Circuit Court of Appeals and, in a statement, says it faces fines of up to $1.3 million per day if it fails to offer contraception coverage in its self-funded plan.

Note: this is the second time a judge has denied a preliminary injunction request on the issue; the first went to the Legatus business group. Three injunctions have been granted.

Legislative update

HHS priorities in 2013

Last week, the HHS Office of Inspector General (OIG) submitted its summary of the most significant management and performance challenges facing HHS, required under Public Law 106-531. The assessment details ten major issues:

  • Management Issue 1: implementing the ACA
  • Management Issue 2: identifying and reducing improper payments
  • Management Issue 3: preventing and detecting Medicare and Medicaid fraud
  • Management Issue 4: ensuring patient safety and quality of care
  • Management Issue 5: avoiding waste and promoting value in health care
  • Management Issue 6: ensuring efficiency and effectiveness of Medicare and Medicaid program integrity contractors
  • Management Issue 7: grants management and administration of contract funds
  • Management Issue 8: protecting consumers of food, drugs, and medical devices
  • Management Issue 9: integrity and security of health information systems and data
  • Management Issue 10: fostering an ethical and transparent environment

Senate committee requests information from state pharmacy boards

Senators Tom Harkin (D-IA) and Mike Enzi (R-WY), leaders of the Senate Committee on Health, Education, Labor, and Pensions (HELP) sent requests to each state’s board of pharmacy seeking information about any complaints filed against the New England Compounding Center (NECC)—the facility at the center of the fungal meningitis outbreak responsible for 33 deaths and 500 diagnosed cases.

HIV screening recommended for all Americans

Last Tuesday, the U.S. Preventive Services Task Force (USPSTF) recommended that all Americans 15-65 years of age be tested for the human immunodeficiency virus (HIV). Annually, 200,000 are infected with the virus that can cause acquired immune deficiency syndrome (AIDS) if not detected and treated. Currently, 1.1 million in the U.S. have AIDS with 50,000 new cases annually. Previously, only populations at higher risk of contracting AIDS had been screened for the test, costing $48-$64. The new recommendation, if finalized, would be subject to inclusion in the set of preventive health services that health plans are obligated to provide members at no out-of-pocket cost.

SGR temporary fix to cost $25.2 billion, $7 billion above prior estimate

Last Tuesday, the Congressional Budget Office (CBO) announced its updated calculation for overriding the Sustainable Growth Rate (SGR) formula for 2013, used to set physicians’ Medicare reimbursement. The cost, $25.2 billion for 2013, is $7 billion more than earlier predictions. If the SGR is overridden, as is widely anticipated as part of the fiscal cliff negotiation, the accumulated cost overrun will be added to the accrued liability for physician payments, estimated at $320 billion. If the SGR was permanently fixed, this would be added to the federal debt at a time when rating agencies and economists are concerned about the level of debt now carried by the U.S.

State update

Survey: state health departments modernizing IT systems

Per survey results from 67 state health agencies in 35 states released last week by the American Public Human Services Association (APHSA) and Microsoft:

  • 43 percent of agencies have implemented a new HHS information technology (IT) system within the past ten years
  • 57 percent have not modernized, although most of these agencies (55 percent) plan to do so over the next three to five years
  • 19 percent of respondents had no plans to modernize, mainly due to lack of funding
  • 22 percent are very likely to consider the cloud for future system deployment
  • 47 percent of agencies surveyed experienced an implementation timeframe of more than three years when implementing a new system; states with larger constituent populations also report longer implementation timeframes, but the programs themselves (e.g., Temporary Assistance for Needy Families, Child Welfare, etc.) did not have a direct correlation

(Source: APHSA and Microsoft, “A Promising Future for HHS Transformation–The Real Impact of IT System Modernization,” November 14, 2012)

Industry news

Hospital EHR deadline this Friday

Hospitals seeking a Medicare Electronic Health Record (EHR) Incentive Program payment for fiscal year (FY) 2012 have until this Friday to complete their online attestation. To receive an incentive payment, a hospital must register with the Centers for Medicare & Medicaid Services (CMS), use certified EHR technology, meet the meaningful use criteria, and attest—submit the required quality measurement data generated by certified EHR technology to CMS. If a hospital is attesting for the first time, it must have reported on a continuous 90-day reporting period that ended on or before September 30. If a hospital is attesting for the second time, the reporting period covers all of FY2012 (October 1, 2011 through September 30, 2012).

Meaningful use loans available

Last week, the American Health Information Management Association (AHIMA) announced its partnership with the Delta Regional Authority (DRA) to provide loans in increments of $5,000 and $7,500 to eligible health care providers as a down payment for the purchase of an EHR system, with AHIMA providing the education and provider recruitment support. The HHS’ Office of Minority Health and DRA will also assist in the recruitment of eligible health care professionals providing services to racial and ethnic minorities and underserved communities within the Delta Region.

Medicare claims data released

Wednesday, CMS announced the first three participants in the Medicare Data Sharing for Performance Measurement program that provides Medicare claims data to certified groups to report on provider performance: the Health Improvement Collaborative of Greater Cincinnati, the Kansas City Quality Improvement Consortium, and the Oregon Health Care Quality Corporation. In its statement, CMS noted that the groups are subject to privacy requirements and that the agency will enforce penalties for misuse of data.

Background: in a final rule issued December 5, 2011, CMS allowed access to Medicare claims data about providers for $40,000 for the first year to qualified organizations that use the data from Medicare Parts A, B, and D to measure performance of physicians, hospitals, and suppliers. Qualified entities may purchase data for one or more specific geographic areas and use it in combination with sources other than Medicare data when evaluating performance. The rule was opposed by the American Medical Association (AMA) fearing possible misuse of the data.

Study: use of allied health professionals in primary care increases efficiency, panel size

Primary care faces the dilemma of increasing patient panel sizes and fewer primary care physicians (PCPs). The researchers used a simulation to estimate an optimal primary care panel size under different models of task delegation to non-physician members of the primary care team based on estimates of the time required for a PCP to provide preventive, chronic, and acute care for a panel of 2,500 patients vs. the same services provided by non-physician team members. Using three assumptions about the degree of task delegation that could be achieved (77 percent, 60 percent, and 50 percent of preventive care, respectively, and 47 percent, 30 percent, and 25 percent of chronic care, respectively), the research team concluded that a primary care team could reasonably provide recommended care for a panel of 1,947, 1,523, or 1,387 patients (based on the three sets of assumptions) if services are delegated to non-physician team members.

(Source: Altschuler et al, Annals of Family Medicine, “Estimating a reasonable patient panel size for primary care physicians with team-based task delegation,” September-October 2012, 10(5):396-400)

Study: e-visits associated with fewer diagnostic tests, more prescriptions

A recent study examined the results of 8,100 patient visits to four primary care practices between January 1, 2010 and May 1, 2011. The study cohorts consisted of 5,165 visits for sinusitis, including 465 e-visits (9 percent) and 2,954 visits for urinary tract infections (UTI), including 99 e-visits (3 percent).

The research team concluded that physicians were less likely to order a UTI-relevant test for an e-visit than during an in-person encounter—8 percent for e-visits and 51 percent for in-office visits; and somewhat less likely to order tests, X-rays or CT scans for sinusitis with e-visits than in-person visits (0 percent vs. 1.2 percent).

Physicians were more likely to prescribe an antibiotic for an e-visit than for an in-office visit: oral antibiotics were prescribed 99 percent for e-visits for patients with sinusitis and UTIs, respectively, vs. 94 percent and 49 percent of the time during in-person encounters with patients.

(Source: Mehrotra et al, Archives of Internal Medicine, “A Comparison of Care at E-visits and Physician Office Visits for Sinusitis and Urinary Tract Infection,” November 19, 2012)

Study: portal use associated with higher utilization of services

A study of 89,000 patients enrolled for 24 months (between March 2005 and June 2010) at Kaiser Permanente in Colorado found that patient use of web-based EHR system portals was correlated to higher utilization of office visits and telephone calls to providers.

Two cohorts were compared: users of the Kaiser’s MyHealthManager (MHM) patient online access system and non-users. Among portal users, researchers found significant increases in the per-member rates of office visits (0.7 per member per year), telephone encounters (0.3 per member per year), per-1,000-member rates of after-hours clinic visits (18.7 per 1,000 members per year), emergency department encounters (11.2 per 1,000 members per year), and hospitalizations (19.9 per 1,000 members per year) for MHM users.

Note: the research team concluded they could not determine a causal relationship between portal use and increased utilization: were users more inclined to report a medical problem, or sicker, etc.? Additional study is necessary before it can be concluded that portal use is predictive of increased utilization.

(Source: Palen et al, Kaiser Institute for Health Research, Journal of the American Medical Association [JAMA], “Patients with Online Access to Clinicians, Medical Records Have Increased Use of Clinical Services,” November 21, 2012)

Quotable

“Doctors and hospitals focus on producing health care, what people really want is health. Health care is just a means to that end—and an increasingly expensive one.”

— Asch et al, New England Journal of Medicine (NEJM), “What Business Are We In? The Emergence of Health as the Business of Health Care,” 367:10, September 6, 2012

“The best leaders tend to be outsiders who don’t have a great deal of experience…It’s the unfiltered leaders, the outsiders without lots of experience, who perform the very best.”

— Mukunda, Harvard Business Press, “Indispensable: When Leaders Really Matter,” 2012

“As with any new initiative, the Department faces substantial challenges in ensuring efficient and effective implementation and administration of the ACA so that the programs achieve their objectives and operate free from fraud, waste, and abuse. Developing effective oversight strategies to prevent, detect, and correct any problems that occur is critical. The large number of new and complex program responsibilities under the ACA makes achieving these twin goals challenging…The Department and its partners should be vigilant in identifying and addressing existing and emerging fraud, waste, and abuse risk areas across all ACA-related programs. This will require a comprehensive approach to program integrity that integrates effective front-end program gatekeeping, sound payment design, the promotion of provider compliance, vigilant monitoring of program operations and outcomes, and rapid remediation of detected problems.”

— OIG, “Top Management & Performance Challenges in the U.S. Department of Health and Human Services,” required under Public Law 106-531

“At the end of the day, the debate is about moneycare—who bills for what and how the billing pattern influences utilization. Controversies surrounding physician self-referral and associated incentives wax and wane, and are seemingly repeated each decade. Moving forward in the current era of health reform, the focus should be less about eliminating incentives altogether, and more about getting the price right in the first place.”

Hollenbeck et al, JAMA, “Financial Incentives and the Art of Payment Reform,” November 9, 2012

“Within the subset of Medicare beneficiaries who are age 65 or older, those enrolled in the private Medicare Advantage program were less likely than those in traditional Medicare to have premiums and out-of-pocket costs exceed 10 percent of their income. But they were also more likely than those in traditional Medicare to rate their insurance poorly and to report cost-related access problems.”

— Davis et al, Health Affairs, “Medicare Beneficiaries Less Likely to Experience Cost- and Access-Related Problems than Adults with Private Coverage,” August 1, 2012

Fact file

  • FDA staffing: the number of U.S. Food and Drug Administration (FDA) employees increased 31.5 percent from 11,272 in 2007 to 14,824 in 2010; more than one-quarter were temporary hires. Key findings: the FDA is losing talent due to its elongated procedures for hiring, resulting in high turnover among temporary employees, and FDA employees are generally more satisfied than government workers overall. (Source: Pew Charitable Trusts, “The State of the FDA Workforce,” November 2012)
  • Global drug spending: 2006: $658 billion (41 percent U.S.), 2011: $956 billion (34 percent U.S.), 2016: $1.175 trillion (31 percent U.S.). (Source: IMS Institute for Healthcare Informatics, July 2012)
  • Expedited drug approvals: in FY2011, the FDA classified every new molecular entity as innovative and used expedited review for 16 of the 35 new drugs. (Source: FDA)
  • MA differentials: nationally, Medicare Advantage (MA) plans cost 103.4 percent of Medicare FFS costs in the same county—102.5 percent in urban counties, 105.9 percent in rural; in 2009, MA plans were paid 14.2 percent above Medicare FFS rates totaling $12.7 billion or $1,236/enrollee; in 2010, the differential was 8.9 percent totaling $8.9 billion or $814 per enrollee; changes in Medicare Part C payments in the ACA will likely reduce the net differential to $1.4 billion by adjusting payments downward in the 785 highest cost counties, reducing rebates across the board to Part C plan sponsors, and increasing incentives for highest performing plans—with 3.5 stars or higher; per the CMS Office of the Actuary, private MA plans have operating costs of 13 percent, including 3 percent for profit/retained earnings. (Source: Biles et al, The Commonwealth Fund, “The Impact of Health Reform on the Medicare Advantage Program: Realigning Payment with Performance,” October 2012)
  • Costs of chronic disease: cardiovascular disease, cancer, and diabetes now cause 70 percent of U.S. deaths and account for 75 percent of health expenditures. (Source: Kelly et al, The National Academies Press, “Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health,” 2010)
  • Supplemental coverage: without supplemental coverage, 14.5 percent of Medicare beneficiaries would have had out-of-pocket costs of more than $2,500 in 2009, and 15 percent would have had at least one year (2000-2009) with expenses in excess of $5,000. (Source: Kelley et al, Journal of General Internal Medicine, “Out-of-Pocket Spending in the Last Five Years of Life,” September 5, 2012)
  • Education spending vs. results: global spending on education is 5.6 percent of gross domestic product (GDP), or $3.9 trillion. The U.S. spends $1.3 trillion and ranks 24 of 35 countries in math, 17 in science, and 14 in reading. The U.S. is the only country with high proportions of both top and bottom performers: 20 percent of 15-year-olds do not have basic science skills, 23 percent math. (Source: President’s Council of Economic Advisors, Organisation for Economic Co-operation and Development [OECD], Program for International Student Assessment [PISA] 2009)
  • Medicare Part D Participation: 73 percent of all Medicare beneficiaries enrolled vs. CBO forecast of 87 percent. (Source: Kaiser Family Foundation)
  • Population ethnicity change: projected U.S. population change from 2005 to 2050: +48 percent: white +4 percent, black +56 percent, Asian +192 percent, Hispanic +205 percent. (Source: Pew Research Center)
  • Expectations about impact of ACA on quality of care: 42 percent believe no changes, 38 percent believe quality will decrease, and 20 percent increase; no major differences by age, income. (Source: Truven Health Analytics, Health Leaders, October 2012)
  • Income disparity: including capital gains, the share of U.S. GDP going to the top 1 percent of earners has doubled since 1980, from 10 percent to 20 percent; the share going to the top .01 percent (16,000 families with average income of $24 million) has quadrupled from 1 percent to 5 percent; similar to income trends in UK, Canada, China, India, Sweden. (Source: The Economist, “For Richer, For Poorer,” October 13, 2012)
  • Internet access: by 2015, 2.1 billion in the world will have online access—up from 746 million in 2010; in the G20 countries, Internet commerce will account for 5.3 percent of economic output in 2016, up from 4.1 percent today. (Source: BCG Analytics)
  • Physician self-referral: one in five physicians owns/leases in-office advanced imaging equipment; utilization increased 70 percent in last ten years, including 200 percent increase in payments to cardiologists for in-office imaging studies. (Source: Hollenbeck et al, JAMA, “Financial Incentives and the Art of Payment Reform,” November 9, 2012)
  • Observation units: more than one-third of emergency rooms operate observation units; the average stay in an observation unit is 28 hours per episode; the ratio of observation stays to inpatient admissions increased 34 percent between 2007 and 2009; chest pain, abdominal pain, and shortness of breath are the most frequent symptoms treated in observation units. (Source: Feng et al, Health Affairs, “Sharp Rise In Medicare Enrollees Being Held In Hospitals For Observation Raises Concerns About Causes And Consequences,” June 2012)
National health reform: What now?

National health reform: What now?

At Deloitte, we continue to explore and debate the key questions facing 
the industry, and we look forward to helping our clients find and implement 
the right answers for their organizations. To learn more, visit www.deloitte.com/us/healthreform/whatnow today.

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