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Health Care Reform Memo: January 22, 2013

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: Medicare problems and solutions: fixing delivery and financing while protecting what works

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

My mom taught history for 40 years in a public school in Chattanooga. She spent her free time studying our past—traveling to historic sites and reading biographies of notables and some not so well known biographies. And she relished in sharing stories in her classroom and at our dinner table about what happened in the past that helps inform our future.

As we discussed health reform, she’d often harken back to Lyndon Johnson’s Great Society program in 1965 that brought Medicare and Medicaid to life. She’d remind me that Franklin D. Roosevelt had considered both in his New Deal, but settled for Social Security as his signature legislative achievement believing Medicare and Medicaid would follow.

In 1965, Medicare was non-existent. In 2011, it was a $554 billion dollar federal program―3.68 percent of gross domestic product (GDP) – with 48 million enrollees, and 1 million joined its ranks as beneficiaries.1

The average beneficiary in 2011 paid $119,000 in premiums via payroll taxes and will receive $367,000 in health services—27 percent in the last year of their life. And by 2020, the average beneficiary will spend $6,125 out of pocket for his/her health care annually—much not covered through the Medicare program.2

It’s a popular program: compared to those covered by employer-based insurance, Medicaid, and individual policy-holders, Medicare enrollees are more satisfied with the U.S. health care system and least inclined to support major changes.3

Medicare beneficiaries give a higher grade to the U.S. health care system than do those with other types of health care insurance

Medicare beneficiaries give a higher grade to the U.S. health care system than do those with other types of health care insurance

Source: Deloitte Center for Health Solutions, “Survey of U.S. Health Care Consumers,” 2012

The issue, however, is not with Medicare’s popularity: the issue is in the math. Per the Centers for Medicare & Medicaid Services (CMS), in fiscal year (FY) 2012, Medicare spending per beneficiary increased 0.4 percent and the total program costs increased 6.2 percent compared to 3.9 percent overall increase in health care costs in calendar year 2011. According to the CMS Office of the Actuary, between 2013 and 2022, Medicare spending per capita is projected to grow at the rate of growth of per capita GDP.4 But that’s not the full story.

Medicare pays providers less than what their services cost. As a result, they mark up what they charge those with private health insurance coverage to make up for the shortfall. But that’s the problem and it could get worse. Two facts:

  • The numbers of workers who pay into the Medicare fund through payroll taxes is shrinking: 3.3 workers per Medicare beneficiary; by 2030 there will be 2.3 workers, and 2.1 by 2086.5
  • And the numbers who have private health insurance coverage or who are susceptible to cost shifting might decrease: up to 4.8 million may lose employer-sponsored coverage in the next decade due to cost, thus cutting into the Medicare fund’s income long-term.6

So here’s my take: Medicare is a popular program but its cost is not sustainable. Cost shifting by providers borne by the privately insured is not a long-term solution to the $105 trillion obligation owed current and future beneficiaries. And solutions that incrementally modify the program’s funding—higher premiums, delayed eligibility, required co-payments in MediGap coverage, changes to its annual cost formula using the Chain Consumer Price Index (CPI), a voucher-type alternative and others—without fundamentally restructuring the delivery of services will fall short. While possibly effective in changing what the Medicare program spends, these might not solve the larger issues of costs and cost shifting, or the fundamental challenge of overtreatment and unnecessary care. So the issue is not just what to do with Medicare costs; it’s what to do with health costs! For seniors today, cost is the problem. Tragically, 46 percent die with virtually no financial assets, largely because their out-of-pocket health costs exceeded their savings.7

So my solution is this: protect what works but fix delivery along with its financing. Seniors like the Medicare program, but their trust is rooted mostly in access to services from their doctors and nurses. Eliminating the fear that seniors will not be able to access services is a start. But that probably requires a permanent fix to the sustainable growth rate (SGR) formula used by Medicare to pay physicians, a solution to medical malpractice that voids frivolous lawsuits while protecting those harmed, coverage limitations based on evidence where it’s strong, and expansion of team-based primary care services (i.e. nurses, psychologists, nutritionists, advanced practice nurses, dentists, heath coaches and physicians) that are technologically equipped and properly compensated to manage seniors’ health to the end of their lives.

Mom said she enjoyed history because it informed her future. Our history in the pursuit of a suitable pact with seniors today and tomorrow is rich in lessons we can learn from. It seems to me that a fix to Medicare costs lacking a fix across the system is simply doomed to result in fewer and fewer privately insured who pay more and more.

Paul Keckely

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

PS – On August 28, 2011, the Martin Luther King Jr. Memorial was dedicated on the National Mall. Yesterday in Washington in addition to the inauguration of our 44th President, we celebrated his historic life. I jogged through the Memorial this weekend observing everyone pausing at the simple granite monument. Inscribed nearby is this quote: “The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where stands in moments of challenge and controversy.” The quote seems a timeless challenge, applicable perhaps to a country grappling with our fiscal future, and an industry struggling to build a new normal.

1http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/tables.pdf

2Urban Institute, “Social Security and Medicare Taxes and Benefits Over a Lifetime,” June 2011

3Deloitte Center for Health Solutions, “Survey of U.S. Health Care Consumers,” 2012

4National Health Spending in 2011: Overall Growth Remains Low, But Some Payers And Services Show Signs of Acceleration,” January 2013

5http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2012.pdf

62012 Deloitte Survey of U.S. Employers; Health care reform memo: July 30, 2012

7http://www.aarp.org/research/ppi/security/building-lifetime-middle-class-security-AARP-ppi-sec/; http://www.aarp.org/content/dam/aarp/research/public_policy_institute/security/2013/building-lifetime-middle-class-security-AARP-ppi-sec.pdf 

Implementation update

Medicaid, HIX, and essential benefits coordination: HHS seeks to streamline and simplify

Monday, the U.S. Department of Health and Human Services (HHS) released a 474-page proposed rule for states providing guidance on how to streamline their state Medicaid programs and health insurance exchanges (HIXs) starting in January, 2014 (Section 2201 of the Affordable Care Act [ACA]). Specifically, the guidance covers essential health benefits (EHBs), notices of enrollment, processes related to appeals of coverage decisions, and cost-sharing.

Key takeaway: CMS proposed that states will be able to increase cost-sharing for non-preferred drugs and non-emergent visits to the emergency room for certain populations based on federal poverty level—both benefits are among the ten EHBs. Comments are accepted until February 13, 2013.

CMS: quality measures for Medicaid medical homes announced

Last week, the CMS released guidance about the eight quality measures it proposes to use in assessing the effectiveness of Medicaid health homes:

  • Adult body mass index (BMI) assessment
  • Ambulatory care: sensitive condition admission
  • Care transition: transition record transmitted to health care professional
  • Follow-up after hospitalization for mental illness
  • Plan all-cause readmission
  • Screening for clinical depression and follow-up plan
  • Initiation and engagement of alcohol and other drug dependence treatment
  • Controlling high blood pressure

Note: CMS issued this guidance at the request of states wishing to implement a Medicaid health home program; however, the adoption of these measures is not required until CMS issues a final rule.

Background: Section 2703 of the ACA incentivizes state Medicaid programs to encourage providers to implement health homes (i.e. a team of health providers that coordinate care for an eligible population of Medicaid enrollees—those with two or more chronic conditions, one chronic condition and at risk of a second, and/or serious and persistent mental health conditions). States participating in the health home program will receive 90 percent federal matching rate for the first eight quarters of the program.

MACPAC likely to propose 12-month continuous eligibility for CHIP and Medicaid beneficiaries to reduce churning

The Medicaid and Children’s Health Insurance Program (CHIP) Payment Advisory Commission (MACPAC) met last week to come up with a solution for “churning,” which may lead to inconsistent, fragmented care. In its recommendation to Congress, the commission will likely propose allowing states the option of 12 month continuous eligibility for individuals enrolled in CHIP and Medicaid.

Background: due to changes in a person’s income or other eligibility criteria, an individual might qualify for Medicaid coverage at one point in the year or for subsidized coverage through the HIX in another part of the same year. This “churning” effect is costly to administer and potentially harmful to a person’s health if they fall in the cracks as a result of the churn.

CO-OPs ask for funds to be restored

Friday, the National Alliance of State Health Cooperatives asked HHS Secretary Kathleen Sebelius to work to restore funding for pending Consumer Operated and Oriented Plans (CO-OPs) cut in the fiscal cliff deal (H.R. 8, “American Taxpayer Relief Act of 2012”). At year end, 24 had been approved and 40 additional applications had been filed by the end of last year.

Background: CO-OPs were originally proposed as an alternative to a public option or single payer system as part of the health reform debate in 2009. In the ACA, $6 billion was set aside as a loan program to assist states in setting up and operating a not-for- profit, community-governed exchange in each state—later reduced to $3.4 billion and then H.R. 8 (the fiscal cliff deal two weeks ago) cut $2.3 billion from the program.

Legislative update

Security and privacy rule increases penalties, risk for providers and their business associates; new rule take effect September 21, 2013

Under the new 563-page update to the Health Insurance Portability and Accountability Act's (HIPAA) privacy and security final rule released Thursday, the risk of penalties is higher―up to $1.5 million per year—for security breaches involving personal health information (PHI). And perhaps more problematic, the more stringent standard is applicable to the all parties involved in the information exchanges (i.e. “covered entities must ensure that they obtain satisfactory assurances required by the rules from their business associates, and business associates must do the same with regard to subcontractors, and so on, no matter how far 'down the chain' the information flows”). In essence, the final rule increases the exposure of “business associates” that support hospitals and medical practitioners.

The new rule:

  • Tightens limitations on the use of patient records for marketing.
  • Prohibits the sale of patient information without a patient's consent.
  • Provides patients with a right to insist that a provider not share their patient care records with their insurance company if that care is paid for by the patient out-of-pocket in full.
  • Requires entities with patient record breaches to assess the likelihood that the information could be accessed in determining whether they must notify individuals of the breach.
  • Specifies that business associate designations include patient-safety organizations, health information exchange organizations, e-prescribing gateways, and certain vendors of personal records (excluding public health records owned by individual consumers).
  • Expanded the breach notification rule: under the 2009 interim rule, breaches were defined as incidents that posed a significant risk of financial or reputational or other harm. Covered entities had to perform an assessment to determine whether harm might have occurred, and if it did, then breach notices to patients and the HHS Office for Civil Rights were required. Per Thursday’s rule, an unauthorized use or disclosure of protected health information is presumed to be a reportable breach unless a covered entity can, through a documented assessment, conclude that there is a “low probability” the information has been compromised.

Note: the rule specifies four factors that covered entities must consider in assessing a possible breach: 1) the nature and extent of the protected information involved, including whether it was particularly sensitive, (i.e. mental health treatment records); 2) to whom the breach was made (i.e. a wrong fax to another covered entity, where the risk of misuse was low; 3) was the PHI actually viewed or acquired; and 4) whether the risk has been mitigated.

HHS estimates industry wide compliance costs at $114 million to $225.4 million the first year. The new rule will be published in the Federal Register January 25, 2013 with compliance to start September 21, 2013.

Related: in Friday’s New York Times, Gina Koyata’s article “Web Hunt for DNA Sequences” leaves privacy compromised adds an emerging wrinkle to the trade-off of digital health and personalized medicine and data access. Her article focuses on the increasingly complicated trade-off between gene sequencing involving powerful data mining tools used with large databases, and the potential breaches of privacy and security wherein a researcher uses characteristics and predictive models to identify a small number of individuals who are likely to be candidates for a new therapy.

My take: violation of privacy and security in provider organizations’ complex network of practices, allied health professionals, and third parties including clinical researchers who contract to mine their data is as sensitive and potentially risky as fraud and abuse issues with coding. The new rule—long anticipated—intensifies the focus on processes of capturing and sharing PHI, and exposes all parties involved to increased risk of financial penalties. It’s a big deal! (For more information, contact Mark Ford, Principal, Deloitte & Touche LLP at mford@deloitte.com)

Sequester means 6.4 percent cut to NIH funding

According to the National Institutes of Health (NIH) director Fran Collins, the NIH will lose 6.4 percent of its budget if the sequester cuts are implemented per the Budget Control Act of 2011. Sequestration would force cutbacks at the agency’s 27 centers, reduce grants available to researchers and slow progress in tackling treatments for cancers and other diseases. The NIH budget was cut at 1.5 percent in 2011, and has seen small increases annually in recent years after substantial funding increases from 1998-2003.

Background: NIH is the agency of government tasked with basic research—research that is early stage discovery focused. Its work goes into the public domain for widespread use by companies, academics, and individuals seeking breakthroughs in the diagnosis and treatment of disease.

Gun control executive orders issued by the White House

Last Wednesday, the White House released its plans for 23 executive orders intended to combat gun violence based on recommendations from Vice President Joe Biden’s task force of educators, public health officials, and gun manufacturers. The orders include:

  • Closing background check loopholes to keep guns out of dangerous hands
  • Banning military-style assault weapons and high-capacity magazines, and taking other common-sense steps to reduce gun violence
  • Making schools safer
  • Increasing access to mental health services.

My take: the ACA includes access to mental health coverage as one of ten categories in the EHBs that health plans must cover at parity with physical health benefits. Elsewhere, the ACA beefs up payments to primary care practitioners to improve access especially in under-served communities. The role of primary care in expanding access to mental health diagnosis and screening may be part of the legislative discussion around gun control.

FDA: bare metal hip implants devices face increased regulatory scrutiny

Thursday, the U.S. Food and Drug Administration (FDA) issued an order proposing that manufacturers of metal on metal hip implant devices (class III) be required to file a premarket approval application or a notice of completion of a product development protocol. The proposed order comes from the FDA’s initiative to evaluate medical devices on the market prior to 1976— before the new regulatory system for medical devices was in place.

Background: in recent months, the FDA has stepped up its oversight of 26 categories of medical devices on the market since 1976 including implants, defibrillators, and others. Most in these categories were cleared by the FDA’s 510K “substantially equivalent” fast track approval process. Recently, the FDA has revisited its 510K process, satisfying its concerns in 18 of the 26 categories. Hip implants are one of the eight outstanding. Recent studies about metal on metal hip implant failures published in Lancet (2012) suggested that bare metal implants might be inferior to implants that made of polyethylene or similar ceramic materials. The central focus seems to be the metal ions interaction in the bloodstream suspected of causing skin rashes, vision/hearing impairment and depression.

House Dems propose public option through HIXs

Last week, House Democrats introduced the “Public Option Deficit Reduction Act” that would amend the ACA to establish a public health insurance option exclusive to HIXs.

Background: the public option gained notoriety in 2009 as part of the House’ version of health reform legislation. It was dropped in the final version passed March 23, 2010.

Meaningful use for critical access hospitals and physicians

In an announcement last week, CMS said physicians and other professionals working with critical-access hospitals (CAHs) will be able to participate in the federal electronic health record (EHR) incentive payment program (meaningful use) accepting attestations starting in 2014. At issue was the inability of the CMS to use claims from CAHs to qualify physicians and other professionals under the Medicare EHR incentive Program if the hospitals used the Method 2 billing procedure. According to the CMS fact sheet, in order for CAH physicians to participate, it is “implementing system changes to capture their National Provider Identifier and line-of-service payment information. This ensures their claims are tied to the specific services rendered.” The CMS statement said the physicians at CAHs billing under Method 2 “can begin participation in calendar year 2013.”

State update

Update: health insurance exchanges

Last week, Secretary of HHS Kathleen Sebelius announced it would give states more time to become “HIX ready.” Per the ACA, HHS is required to evaluate a state’s readiness to operate a HIX by January 1, 2013 to ensure states will be operational by open enrollment in October 2013. Eighteen states and the District of Columbia have received conditional approval from HHS to date, but may need extra time before they are qualified to receive final approval. HHS officials reinforced their desire that states develop their own HIX but estimates it will likely partner with state officials in setting up exchanges in at least 25 states.

To date, 18 states and the District of Columbia plan to operate a state-based exchange, seven will operate a state-federal partnership, and the remaining are undecided (which would default to a federally run exchange):

State-based exchange State-partnership exchange Undecided/Federally-facilitated exchange
CA, CO, CT, DC, HI, ID, KY, MA, MD, MN, MS, NM, NV, NY, OR, RI, UT, VT, WA AR, DE, IA, IL, MI, NC, WV AK, AL, AZ, FL, GA, IN, LA, KS, ME, MO, MT, ND, NE, NH, NJ, OH, OK, PA, SC, SD, TN, TX, VA, WI, WY

Note: updated as of January 4, 2012.
Sources: Kaiser Family Foundation, National Association of State Health Policy: State Reform, and Politico Pro.

Exchange announcements last week:

  • Thursday, HHS announced Delaware, Iowa, Michigan, Minnesota, North Carolina, and Vermont were awarded Level One HIX establishment grants; California, Kentucky, Massachusetts, New York, and Oregon were awarded Level Two HIX Establishment Grants.
  • Last week, Mississippi’s Attorney General Jim Hood (D) instructed the state insurance commissioner, Mike Chaney (R) to proceed with HIX implementation; however HHS has deferred conditional approval pending resolution of a dispute between the Commissioner, AG and Governor Phil Bryant (R).

Update: Medicaid expansion

As of January 18, 2013, 19 states and the District of Columbia will expand, 14 states will not participate or are highly unlikely to participate, and 17 states are undecided/undeclared:

Participating Not participating or highly unlikely to participate Undecided or undeclared
AR, AZ, CA, CO, CT, DE, DC, HI, IL, MD, MA, MN, MO, MT, NM, NV, OR, RI, VT, WA AL, GA, ID, IA, LA, ME, MS, NE, OK, SC, SD, TX, UT, VA AK, IN, KS, KY, MI, OH, PA, NC, ND, NH, NJ, NY, TN, WI, WV, FL, WY

Source: Politico Pro, Medicaid Watch, January 18, 2013; Advisory Board, Where the states stand, January 15, 2013.
Note: states do not have a deadline to make a decision on Medicaid expansion and may opt in or out of participation at any time. This chart was compiled using publically available information (as of January 10) and is subject to change.

Other recent announcements:

  • Iowa Governor Terry Branstad (R) and Nebraska Governor Dave Heineman (R) declined to include funds to expand Medicaid eligibility in their proposed state budgets. The Governors cited high costs without a guarantee of improved quality as the reasoning behind their decisions.
  • Kansas Governor Sam Brownback (R) proposed budget provides no funds for expanding Medicaid.
  • California officials identified two strategies for disbursing ACA’s enhanced federal matching funds per Section 2001 of the ACA: state-based and county-based. A state-based approach would expand the existing Medi-Cal program and cover the health care costs, but not long-term care, of individuals up to 133 percent of the FPL. A county-based option would share funds with the “Low Income Health Program” currently administered by 55 of the state’s 58 counties.
  • A new study found Medicaid expansion would reduce state spending in Ohio and drive higher revenues, thereby improving the state’s 2014-2022 budget forecast. In addition, expansion would generate sufficient savings to offset the cost of implementing the ACA’s other provisions, reduce the uninsured population, stimulate employment and wage increases, and reduce employer’s health care costs.
  • Maine’s 39 hospitals are asking the state to provide reimbursements for overdue Medicaid payments dating back to 2009. According to state officials, of the $484 million owed to hospitals, the majority would be reimbursed by the federal government.

State round-up

Two industry groups, the Biotechnology Industry Organization (BIO) and Alliance for Safe Biologic Medicines, lent their support for a Virginia bill H.B. 1422 that permits pharmacists to dispense interchangeable biosimilars unless otherwise directed by the prescriber.

Industry news

Hospitals seek elimination of Section 3141 of the ACA

In a letter to President Obama last week, 20 state hospital associations leaders asked for the reversal of Section 3141 of the ACA, which allows states to set Medicare reimbursements floors at the rate of its rural hospitals. Per their letter, the associations believe Massachusetts hospitals would get an increase in reimbursements because the state’s only rural hospital, on Nantucket Island, establishes a high payment floor for all non-rural providers while hospitals in the 49 other states will see $3.5 billion in cuts over ten years due to the provision.

Industry groups reactions to Stage 3 meaningful use guidance

The American Medical Association (AMA) and the College of Healthcare Information Management Executives (CHIME) submitted comments to the HHS Office of the National Coordinator for Health Information Technology (ONC) policy committee in response to the agency’s proposal released last month on Stage 3 requirements for the meaningful use electronic health record (EHR) program:

AMA:

  • An external, independent evaluation is necessary to improve and inform the future of the program
  • Program requirements should be more flexible and better structured to accommodate various practice patterns and specialties
  • The EHR certification process should address physician usability concerns
  • The health information technology (IT) infrastructure does not enable physicians to readily share patient data with other health care providers electronically; infrastructure improvement to allow an efficient and secure electronic information exchange must be a priority

CHIME:

  • Agree with the concept of allowing eligible professionals and hospitals to demonstrate meaningful use by meeting a large number but not necessarily all the specified measures
  • Caution policy makers not to expect that health professionals will be willing and able to capture significant amounts of structured data—unreasonable expectations in this regard are not only likely to compromise patient care but also lead to an anti-EHR response by the physician community
  • Believe it would be a very serious mistake to impose a health IT safety risk assessment requirement for the foreseeable future—rather than worrying about how EHRs are being used by providers, policy makers should focus on care outcomes
  • Encourage that the time frames for Stage 3 be linked to and preceded by proven health information exchange capabilities
  • Urge policy makers to ensure that EHR certification requirements yield vendor products that allow practitioners and hospitals to fully and easily satisfy any meaningful use documentation and audit requirements. Also, urge that audit measures be standardized to be based clearly on the certification requirements, and not subject to auditor variation

Note: the EHR incentive payment program was appropriated $27 billion by Congress to encourage doctors and hospitals to implement EHRs. Through November 2012, $9.3 billion has been spent, 335,897 physicians and other “eligible professionals” have enrolled, and 162,051 have been paid. In addition, 4,193 hospitals enrolled and 3,393 received payments.

Study: Mobile apps in skin cancer detection have high degree of error due to image resolution

According to University of Pittsburgh Medical Center (UPMC) researchers, reliance on mobile medical applications in cancer detection could delay the diagnosis of melanoma and access to needed treatment. Researchers found that three out of the four smartphone applications tested incorrectly diagnosed 30 percent or more melanomas as “unconcerning.” Almost 200 images of skin lesions were uploaded into each of the applications by researchers, the most accurate of the applications utilized dermatologists to review the uploaded images to help determine the diagnosis.

Background: in 2011 the FDA issued draft guidance on mobile medical applications, defining a mobile medical app as one that meets the definition of a device (an instrument, article, component, or accessory intended for use in the diagnosis of disease or other conditions) or in the cure, mitigation, treatment, or prevention of disease or is either used as an accessory to a regulated device or transforms a mobile platform into a regulated medical device. FDA has yet to issue final guidance on mobile applications, but has included it in the list of documents that the agency intends to publish in fiscal year 2013.

Quotable

“What began as patient protections have in many instances become rigid rules and procedures that seem to exceed patient needs and even common sense. Good intentions spawned these laws (HIPAA), but in practice they can interfere with or delay the delivery of necessary care and crucial communication between caregivers and families—as families of people with serious mental illnesses can attest in often heartbreaking detail.”

— Lloyd Sederer “The Tragedy of Mental Health Law”, Wall Street Journal, January 13, 2013

“I intend to examine and shine a bright public light on the unprecedented host of new regulations and taxes in 2013 and their impact on patients and local health care providers.”

—Representative Kevin Brady (R-TX) announcement as Health Subcommittee Chairman of Ways and Means, January 15, 2013

Fact file

  • Fiscal cliff deal doc fix cuts: the $25.5 billion doc fix in H.R. 8 was paid for by cuts to other parts of the health care system: $10.5 billion coding adjustments, $4.9 cuts in dialysis payments, $4.2 billion disproportionate care hospitals payments fund reduction, $2.3 billion reduction in CO-OP health plan fund, $2 billion cut to Medicare Advantage plan via coding adjustments, $1.8 billion reductions in same day procedure codes, $1.7 billion reduction in Medicare improvement fund, and $2.5 billion from other sources. (Source: Congressional Budget Office)
  • Not-for-profit hospital margins: the 4,973 not-for-profit hospitals increased staffing 1.1 percent in 2011 to 4.03 million including 1.07 million nurses (increase of 1.6 percent). Total revenues were up 3.3 percent ($755.3 billion), expenses up 3.6 percent to ($702.1 billion) resulting in a 7.2 percent margin (vs. 7.0 percent margin in 2010). (Source: Modern Healthcare, “Financially stable,” January 5, 2013)
    Note: through December 2012, not for profit hospitals issued 437 bonds to raise $29.6 billion (Source: Modern Healthcare). Revenues from Medicare increased 2.41 percent vs. 7.16 percent for commercial payers. (Source: Standard and Poors Healthcare Economic Index)
  • Hospital reimbursement rates: rates to acute-care hospitals increased by 2.7 percent from 2011 to 2012 vs. 2.2 percent from 2010 to 2011: Medicare increased 2.1 percent, Medicaid increased 1.7 percent, other payers (private insurers and self-pay patients) increased 3.6 percent, and physician-office reimbursement (excluding mental health services) increased 1.3 percent. (Source: U.S. Bureau of Labor Statistics)
  • Accountable care organizations: total named by HHS to date—116 in 2012, 106 in 2013. (Source: U.S. Department of Health and Human Services)
  • HIT in critical access hospitals: of 1,700 critical access hospitals—hospitals with 25 or fewer beds—1,164 were working with a health technology regional extension center to pursue meaningful use. (Source: Modern Healthcare, “Small hospitals on the radar,” January 5, 2013)
  • Public hospitals payer mix: 35 percent Medicaid, 27 percent commercial, 21 percent Medicare, 11 percent federal/state, 6 percent other/no insurance. (National Association of Public Hospitals)
  • Surgical crises: in 145 out of 10,000 hospital surgical cases, there is a crisis—(i.e., hemorrhage, cardiac arrest). (Source:Boston.com, “Checklists can help caregivers save patients during operating-room crises,” January 16, 2013)
  • Urbanization: 80 percent of U.S. population lives in an urban community—up 12 percent in the last decade. (Source: U.S. Bureau of the Census)
  • Workforce and economics: $1 million investment in military spending produces 11 jobs; in green infrastructure 17 jobs; and in education 27 jobs. (Source: Robert Pollin, University of Massachusetts)
  • Wages as percent of GDP: 43.5 percent in 2012 down from 49 percent in 2001 (averaged 50 percent or higher until 1997); share of wages going to top 1 percent increased from 7.3 percent in 1979 to 12.9 percent in 2010. (Source: Center for Budget and Policy Priorities)
  • Household income: Median income for households headed by someone under 65 decreased 12.4 percent from 2000-2011 to $55,640—during this period economy grew 18 percent. (Source: Center for Budget and Policy Priorities)
  • Entitlement costs: Medicare, Medicaid, and CHIP were 21 percent of federal budget in 2012, 24 percent in 2013, 33 percent by 2019; 5.4 percent of GDP increasing to 10.4 percent in next 25 years; as a result, costs will increase 7.8 percent in 2014 and average 6.2 percent for rest of decade. (Source: Congressional Budget Office)
  • High deductible enrollment: 17 percent of U.S. workforce up from 8 percent in 2012. (Source: Employee Benefit Research Institute)
  • Poll spending cuts and debt ceiling linkage: 58 percent of adults think federal government spending cuts should not be tied to raising the nation’s debt ceiling. (Source: Washington Post-ABC Poll)
  • Online health information: a survey of 3,014 U.S. adults found that 81 percent use the internet, 59 percent have searched online for health information in the past year, and 35 percent have used the internet to try and self-diagnose a medical condition. (Source: Pew Research Center, “Health Online 2013,” January 2013)
  • Sugary drink consumption: low-income children are twice as likely (93 percent) to consume more than 500 calories a day from beverages with high sugar contents. (Source: Han, Powell, Journal of the Academy of Nutrition and Dietetics, “Consumption Patterns of Sugar-Sweetened Beverages in the United States,” January 2013)
  • EHR adoption: at the end of 2011, 68 percent of American family physicians were using EHRs. (Source: Xierali, et. al, Annals of Family Medicine, “The Rise of Electronic Health Record Adoption Among Family Physicians,” January 2013)
  • Health care IT M&A: health care IT merger and acquisition transaction volume increased 21 percent in 2012 compared to data from the previous two years. Total value of transactions increased 5 percent to $11.96 billion. (Source: Berkery Noyes)
  • Surgical checklists: in a study of 106 surgical-crisis simulations, operating teams utilizing checklists missed 17 percent fewer (6 percent vs. 23 percent without checklists) essential steps when administering life-saving procedures. (Source: Arriaga, et. al, New England Journal of Medicine, “Simulation-Based Trial of Surgical-Crisis Checklists” January 2013)
  • E-prescribing by physicians: 6 percent in 2007 to 65 percent in 2012. (Source: Black Book)
  • District of Columbia health employment: overall unemployment in the District of Columbia was 5.3 percent vs. 5.5 percent in 2011; health care employment driving employment growth: from November 2011 to November 2012, health care services employment increased by 11,300; professional services increased by 10,400 and government employment increased by 6,700.
    Note: federal employment was down 4,200. (Source: Center for Regional Analysis, George Mason University)
  • Energy drinks and emergency room visits: emergency department visits in the U.S. linked to energy drink consumption doubled from 2007 to 2011 to 21,000 visits: teens and young adults accounted for most visits; visits from adults 40 and older increased from 1,400 to about 5,200. In 2011, drugs and/or alcohol were a factor in 42 percent of the visits. (Source: U.S. News, “ER visits linked to energy drinks double: report,” January 16, 2013)
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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