indiana Update from the IU Healthcare

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					Update from the IU Healthcare
    Reform Workgroup

              Eric R. Wright, Ph.D.
              Eleanor D. Kinney, J.D., M.P.H.
What is the IU Healthcare
Reform Workgroup?

   Origin: FSSA has awarded a grant to IU to form a faculty
    workgroup to study policy options for improving the quality,
    efficiency, and effectiveness of our healthcare system
   Role:
    –   an independent, non-partisan, non-governmental group committed to
        helping the State identify the best policy options for state-level
        healthcare reform
   Objectives:
    –   to develop a long-term vision of the ideal healthcare system for
    –   to provide data-driven and evidence-based policy recommendations
        for specific steps to achieve this vision by 2035
    –   to provide technical assistance and support in the development of
        legislation to implement these policy recommendations during the
        2008 legislative season
Core Workgroup Members

   Eric R. Wright, PhD, Director, Center for Health Policy
   Eleanor D. Kinney, JD, MPH, Co-Director, Hall Center for Law and
   John Fitzgerald, MD, MBA, Associate Dean, IU School of Medicine
   David Handel, MHA, Director, Health Administration Program,
   Ann M. Holmes, PhD, Associate Professor of Health Economics,
   Douglas B. McKeag, MD, Professor and Chair, Department of
    Family Medicine.
   Eric M. Meslin, PhD, Director, Center for Bioethics, IU School of
   Gregory Steele, PhD, MPH, Associate Professor, Department of
    Public Health, IU School of Medicine
Workgroup Sub-Committees

   Principles and Values
   Finance, Access, and Insurance
   Delivery, Utilization, Price, and Costs
   Public Health and the Environment
   Workforce and Workforce Development
   Legal and Regulatory Issues
   State of State/Data Group
Project Plan – Phase 1

       Summer                                Late Summer     Early Fall
  Workgroup subcommittees examine                                 Report
  critical healthcare reform challenges                       Outlining Best
                                                             Alternatives and
                                                                their Likely
                                              Key Findings
   Listening Tour with Stakeholders and                          Costs and
 the Public on Vision for Indiana’s Future                   Consequences
            Healthcare System
Project Plan – Phase 2

       Fall 2007                                  Winter 2008

Workgroup assists the State Legislature,
the Governor, and FSSA to examine the
          policy alternatives              Development of
       Listening Tour to Discuss
        Policy Alternatives with
      Stakeholders and the Public
Accomplishments to Date

   Core Workgroup/Seven Subcommittees have been meeting
    and working since early 2007
   Summer 2007 Listening Tour
   Report Drafted: Hoosiers’ Vision for the Future of Indiana’s
    Health Care System: Findings from the IU Workgroup on
    Healthcare Reform June 2007 Listening Tour
   Five Subcommittees drafted and in final stages of editing
     –   Principles and Values, Finance, Utilization, Public Health, Workforce
   Workgroup has begun selecting and compiling the specific
    recommendations from the subcommittees into a general
 A Working Framework for
Healthcare Reform in Indiana
Factors Contributing to the
Healthcare Crisis in Indiana

   Uninsured
   Inefficient delivery system
    –   Variation in the availability and quality of services
    –   Over and underuse of some care services
    –   Incentives do not reward most critical health care needs
   Poor Health Status/Outcomes
    –   Poor ranking in terms of the quality of care
    –   Poor ranking relative to significant morbidity and mortality
    –   Significant health disparities
The Three Principal Challenges in
Healthcare Reform
Draft Vision for 2035

By 2035, Indiana will have as a top priority the health of its citizens by providing
everyone access to a reasonable continuum of health care, mental health, and
addiction services. The health care system will emphasize a primary care first,
disease-prevention approach that integrates a foundational structure consisting of a
defined health care home and coordinated public health initiatives. Care will be
provided in an array settings in a holistic, patient-centered manner by a variety of
health profession disciplines who will work in collaboration guided by the principles of
innovative quality and evidence-based care where the outcomes are aimed at
maximizing the health and quality of life for the patients they care for. Citizens will be
inspired to share individual responsibility for their health with respect to their personal
conduct and financial ability to pay. Patients will be cared for with dignity, respect,
compassion, and humility cognizant of their uniqueness as a human being and rights
to privacy. Transparency, efficiency, open communication, and the competent
coordination of care will promote an environment whereby citizens can make
informed and thoughtful decisions about their care in an environment where health
providers are involved as partners in the health delivery process.
Goals for Reform

Indiana will be a national leader in providing an
environment and healthcare system which maximizes the
health of its population.
 Indiana will be in the lowest quartile of states in the
   percent of the population that smoke, are obese, and
   lead sedentary lifestyles.
 Indiana will be in the highest quartile of states on
   positive health status measures.
 Indiana will be in the highest quartile of states in terms
   of health care quality of outcomes and performance.
 Indiana will be in the lowest quartile of states in
   healthcare spending per capita.
Key Components of Indiana’s Future
Healthcare System

   Hoosiers will have universal access
     – Universal insurance coverage
     – Effective access to all aspects of the healthcare system
        by all residents and are not dependent on income class,
        cultural identity, or place of residence within Indiana
   Disease prevention and health promotion will be the
    primary foci of both the delivery and public health systems
   All residents will have a medical/healthcare home which
    will be the source of primary care, disease management,
    and care coordination
Key Components of Indiana’s Future
Healthcare System (cont.)

   The delivery system will focus on and maximize healthcare
    quality, outcomes, and patient safety
   The payment system will be aligned to achieve desired
    patient quality and outcomes and to insure an adequate
    supply and range of healthcare providers and services
   There will be a workforce with adequate capacity to meet
    the needs of Indiana residents
   There will be an effective, statewide infrastructure in IT and
    quality indicators and a public system to support and
    monitor the delivery of high quality cost effective patient
Key Components of Indiana’s
Future Healthcare System (cont.)

   Hoosiers will take an active role in preserving their own
    health and working collaboratively with their healthcare
    providers to address health challenges.
Sample Short-Term Recommendations
for Policy Action Items

   F1: The complexity of the enrollment process for current public
    insurance programs should be simplified, particularly for
    populations with eligibility for multiple programs (e.g., Medicaid,
    Medicare, VA, etc.).
   F3: Targeted educational outreach is needed to ensure people
    enroll in all public insurance programs for which they are
    currently available, particularly for rural residents. Outreach
    efforts also need to be coordinated between providers and
    FSSA, particularly for children who are eligible through school
    or welfare programs.
Sample Short-Term Recommendations
for Policy Action Items (cont.)

   U1: Increase the Number of Community Health Centers
   U2: Improve care for chronic conditions by targeting high-risk
    populations and implementing education and disease
    management programs
   U4: Create a Statewide Clinical Quality Program
   U10. Expand the Indiana Health Information Exchange and
    other Health Information Exchanges plus Quality Health First’s
    Program to cover most if not all of population.
Sample Short-Term Recommendations
for Policy Action Items (cont.)

   W2: Increase financial aid targeted to URMD students and
    students based on prediction for rural and urban inner-city
    primary care practice and provide this aid to students studying
    out of state who are willing to practice in Indiana.
    W4: Legislatively mandate required clinical training
    experiences in rural and urban inner-cite primary care medically
    underserved settings for health care students
   W11: Encourage interdisciplinary training of teams of providers
    so that mid-level providers could team with higher level
    providers to help meet more of the health care needs.
Sample Short-Term Recommendations
for Policy Action Items (cont.)

   P2: Adopt legislation, fully consistent with CDC’s Best Practice
    recommendations, to take the state smoke-free in all public and
    work places.
   P5: The state support and fund the implementation of a
    comprehensive, coordinated, state-wide program to promote
    healthy lifestyle choices among citizens of all ages.
Sample Long-range Recommendation
for Policy Action - Access

   Recommendation: Achieve universal
    coverage in Indiana by 2010
    –   Individual mandate
            Premium linked to income and/or subsidy provided by state (tax credit
             too expensive considering admin costs)
            Continuous enrollment = same premium if no lapses (vs. opt-out and
             then re-enter, premium reassessed/adjusted)
            Tax penalty for non-compliance
            Supplemental insurance allowed
Sample Long-range Recommendation
for Policy Action – Access (cont.)

  –   Define standard minimum benefit
          Question: include catastrophic occurrences in this?
  –   Employer contribution
          Payroll tax – every employer pays, including non-profit
          Tax credit/deduction (corporate tax) – for employers
           already providing
Sample Long-range Recommendation
for Policy Action – Access (cont.)

  –   Out-of-pocket
          Tiered co-payment (3-4 levels small co-pay, negative
           co-pay, etc.)
             – Can be income-adjusted, health/illness adjusted, but
               that adds complexity and administrative cost
  –   Corporate tax (already high)
          Rate = expected cost recovery from the reform and
           would either be on
            – HC providers/Insurance co’s (?) OR
            – FP HC providers and specialty hospitals
Sample Long-range Recommendation
for Policy Action – Access (cont.)

  –   Sales & Income tax
  –   Piggy-back admin on IT
          Incorporate bulk-billing incentives if standardized w/
           public (+ P4P)
  –   Insurance pool
          Max benefit guaranteed issue
          Reinsurance or risk-adjusted
  –   Specialty Hospital/Health Insurance Corporate
      Tax (like an excess profits tax)
Sample Long-range Recommendation
for Policy Action - Delivery

Recommendation: Enhance public health and
primary care infrastructure to provide healthy
Indiana regional networks for the efficient
delivery of services to the uninsured and/or
   Establish primary care districts in the same ten districts as
    the public health districts. In each primary care district, identify
    primary care health providers, including primary care medical
    groups, community health centers and hospital-based clinics,
    that would (upon meeting established criteria) constitute a
    medical home for the target population.
Sample Long-range Recommendation
for Policy Action – Delivery (cont.)

   Consolidate publicly funded public health services to
    public health authorities in ten districts throughout the
    state to provide a more coordinated, consistent, and efficient
    system of public health service delivery. The ten-district model,
    first initiated in Indiana for purposes of emergency
    preparedness, is a promising model. The district model would
    allow for more fluid and efficient allocation of staff and
    resources as well as improved coordination of services both
    locally and with state agencies. In addition, the privatization of
    specific public health functions currently performed at the
    county level, such as inspections of regulated facilities, should
    be adopted where appropriate.
Sample Long-range Recommendation
for Policy Action – Delivery (cont.)

   Within each public health/primary care district, establish
    regional networks of service providers that will support the
    designated “medical homes” in the districts and enable
    these medical homes to qualify as medical homes eligible for
    reimbursement breaks and other benefits.
   Such networks will include hospitals will take to provide
    secondary and tertiary care to those in the population enrolled
    in the Healthy Indiana, Medicaid or other health insurance
    programs and secondary care (from the hospital’s community
    benefit obligation) for the uninsured.
Sample Long-range Recommendation
for Policy Action – Delivery (cont.)

   The entire network oversight and delivery can be established to
    manage the care for this population, which often is not transient
    and can be followed for many years. Records and disease
    management techniques can be used to support the care. The
    network can be administered through the existing State
    Department of Health, much as the CMHCs are administered
    that the State Division of Mental Health.
Next Steps

   Over the next few weeks, we will continue to develop the
    framework and associated recommendations and plans.
   At the SCI Institute in Chicago, we will work on refining the
   Work with FSSA, Legislators to identify specific components to
    develop into formal legislative proposals for 2008.
   Publish the subcommittee reports and the document outlining the
   Launch the second listening tour in mid October to get Hoosiers’
    feedback on the recommendations.

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