Healthcare Trends in America

Healthcare Trends in America
A Reference Guide from BCBSA 2010 Edition
Contents
Introduction......................................................................................... 1 . Section.1:.Improving.Access.to.Health.Coverage............................ 3 Section.2:.Keeping.Healthcare.Affordable...................................... 17 Section.3:.Improving.Quality.and.Safety........................................33 Section.4:.Improving.Consumer.Health..........................................53 Section.5:.Changing.Care.Delivery.Models.................................... 77 Methodology. ....................................................................................90 . Glossary.of.Abbreviated.Terms....................................................... 91 Index.of.Tables. ................................................................................. 92 . Bibliography. ..................................................................................... 95 .
Dear Colleague: I am pleased to share with you the 2010 Healthcare Trends in America: A Reference Guide from the Blue Cross and Blue Shield Association, offering a comprehensive compendium and analysis of healthcare economics and key trends influencing healthcare in our country. Now in its eighth year of publication, the guide organizes data in four key categories essential to improving our nations healthcare system: improving access to health coverage, keeping healthcare affordable, raising the quality and safety of care and improving consumer health. We have also devoted an entire section of the guide to changing care delivery models designed to improve our healthcare system. Through the use of national research and other well-respected, fact-based data sources, the guide is designed to make us all more informed about healthcare and the economics of healthcare through an extensive annual examination of healthcare costs and trends. In keeping with our 80-year heritage of local and national healthcare leadership, Blue Cross and Blue Shield companies are collaborating with key stakeholders from policy makers and leading medical organizations to consumer groups and major employers to design and implement a better healthcare delivery system for our nation. New data from Blue Health Intelligence (BHI) the nations largest healthcare data warehouse with claims information on more than 54 million members is helping us achieve our goal. The robust new information and insights from BHI included in the Reference Guide provides far greater transparency to help alter the way we view healthcare and help change the way care is delivered in our country. We also have included a CD-ROM in the guide with an interactive PDF version for access to PowerPoint slides of each chart. Yours in good health,
Scott P. Serota President and Chief Executive Officer Blue Cross and Blue Shield Association
Blue Cross and Blue Shield Association
Healthcare.Trends.in.America:.A.Reference.Guide.from.BCBSA.(2010.Edition)
Improving Access to Health Coverage
Section
U.S..Population.with.Health.Insurance.in.Millions...................................................... 5 Coverage.by.Type.of.Health.Insurance......................................................................... 6 Employers.Offering.Health.Benefits............................................................................. 7 Employer-Sponsored.Health.Plan.Enrollment............................................................. 8 Enrollment.in.COBRA..................................................................................................... 9 Account.Implementation.of.Benefit.Changes.as.a.Result.. of.Current.Economic.Environment.............................................................................. 10 Enrollment.in.Medicaid.and.Medicare........................................................................ 11 Medicare.Advantage.Enrollment.in.Millions. ............................................................ 12 . Percentage.of.Uninsured.by.Income.Level................................................................ 13 Percentage.of.Uninsured.by.State.............................................................................. 14 Breakdown.of.the.Uninsured....................................................................................... 15
Summary
While more than 85 percent of the nations 300 million people have health insurance, 15 percent of Americans do not have coverage and many others may lose their health insurance due to the struggling economy. Of the insured population, nearly 60 percent receive their health insurance through their employers. Enrollment in government programs has risen slightly in the past few years and now represents nearly 30 percent of those with coverage. Direct purchasers represent the remainder. Blue Cross and Blue Shield is committed to extending health insurance to those who do not have coverage, and The Blues believe the best way to accomplish this goal is to build on our employer-based system. In 2009, more than 95 percent of American firms with more than 50 employees offered health insurance coverage to their employees. However, less than half of companies with fewer than 10 employees offer health
benefits. Increasing the percentage of small employers that offer health benefits is critical to increasing coverage levels. Additionally, there must be a focus on those most likely to lack coverage, such as young adults aged 18-34, Hispanics, and African-Americans. The Blues have been active participants in the ongoing healthcare reform debate and have led the industry in identifying insurance reforms that would guarantee coverage to everyone, regardless of pre-existing conditions or health status. In order to accomplish this goal and keep coverage affordable for everyone, there must be a mechanism for ensuring that people have insurance and not simply wait until they are sick to purchase insurance. It is imperative that we find new and innovative ways to address the crisis of the uninsured.
U.S. Population with Health Insurance in Millions
In 2008, about 85 percent of more than 300 million Americans had health insurance.
291.2 247.7
293.8 249.0
296.8 249.8
299.1
301.5
253.4
255.1
176.2
176.9
177.2
177.4
176.3
2004 85.1%
2005 84.7%
2006 84.2%
2007 84.7%
2008 84.6%
Percentage.with.Health.Insurance Persons with Employer-Sponsored Coverage

Source: U.S. Census Bureau (2009) Historical Health Insurance Tables, Table HIA-2.
Persons with Health Insurance
U.S. Population
Coverage by Type of Health Insurance
Among those with health insurance coverage, two-thirds are covered by private insurance plans.
Private Insurance
Government Insurance
Uninsured
Any Private Plan*
66.7% 69.0%
Any Government Plan
29.0% 27.3% 14.3% 13.6% Uninsured 14.1% 13.0% 3.8% 3.7% 15.4%
Medicare Employment-Based 58.5% 60.5% Medicaid
14.9%
Direct Purchase
8.9% 9.5% Military Healthcare**
2004
2008
*Any private plan includes employment-based and direct purchase health insurance plans. **Military healthcare includes Comprehensive Health and Medical Plan for Uniformed Services (CHAMPUS)/Tricare and Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), as well as care provided by the Department of Veterans Affairs and the military. Note: The estimates by types of coverage are not mutually exclusive; people can be covered by more than one type of health insurance during the year. Source: U.S. Census Bureau (2009) Historical Health Insurance Tables, Table HIA-2.
Employers Offering Health Benefits
The percentage of employers offering health benefits to employees has been relatively stable. At least 95 percent of firms with more than 50 employees offer health benefits.
Employer-Sponsored Insurance Coverage

Percentage of Employers Offering Health Benefits 60% 60% 87% 87% 72% 72% Percentage of Firms Offering Health Benefits by Size 93% 95% 98% 98%
33% 31% 28%

29%
47% 46%
2005
2009
3-9
10 - 24
25 - 49
50 - 199
Offering Health Benefits* Offering Retiree Health Benefits** Offering Health Benefits to Part-Time Workers***
Number of Workers per Firm 2005 2009
200 or more
*Among all firms. **Among all firms with 200 or more workers offering health benefits to active workers. ***Among firms offering health benefits. Source: Employer Health Benefits 2009 Annual Survey, (#7936), The Henry J. Kaiser Family Foundation and HRET, September 2009. This information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation is a non-profit private operating foundation based in Menlo Park, Calif., dedicated to producing and communicating the best possible information, research and analysis on health issues.
Employer-Sponsored Health Plan Enrollment
Sixty percent with employer-sponsored coverage are covered by PPOs. Over time, HDHP enrollment has increased to 8 percent, likely driven by more employers offering them.

Employer-Sponsored Health Plan Enrollment by Plan Type 15% 8% 10% 7% 6% 61% 60% 3% 2% 2% 21% 3% 2005 Conventional HMO PPO 2009 POS HDHP/SO Definitions 20% 1% 2005 2006 HDHP/HRA 2007 2008 2009 1% 3% 2% Among Firms Offering Health Benefits, Percentage that Offer an HDHP/HRA or an HSA-Qualified HDHP 11% 10%
HSA-Qualified HDHP
High-deductible.health.plans.with.savings.option.(HDHP/SOs).are.defined.as.a: HDHP/HRA:.Health.plan.with.a.deductible.of.at.least.$1,000.for.single.coverage.and.$2,000.for.family.coverage.offered.with.a.Health.Reimbursement.Arrangement.(HRA). HSA-qualified.HDHP:.High-deductible.health.plan.that.meets.the.federal.legal.requirements..a.deductible.of.at.least.$1,150.for.single.coverage.and.$2,300.for.family. coverage.in.2009..to.permit.an.enrollee.to.establish.and.contribute.to.a.Health.Savings.Account.(HSA).
Note: HMO is health maintenance organization. PPO is preferred provider organization. POS is point-of-service. Source: Employer Health Benefits 2009 Annual Survey, (#7936), The Henry J. Kaiser Family Foundation & HRET, September 2009. This information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, Calif., dedicated to producing and communicating the best possible analysis and information on health issues.
Enrollment in COBRA
Higher unemployment rates coupled with government subsidy is likely driving increased COBRA uptake.
9.7% 9.5% 8.9% Est. Unemployed Population 7.5 million 6.1% 5.5% 4.8% 5.0% 8.2% 7.4% 6.6%
10.1% 10.0% COBRA Subsidies Government.legislation. provided.temporary. subsidies.to.some. workers.who.were. involuntarily.terminated. between.Sept..2008. through.Feb..2010,.to. help.maintain.coverage: Uptake of COBRA by eligible workers doubled during subsidy period
7.0
Est. Unemployed Population 15.3 million
2.8
3.1 2.6
Aug-08
Oct-08 Jun-09 Feb-09 Aug-09 Dec-08 Dec-09 Apr-09 Oct-09
Without.subsidy,. eligible.workers.pay. the.full.premium. plus.2.percent. administrative.fee Subsidies.covered. 65.percent.of.the. cost.of.COBRA.for. a.cumulative.15. months
Apr-08
Jun-08
Feb-08
2004
2005
2006
2009(p)*
*Projected by the Confessional Budget Office. Note: Government programs include American Recovery and Reinvestment Act (ARRA) and Defense Appropriations Bill. Source: U.S. Department of Labor, Bureau of Labor Statistics (2009); UBS Investment Research (2009) Managed Care UBS COBRA Tracker; Congressional Budget Office (2009); National Business Group on Health (2009) Congress Extends Federal COBRA Subsidies; The COBRA Subsidy and Health Insurance for the Unemployed (#7875-02), The Henry J. Kaiser Family Foundation, December 2009 , This information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, Calif., dedicated to producing and communicating the best possible analysis and information on health issues.
Account Implementation of Benefit Changes as a Result of Current Economic Environment
As a result of current economic conditions, many large, multi-state employers are increasing employee cost sharing.
Increase Employee Cost Sharing Move Employees to HDHP Institute Single-Plan Design as Full Replacement Limit or Cut Retiree Benefits Limit or Exclude Dependent Coverage Decrease or Eliminate HSA Contribution Provide Defined Contribution Limit New Hire Benefits 5% 5% 5% 3% 4% 7% 8% 12%
19% 20% 6% 4% 6% 5% 4% 7% 13% 12% 11% 10% 9%
30% 32%
49%
Already Implemented
Plan to Implement
Source: Blue Cross and Blue Shield Association (2009) National Account Decision-Maker Survey.
10
Enrollment in Medicaid and Medicare
Enrollment in Medicaid and Medicare Part A and B has been relatively stable in the last three years. More than 90 percent of Medicare beneficiaries have drug coverage.
Public Programs
Medicaid and Medicare Beneficiaries (in Millions) Prescription Drug Coverage Among Medicare Beneficiaries in 2009
Medicare Beneficiaries = 45.2 Million 46.9 39.2 33.6 37.4 48.1 43.0 40.4 43.9 41.4 47.1 45.0 42.0 Medicare Advantage Drug Plan 9.2M Retiree Drug Coverage 7.9M Other Drug Coverage* 6.2M No Drug Coverage** 4.5M
25.9 17.4 11.0
Stand-alone PDP 17.5M 2007 2008
2000
2006
Medicaid
Medicare Part A
Medicare Part B
Medicare Part D
*Includes Veterans Affairs, retiree coverage without retiree drug subsidy (RDS), Indian Health Service, state pharmacy assistance programs, employer plans for active workers, Medigap, multiple sources and other sources. **Includes RDS and FEHBP and TRICARE retiree coverage. Note: Medicare Part D was introduced in 2006. PDP is prescription drug plan. Figures may not add up due to rounding. Source: Centers for Medicare and Medicaid Services (2009); The Medicare Prescription Drug Benefit An Updated Fact Sheet (#7044-10) The Henry J. Kaiser Family Foundation, November 2009 , This information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, Calif., dedicated to producing and communicating the best possible analysis and information on health issues.
11
Medicare Advantage Enrollment in Millions
More than 11 million are enrolled in Medicare Advantage, growing more than 40 percent since 2006.
Public Programs
10.1 8.8 7.7
10.6
11.0
2006
2007
2008
2009
2010*
*2010 Medicare Advantage enrollment as of January 2010. Note: Enrollment figures are as of December of each year. Source: Centers for Medicare and Medicaid Services (2010).
12
Percentage of Uninsured by Income Level
As of year-end 2008, the uninsured rate was 15.4 percent a marginal increase from the previous year. Nearly 40 percent of the 46.3 million uninsured have a household income more than $50,000.
The Uninsured
Income Level <$25,000 $25,000 - $49,999 14.4% 14.5% 14.0% 24.3% 19.8% 24.2% 20.1% 24.9% 21.1% 24.5% 21.1% 24.5% 21.4%
Uninsured by Income Level (2008 Uninsured: 46.3M) 13.7M 14.9M
$50,000 - $74,999
13.0%
13.3%
8.0M
$75,000+
8.2%
7.7%
8.5%
7.8%
8.2%
9.7M
2004 Overall.Percentage.of. Uninsured Average.. Unemployment.Rate 14.9% 5.5%
2005 15.3% 5.1%
2006 15.8% 4.6%
2007 15.3% 4.6%
2008 15.4% 5.8%
Note: Income levels per the Income, Poverty and Health Insurance Coverage in the United States report. Source: U.S. Census Bureau (2009) Historical Health Insurance Tables, Table HIA-2; U.S. Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2004-2008.
13
Percentage of Uninsured by State
In 2008, 17 states had a higher uninsured rate than the national level of 15.4 percent.
The Uninsured
WA
MT
ND MN SD WI MI NE IA IL OH WV KY OK TN AR SC MS TX LA AL GA VA NC PA NJ DE MD NY VT NH MA CT RI ME
OR
ID
WY
NV
ID
UT
CO
KS
MO
CA
AZ
NM
17.5% or higher 15.5% to 17.4% 12.4% to 15.4%
FL AK
12.3% or lower
HI
Source: Health Insurance Coverage of the Total Population, states (2007-2008), U.S. (2008) statehealthfacts.org, The Henry J. Kaiser Family Foundation, 2009 , This information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible analysis and information on health issues. Reprinted with permission of the Urban Institute.
14
Breakdown of the Uninsured
Young adults aged 18-34 comprise the largest portion of the uninsured; nearly one-third of the uninsured are Hispanic.
The Uninsured
2008 Uninsured: 46.3M
By Age Asian 5% 35 - 44 17% 45 - 64 24% 65 and Older 1%
By Ethnicity
By Citizenship Status
Hispanic 31% Black 16%
American Citizens 73%
Naturalized Citizens 6%
25 - 34 23% 18 - 24 18%
Under 18 16%
Non-Hispanic White 46%
Not a Citizen 21%
Note: Figures may not add up to 100 percent due to rounding. Segments per U.S. Census Bureau. Source: Census Bureau (2009) Income, Poverty, and Health Insurance Coverage in the United States: 2008.
15
16
Keeping Healthcare Affordable
Section
Components.of.Gross.Domestic.Product.(GDP)....................................................... 19 . Healthcare.Spending.in.Billions.................................................................................. 19 International.Healthcare.Spending.as.a.Percentage.of.GDP. .................................. 20 . Growth.Rates.of.Healthcare.Spending,.Wages.and.Salaries,.. and.the.CPI..................................................................................................................... 21 The.Nations.Healthcare.Dollar. .................................................................................. 21 . Percentage.Spent.on.Healthcare.by.Source.of.Funds.............................................. 22 Change.Between.2004.and.2007.in.Total.Costs.for.Hospital.Stays......................... 22 Percentage.Change.in.Healthcare.Utilization.and.Costs.......................................... 23 Physician.Office.Visits.................................................................................................. 24 Hospital.Employees.in.Millions.and.Percentage.of.Hospitals.. with.Physician.Affiliations.by.Organization............................................................... 25 Annual.Growth.in.Drug.Spending. ............................................................................. 26 . Generic.Prescriptions.as.a.Percentage.of.Total.Scripts,.2006.-.2008...................... 27 Average.Consumer.Pharmacy.Copayments.by.Tier................................................. 27 Generic.Drug.Approvals............................................................................................... 28 Average.Annual.Premium.for.Family.Coverage........................................................ 29 Hospital.Payment-to-Cost.Ratios.for.Medicare,.Medicaid.. and.Private.Payers........................................................................................................ 30 Percentage.of.Members.Out-of-Pocket.Cost.Sharing.by.Product.Line,.. 2006.-.2008..................................................................................................................... 30 Actions.Organizations.Are.Taking.Regarding.Their.Healthcare... Programs.Given.Recent.Events.in.Economy.............................................................. 31
Private.Health.Plan.Administrative.Expenses.as.a.Percentage.. of.Premiums.................................................................................................................. 32 Savings.and.Recoveries.from.Fraud.Investigations.in.Millions. ............................. 32 .
17
Summary
Comprising 17.3 percent of the nations Gross Domestic Product, healthcare spending represents a significant portion of the U.S. economy. The current healthcare spend represents more than $8,000 annually for every man, woman and child in the nation a far greater per-capita spend than any other country. Government programs fund almost half of the nations total healthcare expenses, while private insurance funds one-third. The remainder is largely covered by consumer out-of-pocket payments. Two-thirds of the total healthcare spend is devoted to hospital care, physician and clinical services, and prescription drugs. Major trends in these three largest components show: The cost of hospital stays are increasing, even though length of hospital stays are on the decline. While the total number of physician visits has remained relatively flat with the majority of visits to general/family
practitioners and internists the trend shows a rapidly growing number of visits to specialists. Growth in total and specialty drug spending has risen, driven largely by higher unit costs. Health insurance premiums have risen, reflecting the impact of overall rising healthcare costs. Private payers continue to pay hospitals more than Medicare and Medicaid as hospitals apply higher charges to private payers to compensate for a widening gap in payments from government programs. Recognizing the value of offering coverage to their employees, employers continue to cover nearly 75 percent of annual employee premiums. Facing a projected growth rate of 3.9 percent, stemming the rise in healthcare costs is a top national priority. Finding ways to improve healthcare quality and safety, while keeping healthcare affordable remains a major challenge.
18
Components of Gross Domestic Product (GDP)
Healthcare Spending in Billions
The whole healthcare sector represents a significant portion of the U.S. economy.
Healthcare is projected to be almost 18 percent of GDP by 2015.
Healthcare Spending
Healthcare Spending
17.3% 15.8% 13.1% $2,240 $2,339 $2,472 15.9% 16.2% 17.3%
17.3%
17.7% $3,442
$2,570
$2,113
5.5%
5.5%
2.5%
2.2% 2006 2007 NHE $7,071 $7,423 2008 2009(p)* 2010(p)* 2015(p)*
Healthcare*
Housing National and Utilities Defense
Food
Gasoline Motor and Other Vehicles Energy Goods and Parts
NHE as a Percentage of GDP $7,681 $8,047 $8,290 $10,631
Per.Capita
*Annual figure for 2009 projected by Centers for Medicare and Medicaid Services. Other data points are as of Q4 2009. Note: Healthcare costs reflect National Health Expenditure (NHE) which measures the total amount spent in the U.S. to purchase healthcare goods and services during the year. The amount invested in medical sector structures and equipment and in non-commercial research in the U.S. is also included. Source: Bureau of Economic Analysis (2010); Centers for Medicare and Medicaid Services (2010).
*Projected by Centers for Medicare and Medicaid Services. Source: Centers for Medicare and Medicaid Services (2010).
19
International Healthcare Spending as a Percentage of GDP
The U.S. spends a higher proportion of GDP on healthcare than any other country, four percentage points or more above all others.
Healthcare Spending
Global GDP Spending on Healthcare
U.S..spends.the.most.on. healthcare:.17.3% Germany,.France.and. Switzerland:.10.1%.-.13.0% Canada,.the.United.Kingdom. and.Japan:.8.1%.-.10.0% Russia,.Mexico.and.Brazil:.. 5.1%.-.8.0%
China,.India.and.Saudi.Arabia:.. 3.1%.-.5.0%
>13 10.1 - 13 8.1 - 10 5.1 - 8 3.1 - 5 Less than or equal to 3 Data not available
Source: World Health Organization (2009); Centers for Medicare and Medicaid Services (2010)
20
Growth Rates of Healthcare Spending, Wages and Salaries, and the CPI
The Nations Healthcare Dollar
Healthcare spending in 2010 is expected to grow 3.9 percent, twice as much as CPI but less than wages and salaries.
Nearly two-thirds of annual healthcare spend is for hospital care, physician and clinical services and prescription drugs.
Healthcare Spending
Healthcare Spending
Where it Came From 6.6% 6.3% 5.6% 6.0% 5.7% 4.4% 4.0% 4.0% 1.7% Out of Pocket 12% 5.9% 3.9% Other Private 7%
Where it Went* Government Administration and Net Cost of Private Health Insurance 7% Nursing Home Care 6% Hospital Care 31% Physician & Clinical Services 21%
Home Healthcare 3%
3.2%
3.8% 2.8%
Federal 35%
-1.0% 2006 NHE 2007 2008 2009(p)* 2010(p)*
Private Insurance 34%
Other Spending** 23%
State & Local 12%
Wages and Salaries
Consumer Price Index (CPI)
Prescription Drugs 10%
*Projected by Centers for Medicare and Medicaid Services. Source: Centers for Medicare and Medicaid Services (2010); Congressional Budget Office (2010).
*Figures do not add to 100 percent due to rounding. **Other spending includes dental services, other professional services, durable medical products, other non-durable medical products, public health activities, structures and equipment, other personal healthcare and research. Note: Figures are from year-end 2008. Source: Centers for Medicare and Medicaid Services (2010).
21
Percentage Spent on Healthcare by Source of Funds
Change Between 2004 and 2007 in Total Costs for Hospital Stays
Hospitals, physician and clinical services, and prescription drugs account for 77 percent of private health insurance spending, 61 percent of public spending and 43 percent of out-of-pocket spending.
Healthcare Spending
Hospital costs are on the rise; between 2004 and 2007, costs for all hospital stays increased $344 billion.
Hospital and Physician Expenditures
23% 40% 13% 8% 31% 16% 17% 33% 37% 18% 8% Private Health Insurance Hospital Public** Out-of-Pocket** Prescription Drugs Other* 56%
$344B $296B
All Hospital Stays
Hospital Stays with Procedure Performed 7.2%
Physician and Clinical Services
6.3% Percentage.Change
*Other spending includes nursing home, home health, dental services, other professional services, durable medical products, other non-durable medical products, public health activities, research, structures and equipment, government administration and net costs of private health insurance, and other personal healthcare. Figures are from year-end 2008. **Figures do not add to 100 percent due to rounding. Source: Centers for Medicare and Medicaid Services (2010).
Source: Agency for Healthcare Research and Quality, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2004 and 2007 .
22
Percentage Change in Healthcare Utilization and Costs
Inpatient healthcare utilization declined between 2007 and 2008, but outpatient care and professional visits rose. Costs associated with healthcare services increased in the same time frame.

Percentage Change in Healthcare Utilization Between 2007 and 2008 7.7% 1.7% 1.7% Percentage Change in Healthcare Costs Between 2007 and 2008
-0.4% -3.9% 4.4%
2.9% 2.5%
Outpatient Professional Inpatient Days Services per Office Services per 1,000 Member per Member
Pharmacy Scripts per Member
Inpatient Allowed Amount per Day
Outpatient Professional Allowed Allowed Office Allowed Amount per Amount per Amount per Script Service Service
Note: Data include commercially insured individuals below age 65. Source: BHI (2009) BHI is a registered trademark of the Blue Cross and Blue Shield Association. The information contained herein is proprietary and was derived from claims information submitted by Member Plans of the Blue Cross and Blue Shield Association. 2009 BHI All Rights Reserved. No reproduction without permission.
23
Physician Office Visits
The total number of physician visits has remained relatively stable. Over half of visits are for primary care.

Physician Office Visits per 100 People Office Visits by Physician Specialty
317
315
329 307
336
All Others 28%
General and Family Medicine 23%
Oncology 2% Orthopedic Surgery 5% Opthalmology 6% Obstetrics and Gynecology 8%
Internal Medicine 14%
Pediatrics 14%
2003
2004
2005
2006
2007
Source: Centers for Disease Control and Prevention. Health, United States, 2006-2009, Centers of Disease Control and Prevention (2008) National Health Statistics Reports, Number 3.
24
Hospital Employees in Millions and Percentage of Hospitals with Physician Affiliations by Organization
Hospitals are employing more staff and reducing external affiliations.
4.5 4.1 21% 16% Physician-Hospital Organization 13% Independent Practice Organization 10% 9% Management Service Organization Group Practice without Walls 4% 3% 19% Hospital Full-time Equivalents
2003
2007
Source: Adapted from the American Hospital Association and Avalere Chartbook 2009: Trends Affecting Hospitals and Health Systems.
25
Annual Growth in Drug Spending
After several years of declining trend, the rate of growth in specialty and overall drug spending rose between 2007 and 2008, driven by increased unit costs.
Prescription Expenditures
2004 20.4% 4.5% 2005 2006 2007 2008
16.9%
16.1%
15.8% 12.4%
Specialty Pharmaceutical Specialty.drugs.accounted.for. 12.8%.of.total.pharmacy.spend. in.2008..The.top.therapeutic. classes.contributing.to.specialty. drug.pharmacy.spending. include.autoimmune.conditions,. multiple.sclerosis.and.cancer,. together.comprising.60.percent. of.specialty.drug.spend.
15.9%
6.6% 8.8% 8.5% 3.1% 10.3%
11.5%
8.4% 5.4% 2.7% 2.7% 7.3% 2.8% 1.8% 1.0% Specialty Total Drug Drug Utilization 3.9% 2.0% 1.6% 3.3% 0.4% 4.3% 4.4%
5.4%
Specialty Total Drug Drug
Specialty Total Drug Drug
Specialty Total Drug Drug Unit Cost
-1.1% Specialty Total Drug Drug
Note: Medicare utilization is included in Medcos overall trend as of January 1, 2006. Source: Drug Trend Report: The Great Healthcare Debates. 2009 Medco Health Solutions, Inc.; Drug Trend Report: Predictions. 2008 Medco Health Solutions, Inc.; Drug Trend Report: Humanomics. 2007 Medco Health Solutions, Inc.; Drug Trend Report: Personalizing Healthcare. 2006 Medco Health Solutions, Inc.
26
Generic Prescriptions as a Percentage of Total Scripts, 2006 - 2008
Average Consumer Pharmacy Copayments by Tier
As a percentage of all scripts, generic scripts are on the rise, up 5.4 percentage points between 2006 and 2008.
While average copayments for generic prescriptions remain at $10, copayments for other prescriptions continue to rise.
$85 53.4% 56.1% 58.8% $74
$46 $40 $23 $10 $10 $27
Generic Drugs (Tier 1) 2006 2007 2008
Preferred Drugs (Tier 2)
Non-Preferred Drugs (Tier 3)
Other (Tier 4)*
2005
2009
Note: Data include commercially insured individuals below age 65. Source: BHI (2009) BHI is a registered trademark of the Blue Cross and Blue Shield Association. The information contained herein is proprietary and was derived from claims information submitted by Member Plans of the Blue Cross and Blue Shield Association. 2009 BHI All Rights Reserved. No reproduction without permission.
*Fourth-tier drugs are drug products, such as lifestyle or injectable drugs, that are paid for using new types of cost-sharing arrangements that typically have higher copayments or coinsurance. The average copayment for fourth-tier drugs is calculated using information from only those plans that have a fourth-tier copayment amount. Source: Employer Health Benefits 2009 Annual Survey, (#7936), The Henry J. Kaiser Family Foundation and HRET, September 2009. This information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, Calif., dedicated to producing and communicating the best possible information, research and analysis on health issues.
27
Generic Drug Approvals
Each year about 100 first-time generics are introduced. Patent expirations of several blockbuster drugs in the next two years will open almost $18 billion to generic competition.
First-Time Generic Drug Approvals 112 100 93 99 91 Patent. Expiration
Blockbuster Drugs Going Off-Patent
Drug.Brand.Name. (Manufacturer) Flomax.(Boehringer. Ingelheim) Effexor.XR.(Wyeth) Aricept.(Eisai) Levaquin. (Ortho-McNeil) Actos.(Takeda) Zyprexa.(Lilly) Lipitor.(Pfizer)
Use/Indication Benign.Prostatic. Hypertrophy Depression Alzheimers.Disease Bacterial.Infections Type.2.Diabetes Schizophrenia High.Cholesterol Total
2008.U.S.. Sales (Billions.of. Dollars) $1.3 $2.8 $1.2 $1.7 $2.6 $1.9 $6.4 $17.9
2010
2011
2005
2006
2007
2008
2009
Note: First-time generics are those drug products that have never been approved before as generic drug products and are new generic products to the marketplace. Source: Center for Drug Evaluation and Research, Food and Drug Administration (2010) www.fda.gov/cder/ogd/approvals/default.htm, Drug Trend Report: The Great Healthcare Debates. 2009 Medco Health Solutions, Inc.
28
Average Annual Premium for Family Coverage
Due to rising healthcare costs, annual family health insurance premiums have risen 23 percent in the last five years; employers continue to cover nearly three-fourths of those costs.
Private Health Insurance
75.1%
74.1%
72.9%
73.5%
73.7% $13,375 $3,515
$10,880 $2,713
$11,480 $2,973
$12,160 $3,281
$12,680
$3,354
$8,167
$8,508
$8,824
$9,325
$9,860
2005
2006 Employer Contribution
2007
2008 Employee Contribution
2009
Percentage of Employer Contribution

Note: Coverage is for a family of four. Source: Calculated based on Employer Health Benefits 2009 Annual Survey, (#7936), The Henry J. Kaiser Family Foundation and HRET, September 2009 This information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, Calif., dedicated to producing and communicating the best possible information, research and analysis on health issues.
29
Hospital Payment-to-Cost Ratios for Medicare, Medicaid and Private Payers
Percentage of Members Out-of-Pocket Cost Sharing by Product Line, 2006 - 2008
Hospitals use higher charges to private payers to compensate for a gap in payments from Medicare and Medicaid.
Between 2006 and 2008, percentage of members out-ofpocket cost sharing remained relatively flat, but actual member out-of-pocket spending increased.

13.2%
13.0% 11.5%
13.1% 11.1% 10.8%
129%
129%
130%
132% 128%
11.6%
Break Even (Payment = Cost)
9.3%
10.4%
100% 92% 90% 92% 91% 91% 88% 91% 89% 2006 Annual.Member. Out-of-Pocket.. Spending 2007 2008 5.6% 5.7% 5.9%
87%
86%
2004
2005
2006
2007
2008
$230
$261
$287
Private Payers
Medicare
Medicaid
HMO
POS
TRD
PPO
Note: Payment-to-cost ratios indicate the degree to which payments from each payer covers the costs of treating that providers patients. Data are for community hospitals and cover all hospital services. Imputed values were used for missing data (about 35% of observations). Most Medicaid managed care patients are included in the private payers category. Source: Adapted from the American Hospital Association and Avalere Health TrendWatch Chartbook 2009: Trends Affecting Hospitals and Health Systems; Avalere Health analysis of American Hospital Association Annual Survey data, 2008, for community hospitals. Healthcare.Trends.in.America:.A.Reference.Guide.from.BCBSA.(2010.Edition)
Note: Data include commercially insured individuals below age 65. TRD is traditional health plan. Source: BHI (2009) BHI is a registered trademark of the Blue Cross and Blue Shield Association. The information contained herein is proprietary and was derived from claims information submitted by Member Plans of the Blue Cross and Blue Shield Association. 2009 BHI All Rights Reserved. No reproduction without permission.
30
Actions Organizations Are Taking Regarding Their Healthcare Programs Given Recent Events in Economy
About 60 percent of companies are very confident they will continue to offer healthcare benefits in a decade, a decline from 2007.
Actions Organizations Are Taking Regarding Their Healthcare Programs Given Recent Events in Economy
Employers Who are Very Confident that Healthcare Benefits Will be Offered by Employers for the Next Decade
Have.Already. Taken.Action Delay/Cancel. Planned.Changes. in.Plan.Design Delay/Cancel. Planned.Program. Offerings Develop. Contingency. Plan.for.Midyear. Changes Increase.Employee. Cost.Sharing Revamp. Healthcare. Strategy 6%
Expect.to.. Take.Action 7%
No.Action. Expected 87% 43% 59%
73% 62%
5%
8%
86%
1%
13%
86%
34% 30%
23% 30%
44% 41%
2003
2005
2007
2008
Source: Towers Watson and NBGH (2009) The Keys to Continued Success: Lessons Learned from Consistent Performers. 14th Annual Employer Survey on Purchasing Value in Healthcare.
31
Private Health Plan Administrative Expenses as a Percentage of Premiums
Savings and Recoveries from Fraud Investigations in Millions
Administrative costs of private health plans represent about 9 percent of overall premiums. Additionally, administrative functions covered by private health plans exceed that of Medicare.
Administrative Cost Efficiencies
Blue Cross and Blue Shield Companies anti-fraud efforts are helping to control costs, yielding savings and recoveries of nearly $350 million in 2008.
Administrative Cost Efficiencies

16,612
9.2%
Private Health Plans Administrative Functions In.addition.to.the. administrative.functions. that.Medicare.performs,. private.health.plans.also. perform.the.following. functions: 9,817
11,655
$347
$248
$150
Medical.Management/ Quality.Assurance,. including.Care. Coordination,.Disease. Management.and. Wellness Provider.Contracting* Corporate.Services
$187
$114
$128 $197 $134 $59 2006 2007 2008
Savings
Recoveries
Investigations Closed
*Medicare may perform these functions in a limited capacity. Source: Douglas B. Sherlock, CFA, Administrative Expenses of Health Plans (2009).
Source: Blue Cross and Blue Shield Association (2009).
32
Improving Quality and Safety

Potential.Savings.from.Improvements.in.Healthcare.Quality.and.Safety.............. 35 Sentinel.Events. ............................................................................................................ 36 . Variations.in.Treating.Patients. ................................................................................... 37 . Knee.and.Hip.Replacement.Surgery.per.10,000.Members.in.2007.by.Region....... 38 Inappropriate.Use.of.Antibiotics................................................................................. 39 Examples.of.MHA.Keystone.Center.Collaborative.................................................... 40 AHRQ/Boston.Medical.Center.Project.RED.(Re-Engineered.Discharge)................ 41 Percentage.of.Hospital.Patients.Receiving.Evidence-Based.Care.......................... 42 . Blue.Distinction.Centers .Designations..................................................................... 43 Patient.Outcomes.at.Blue.Distinction.Centers .........................................................44 Average.Cost.of.Initial.Bariatric.Procedure................................................................ 45 Clinical.Quality.Information.Needed.When.Selecting.. a.Physician/Facility....................................................................................................... 46 Effective.Policy.Strategies.to.Control.Costs.while.Maintaining.. or.Improving.Quality.................................................................................................... 46 . Initiatives.Aimed.to.Increase.Quality.of.Care............................................................ 47 Payment.Policies.Involving.Never.Events.................................................................. 48 Pay-for-Performance.(P4P).Programs. ....................................................................... 49 . Components.in.Provider.Measurement.for.P4P.Programs...................................... 50 Percentage.of.P4P.Programs.Reporting.Improvement............................................. 51 CMS.Hospital.P4P.Demonstration.Average.Composite.Quality.Score................... 52
Section
33
Summary
Improving patient safety and care by delivering consistent, high-quality care is critical to achieving a better healthcare system. Inconsistencies in the quality of care can lead to preventable illness, injury, unnecessary hospitalization or even death. Promoting and adhering to proven, evidence-based treatments and procedures will help save lives and lower healthcare costs. The impact of treatment variations and inconsistencies is significant, with some estimates indicating that better quality and safety could save nearly 90,000 lives and as much as $400 billion a year. There are positive signs as payers are no longer reimbursing claims related to never events serious medical errors that should not happen. In fact, all 39 Blue Cross and Blue Shield companies have adopted payment policies that prohibit reimbursement to contracted acute care hospitals for 12 preventable events identified by the Centers for Medicare & Medicaid Services.
Collaborating with leading medical organizations across the country, Blue Cross and Blue Shield companies have more than 1,600 Blue Distinction programs in 46 states and the District of Columbia committed to improved quality and safety standards in the areas of cardiac care, bariatric surgery, complex and rare cancers, transplants, spine surgery and knee/hip replacement. In order to receive a Blue Distinction designation, facilities must meet stringent evidence-based, quality-focused selection criteria developed with the help of expert physicians and medical organizations. Efforts by the Blues and others to reward higher quality care will improve health outcomes and patient medical experiences, and is a cornerstone for maintaining healthcare affordability.
34
Potential Savings from Improvements in Healthcare Quality and Safety
Quality and safety initiatives can help reduce unnecessary medical spending, estimated at more than $400 billion annually or 16 percent of healthcare spending.
$402B
$210B
$100B $25B $1B Overprescribing Antibiotics $3B Hospital Acquired Infections $10B Treatment Variations $14B $17B $22B
Unnecessary ER Visits
Medical Errors
Poorly Managed Diabetes
Preventable NonHospital Adherence Re-admissions
Defensive Medicine
TOTAL
Source: PricewaterhouseCoopers Health Research Institute (2009) The Price of Excess: Identifying Waste in Healthcare Spending.
35
Sentinel Events
Sentinel or never events situations that should not happen continue to be a problem nationwide.
Self-Reported Sentinel Events 510 450 12 367 344 12 507 33
JCAHO Reviewed Sentinel Events per Million by State
18 32 15
16 21 8 33 19 14 16 11 16 22 13 57 10 16 14 23 14 19 24 25 17 14 16 43 15 26 18 21 DC: 96 25 19 22 17 16
12
21
15 17 18
19
23
15 14
34 PR: 12 2005 2006 2007 2008 2009* 29
*Cumulative as of Q3 2009. Note: A sentinel or never event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase or the risk thereof includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called sentinel because they signal the need for immediate investigation and response. Source: Joint Commission (2009) Sentinel Event Statistics as of Sept. 30, 2009.
36
Variations in Treating Patients
There is considerable variation by region in the quality of care delivered for treating diabetes and cardiovascular disease.
Variation in the Quality of Care for Diabetes
Variation in the Quality of Care for Cardiovascular Disease
Pacific: +1.2
Mountain: -0.8
West North Central: +1.3
East North Central +1.8
Mid Atlantic: +0.5
New England +5.6
Pacific: -0.5
Mountain: -1.5
West North Central: -0.7
East North Central +2.0
Mid Atlantic: +2.3
New England +5.3
South Central: -5.3
South Atlantic: -1.7
South Central: -4.9
South Atlantic: -1.5
-2.5% or more
-1.0% to -2.5%
Within 1.0% of mean
+1.0 to 2.5%
+2.5 or more
Difference From National Average
Note: Measures include only commercially insured members and exclude Medicare and Medicaid members. Source: National Committee for Quality Assurance. The State of Healthcare Quality Report, 2007-2009.
37
Knee and Hip Replacement Surgery per 10,000 Members in 2007 by Region
There also is variation in procedures, for example, the rate of hip and knee replacement surgeries nationwide.
Knee Replacements National Average: 17.4 Pacific: 13.6 West North Central: 21.5 Pacific: 8.3
Hip Replacements National Average: 8.5 West North Central: 10.2
Mountain: 20.9
East North Central 18.2
New England 14.0
Mountain: 10.3
East North Central 9.8
New England 9.4
Mid Atlantic: 13.6
Mid Atlantic: 8.7
West South Central: 17.2
East South Central: 17.5
South Atlantic: 16.1
West South Central: 6.7
East South Central: 7.6
South Atlantic: 8.3
Note: Data include commerically insured individuals below age 65. Source: BHI (2009). BHI is a registered trademark of the Blue Cross and Blue Shield Association. The information contained herein is proprietary and was derived from claims information submitted by Member Plans of the Blue Cross and Blue Shield Association. 2009 BHI All Rights Reserved. No reproduction without permission.
38
Inappropriate Use of Antibiotics
There is inconsistency in the appropriate use of antibiotics.
Use of Antibiotics for Acute Bronchitis
Acute.bronchitis.is.a. respiratory.infection. characterized.by.a.cough. that.lasts.up.to.three.weeks. and.is.caused.by.a.bacteria. in.only.one.in.every.10. cases,.suggesting.that. antibiotic.treatment.is.. rarely.warranted. Prescription.of.antibiotics. for.viral.infections.are. ineffective.and.result.in. wasted.expenditure. Over.prescription.of. antibiotics.can.potentially. lead.to.resistance.and. increased.costs.
71.3%
74.6%
75.4%
2006
2007
2008
Measure: Percentage of people aged 18 to 64 diagnosed with acute bronchitis and given an antibiotic prescription.
Note: Measures include only commercially insured members and exclude Medicare and Medicaid members unless stated. Source: National Committee for Quality Assurance. The State of Healthcare Quality Report, 2007-2009.
39
Examples of MHA Keystone Center Collaborative
Quality initiatives, such as the use of checklists, have resulted in lives saved, shorter hospital stays and reduced costs.
Quality Initiatives
Intensive.Care.Unite.(ICU) Initiative
Hospital-Associated.Infection.(HAI)
Launched.in.October.2003.with.results.from.74.hospitals.as.of.March.2009 Reduce.central.line-associated.bloodstream.infections.(CLABSIs).and. ventilator-associated.pneumonia.(VAP).in.intensive.care.unit.(ICU). patients Set.up.a.team.that.includes.hospital.administrator,.directors,.nurses.. and.physicians Utilize.a.checklist.to.ensure.adherence.to.infection.control.practices $271M $271M 1,830 1,830 140,700 140,700
Launched.in.2007.with.initial.results.from.16.hospitals Eliminate.HAIs
Interventions
Focus.on.appropriate.hand.hygiene,.reducing.catheter-associated.. urinary.tract.infections.(CA-UTI).and.avoiding.CLABSIs Collect.data,.share.findings.and.tweak.intervention.accordingly
32K 32K Patients Patients with CA-UTIs with CA-UTIs
29K 29K
1,000 1,000
$1M $1M
Results
Lives Saved Lives Saved
Avoided Avoided Hospital Days Hospital Days
Healthcare Healthcare Dollars Saved Dollars Saved
Jan 08 Jan 08
Jul 08 Jul 08
Avoided Avoided Hospital Days Hospital Days
Healthcare Healthcare Costs Saved Costs Saved
Note: MHA is the Michigan Health and Hospital Association. Source: MHA Keystone Center for Patient Safety and Quality (2009) Setting the Healthcare Agenda. 2009 Annual Report.
40
AHRQ/Boston Medical Center Project RED (Re-Engineered Discharge)
A well-defined hospital discharge protocol leads to better patient outcomes and reduced costs.
Quality Initiatives
Cost for: Hospital Visits* $412,544 $21,389 $1,203 ER Visits PCP Visits Per Discharged Patient
Overview Focus.on.educating.patients.about. post-hospital.care. 1.. Define.roles.and.responsibilities. of.each.staff.member 2..Educate.patients.throughout. hospitalization 3..Use.a.written.discharge.to. facilitate.flow.of.information. between.patients.doctor.and. hospital.team
$268,942 $11,825 $8,906 $12,617 $791
Non-Intervention Patients
*Hospital visits include initial visit plus readmission when applicable. Source: Agency for Healthcare Research and Quality (2009) Project RED (Re-Engineered Discharge) Toolkit.
Intervention Patients
41
Percentage of Hospital Patients Receiving Evidence-Based Care
There has been a dramatic increase in the percentage of patients receiving evidence-based care for heart failure, pneumonia and heart attacks.
Quality Initiatives
91.6%
92.9% 86.9% 72.3%
96.7%
59.7% Heart.Failure.Care.Composite Pneumonia.Care.Composite Heart.Attack.Care.Composite
Improvement. Since.Inception.of.Metric 31.9% 20.6% 9.8%
Heart Failure Composite
Pneumonia Care Composite 2002 2008
Heart Attack Care Composite
Note: All improvements in performance are statistically significant. Composite measures combine the results of all individual measures into a single percentage rating calculated by adding, or rolling up, the number of times recommended care was provided to patients and dividing this sum by the total number of opportunities to provide this care. Source: The Joint Commission (2009) Improving Americas Hospitals: The Joint Commissions Annual Report on Quality and Safety.
42
Blue Distinction Centers Designations
The Blues promote quality care with more than 1,600 programs designated as Blue Distinction Centers (BDCs) across 46 states in the U.S.
Quality Initiatives
Blue Distinction Centers for Bariatric Surgery Blue Distinction Centers for Cardiac Care Blue Distinction Centers for Complex and Rare Cancers Blue Distinction Centers for Knee and Hip ReplacementSM Blue Distinction Centers for Spine SurgerySM Blue Distinction Centers for Transplants
WA
MT
ND SD WY NE
MN WI IA IL VT NH NY MI MA CT RI PA OH ID NJ DE WV MD VA KY TN AR MS AL GA NC SC ME
OR
ID
NV CA
UT
CO
KS MO OK TX
AZ
NM
LA
FL AK HI
Note: Designation as Blue Distinction Centers means these facilities overall experience and aggregate data met objective criteria established in collaboration with expert clinicians and leading professional organizations recommendations. Individual outcomes may vary. To find out which services are covered under your policy at any facilities, please call your local Blue Cross and/or Blue Shield Plan. Source: Blue Cross and Blue Shield Association (2010).
43
Patient Outcomes at Blue Distinction Centers
Blue Distinction Centers (BDCs) deliver significantly better overall quality outcomes.
Quality Initiatives
54%
39%
19% 11% 2% 3% Adult Allogeneic Stem Cell Transplant (1 year post) Mortality Rates Heart Transplant (1 year post) 5%
8%
Bypass Surgery
Bariatric Surgery (30 days post)
Complication Rates
BDC
Other
Statistically significant difference
Note: Results shown are mean values. Mortality rates for bypass surgery and heart transplant are risk-adjusted. Source: Blue Cross and Blue Shield Association (2010) BCBSA Analysis of 2005-06 Hospital RFI Data. Bone marrow transplant data based on 2009 actuarial analysis of RFI data. Heart transplant data include facility results abstracted from the Scientific Registry for Transplant Recipients.
44
Average Cost of Initial Bariatric Procedure
Blue Distinction Centers (BDCs) demonstrate a statistically significant cost advantage while demonstrating quality expected from BDCs robust designation requirements
Quality Initiatives
Highest Volume Bariatric BDCs
Fastest Growing
(3.7%) (11.0%)
BDCs.perform.significantly.greater.volume.. of.bariatric.procedures.than.non-BDCs Majority.of.Bariatric.BDCs.are.accredited.by.one. of.two.bariatric.specialty.medical.organizations. (vs..only.1/3.of.non-BDCs.that.have.the.same. accreditation) Comparable.readmission.rates.for.BDCs.and. non-BDCs.for.the.same.procedures HealthCore.Inc..analysis.found.that.BDCs.deliver. better.quality.as.demonstrated.by.significantly. lower.complication.rates.for.overall.bariatric. surgeries 18,059 $18,750
11,445
$12,865
Laparoscopic Gastric Bypass - Inpatient
Laparoscopic Gastric Bypass - Outpatient
BDC
Non-BDC
Statistically significant difference
Note: BDC significantly different than non-BDC with p<0.05. Source: American Society for Metabolic and Bariatric Surgery (ASMBS) and American College of Surgeons (ACS); HealthCore Inc. 2009 evaluation of Bariatric Surgery BDCs: WellPoint data; 2009 Milliman Evaluation of Bariatric Surgery BDCs; BHI (2009); 2009 Blue Cross and Blue Shield Association (BCBSA) Analysis of Bariatric Surgery RFI Data. BHI is a registered trademark of the Blue Cross and Blue Shield Association. The information contained herein is proprietary and was derived from claims information submitted by Member Plans of the Blue Cross and Blue Shield Association. 2009 BHI All Rights Reserved. No reproduction without permission.
45
Clinical Quality Information Needed When Selecting a Physician/Facility
Effective Policy Strategies to Control Costs while Maintaining or Improving Quality
Consumers indicate that physician participation in and recognition by quality programs influences selection of physician or facility.
Leading health experts believe aligning incentives is a way to control costs and improve quality.
Quality Initiatives
Aligning Incentives
Provider payment reform, moving away from FFS toward bundled payment
70%
68% 53% 53% 49%
P4P with rewards to high-quality providers All-payer rate setting Incentives for patients who choose high-quality providers Reporting information on provider quality and efficiency Malpractice liability reform
45% 40%
35%
30%
Hospital participates in medical errors program
Physician follows prescription medication guidelines
Physician follows Physician early disease recognized by detection quality assessment guidelines organization
24%
More consumer cost-sharing
19%
Source: Blues Cross and Blue Shield Association (2009) Transparency Survey.
Base: Opinion leaders in health policy and innovators in healthcare delivery and finance within the U.S., as identified and nominated by peers. Figure captures response of very or extremely effective. Source: Commonwealth Fund Healthcare Opinion Leaders Survey, April 2009.
46
Initiatives Aimed to Increase Quality of Care
Several quality improvement initiatives are focused on aligning incentives with performance.
Aligning Incentives
Efforts Provider Performance Measurement and Recognition
Organizations
Tactics

Federal.and.State.Government..Medicare.and.. Medicaid.Programs
Measure.provider.performance.for.various.metrics.related.to. diagnosis,.treatment.and.management.of.disease.to.provide.. a.baseline.for.providers.and.gain.insight.about.possible.areas.. of.improvement... Promote.adherence.to.evidence-based.care. Make.information.available.to.consumers.to.increase. transparency.and.aid.in.decision.making. Align.financial.incentives.among.providers.to.create.a.system.. of.joint.clinical.and.financial.accountability.. Not.paying.for.never.events. Possibly.provide.disincentives.for.the.provision.of.lower.quality. healthcare. Create.mechanisms.to.review.and.monitor.information.to.identify. potential.errors.and.risks.
Shared Accountability
The.Joint.Commission.on.the.Accreditation.of. Healthcare.Organizations.(JCAHO).
Incentive Programs
The.Leapfrog.Group
Employers
Private.Payers
Source: Blue Cross and Blue Shield Association (2009).
47
Payment Policies Involving Never Events
Payers are not reimbursing hospitals for never events, which encourages quality of care.
Aligning Incentives
Never Events Overview
In.2002,.the.National.Quality.Forum.(NQF).established.27.never.events. (currently.there.are.28),.adverse.events.that.were.serious,.largely. preventable. .Example.includes.wrong-site.surgery. In.2006,.The.Leapfrog.Group.issued.a.never.event.policy.based.on.the. NQF.list.that\.asks.hospitals.to.waive.incremental.costs.associated.with. never.event. On.January.15,.2009,.the.Centers.for.Medicare.and.Medicaid.Services. (CMS).no.longer.covered.a.surgical.or.invasive.procedure..cost.of. operating.room,.hospitalizations.and.other.services..related.to.a. practitioner.erroneously.performing.a.different.procedure,.the.correct. procedure.but.on.the.wrong.body.part;.or.the.correct.procedure.but.on. the.wrong.patient.. Private.payers.are.not.paying.for.never.events
Percentage of Hospitals Agreeing to Implement Leapfrogs Never Event Policy*
65% 53%
All.39.independent.Blue.Cross.and.Blue.Shield.companies.have. established.a.payment.policy.that.prohibits.reimbursement.to. contracted.acute.care.hospitals.for.never.events. Aetna,.CIGNA.and.UnitedHealthcare.are.incorporating.never.events. language.into.their.contracts
2007
2008
*2008 survey results are based on 1,282 acute care hospitals in 44 states. Source: Centers for Medicare and Medicaid Services (2009); The Leapfrog Group, Leapfrog Hospital Survey Report, 2009; Lembitz, A et al. (2009) Clarifying Never Events and Introducing Always Events. Patient Safety in Surgery. December 2009; Blue Cross and Blue Shield Association (2010); Dallas Business Journal (2008) Medicare, Insurers to Stop Reimbursing for Errors. October 17 2008. ,
48
Pay-for-Performance (P4P) Programs
Pay-for-performance (P4P) programs are expanding and many are leading to improvements in both quality and cost.
Aligning Incentives
Average P4P Incentives as a Percentage of Total Compensation
Percentage of Programs Reporting Improvements in Performance*
6.8%
7.3% 43% 2.5% 10% 2008 62 Physician 52 Hospital 2006 Quality
52%
1.9% 2006
21%
2008 Cost
*Data are specific to physician P4P programs only and does not include hospital P4P . Note: Fifty-two plans responded to the survey in 2006 and 62 plans reported to the survey in 2008. Source: Med-Vantage, Inc., The Leapfrog Group and Integrated Healthcare Association (IHA). 2008 Surveys of P4P and Transparency Programs. All rights reserved.
49
Components in Provider Measurement for P4P Programs
Clinical quality, safety and efficiency are common features in the Various P4P programs offered by individual Blue Cross and Blue Shield Plans.
Aligning Incentives
Hospitals
Physicians*
5% 9%
7% 27% Clinical quality accounts for at least 50 percent of P4P metrics
51% 5% 16% 2%
21%
58%
Clinical quality Efficiency or cost of care
Patient safety or medical error reduction Patient satisfaction
Other (Administrative, Clinical HIT Adoption, Member Access**, and Utilization***)

*Figures do not add up to 100% due to rounding. **Not part of hospital-based survey. ***Not part of physician-based survey. Note: Each BCBS Plan, acting as an independent entity, makes its own determination on all issues involving benefits, claims, coverage, accounts, and provider contracting (including but not limited to and P4P features). Source: Med-Vantage 2009 National P4P Survey - BlueCross BlueShield Plan Responses.
50
Percentage of P4P Programs Reporting Improvement
Of the Blue Cross and Blue Shield Plans that analyzed the impact of P4P programs, more than 80 percent report improvements in physician and hospital clinical measures after implementing P4P.
Aligning Incentives
82%
88%
64% 55%
25% 13%
27%
25% 18% 13%
Performance on clinical measures has improved
Providers have invested in QI or electronic systems
Performance on patient surveys has improved
Cost performance has improved
Too early to tell
Physician
Hospital
Source: Med-Vantage 2009 National P4P Survey - BlueCross BlueShield Plan Responses.
51
CMS Hospital P4P Demonstration Average Composite Quality Score
CMS P4P demonstration program has resulted in the delivery of higher quality care.
Aligning Incentives
97.4% 84.8% 84.6% 96.9% 87.5%
88.7% 69.3%
90.5%
96.1% Hospital P4P: Premier Demonstration Overview
64.5%
Demonstration.started.in.. October.2003 250.hospitals.in.38.states CMS.P4P.covered.five.. clinical.areas:

8.6%
Acute.Myocardial.Infarction. (AMI) Coronary.Artery.Bypass.Graft. (CABG) Heart.Failure Pneumonia Hip.and.Knee.Replacement
Heart Failure
Pnuemonia
CABG
Hip and Knee Replacement 12.3%
AMI
24.2%
21.2%
12.6%
Improvement.Between.Year.1.and.Year.3
Year 1
Year 3
Source: Centers for Medicare and Medicaid Services (2008) Roadmap for Implementing Value Driven Healthcare in the Traditional Medicare Fee-for-Service Program.
52
Promoting Quality and Health Improving Consumer Safety
Improving Consumer Health

Leading.Causes.of.Death.in.Thousands..................................................................... 55 Direct.and.Indirect.Costs.Related.to.Disease.and.Poor.Lifestyle.. Choices.in.Billions......................................................................................................... 56 Increase.in.Visiting.Physicians.Annually.Between.2006.and.2008.. ....................... 57 . Employer.Strategies.for.Promoting.Primary.Care.................................................... 57 . Adults.Age.18.and.Over.with.Cardiovascular.Disease.in.Millions........................... 58 Hospital.Discharges.for.Cardiovascular.Disease...................................................... 59 . Managing.Cardiovascular.Disease. ............................................................................ 60 . Screening.for.and.Managing.Cardiovascular.Disease.............................................. 61 Prevalence.of.Cancer.................................................................................................... 62 Impact.of.Cancer.Screening........................................................................................ 63 . Preventive.Screening.for.Cancer. ............................................................................... 64 . Physical.Activity.Levels.in.Children.and.Adults........................................................ 65 Children.and.Adults.Considered.Overweight............................................................ 66 Prevalence.of.Obesity.Among.U.S..Adults.by.State................................................. 67
Section
Increase.in.Adult.Per.Capita.Medical.Spending.Attributable.to.Obesity,.. By.Insurance.Status.and.Type.of.Service,.2006.(in.2008.Dollars)........................... 68 Utilization.Rates.and.Medical.Expenditures.for.Children.. with.Private.Insurance.................................................................................................. 68 Screening.and.Managing.Obesity.and.Promoting.Physical.Activity...................... 69 Obesity.and.Diabetes................................................................................................... 70 Prevalance.of.Diabetes.Among.Children.and.Adults................................................ 71
Preventing.and.Managing.Diabetes............................................................................ 72 Screening.for,.Monitoring.and.Managing.Diabetes.................................................. 73 Prevalance.of.Smoking.Among.High.School.Students.and.Adults.. ...................... 74 . Impact.of.Smoking........................................................................................................ 75 Monitoring.and.Advising.Against.Smoking............................................................... 76
53
Summary
Improving the health of Americans represents a major challenge. By some estimates, nearly half of our total national health expenditures are spent on treating heart disease, cancer, diabetes (three of the top five leading causes of death in the U.S.) and poor lifestyle choices such as smoking, sedentary behavior and over-eating. Obesity and sedentary behavior are linked to the onset of diabetes and are risk factors for several other conditions. Obese adults spend $1,400 more on healthcare services and prescription drugs annually than adults with normal weight. Overweight children are also more likely to need physician visits, be hospitalized or need treatment for mental or physical conditions. Regular exercise and maintaining a healthy weight help prevent diabetes. Today, two-thirds of adults and one in six children aged six-19 are overweight. Fewer than half of all children meet physical activity guidelines, and only 31 percent of adults report
having regular exercise, while nearly 40 percent of adults report being inactive. In addition, the rate of children and adults diagnosed with diabetes is on the rise even though in many cases the onset of diabetes can be prevented. Prevention can help alleviate the impact of other diseases as well. Early screening for cancer can reduce the number of people who die from colorectal cancer by at least 60 percent while blood pressure control reduces the risk of heart disease and stroke among people with diabetes by as much as 50 percent. Blue Cross and Blue Shield companies are teaming up with employers and other key stakeholders to provide education materials and health information to improve the health of the communities they serve. Most recently, Blue Cross and Blue Shield companies produced a diabetes toolkit for healthcare physicians and patients to help them prevent, treat and manage diabetes in children and adults.
54
Improving Healthcare Health National Consumer Trends
Leading Causes of Death in Thousands
Preventable and controllable illnesses, such as cardiovascular disease, diabetes and stroke, are among the leading causes of death in the U.S.
Burden of Disease
711 652 632 553 559 560
168
144
137
122
131
125 69 75 72
Heart Disease
Malignant Neoplasms (Cancer)
Cerebrovascular Disease (Stroke)
Chronic Lower Respiratory Disease
Diabetes
2000
2005
2006
Source: Centers for Disease Control and Prevention. (2009) Health, United States, 2003 and 2008.
55
Direct and Indirect Costs Related to Disease and Poor Lifestyle Choices in Billions
The estimated costs related to three major conditions cardiovascular disease, cancer and diabetes and poor lifestyle choices have been rising.
Burden of Disease
$474.8
$368.4
$161.5 Poor Lifestyle Choices $243.4 $313.3 $189.8 $144.4 $120.4 $85.3 $23.8 $69.4 $99.0 $61.5 2004 $115.9 $30.3 $85.6 2009 Obesity/Overweight $200.billion Smoking. Up.to.$191.billion
$141.7
$226.7
2004
2009
2004 Cancer Direct Costs
2009
Cardiovascular Disease
Endocrine, Nutritional and Metabolic Indirect Costs
Source: National Institutes of Health, National Heart, Lung and Blood Institute Fact Book, Fiscal Year 2003, 2007 and 2008, PricewaterhouseCoopers Health Research Institute (2009) The Price of Excess: Identifying Waste in Healthcare Spending.
56
National Consumer Trends Improving Healthcare Health
Increase in Visiting Physicians Annually Between 2006 and 2008
Employer Strategies for Promoting Primary Care*
Primary care, such as annual visits with a members physician, can identify at-risk individuals early. More people are seeing their physician on an annual basis, but there is room for improvement.
Primary Care
Employers are promoting the use of primary care through educational materials and incentives.
Primary Care
Provide general education material to employees and dependents
56%
6% 62%
25%
Designate in the network provider directory Waive/reduce copays for primary care office visits 24%
40%
1%
41%
2%
26%
14%
Steerage at times of interaction with health management programs Incent selection/use of primary care physicians Provide online messages to support primary care utilization Participate in community-based pilot programs
21% 3%
4%
25%
16%
19%
9% 5% 14%
Males, Age 20-64, with an Females, Age 20-64, with Annual Physician Visit an Annual Physician Visit
4% 2%
6%
In place now
Planned for 2010
Note: Data include commercially insured individuals below age 65. Source: BHI (2009). BHI is a registered trademark of the Blue Cross and Blue Shield Association. The information contained herein is proprietary and was derived from claims information submitted by Member Plans of the Blue Cross and Blue Shield Association. 2009 BHI All Rights Reserved. No reproduction without permission.
*Percentage of employers with better healthcare cost trends implementing strategies relative to those with worse cost trends. Source: Towers Watson and NBGH (2009) The Keys to Continued Success: Lessons Learned from Consistent Performers. 14th Annual Employer Survey on Purchasing Value in Healthcare.
57
Adults Age 18 and Over with Cardiovascular Disease in Millions
In 2008, more than 33 million Americans had cardiovascular disease an increase of about 3 million in the last five years.
33.1 30.2 5.5 30.8 5.2 29.7 5.6 30.5 6.5 5.4
24.7
25.6
24.1
25.1
26.6
2004
2005
2006
2007
2008
Heart Disease
Stroke
Source: Centers for Disease Control and Prevention (2009) National Health Interview Survey 2004-2008.
58
Hospital Discharges for Cardiovascular Disease
More people are hospitalized as a result of cardiovascular disease than any other condition.
Hospital Discharges in Millions for the Leading Diagnostic Groups Hospital Discharges Associated with Cardiovascular Disease in Thousands
Cardiovascular
6.2 6,294 4.1
6,373
6,363
6,161
Obstetrical
5,161
Digestive System
3.5
Respiratory System
3.5
Endocrine System
1.7
Neoplasms
1.6 1990 2000 2002 2004 2006
Source: Centers for Disease Control and Prevention, National Center for Health Statistics (2009), National Heart, Lung and Blood Institute (2009).
59
Managing Cardiovascular Disease
Reducing blood pressure and cholesterol levels significantly lowers the risk of cardiovascular disease.
Reducing.systolic.blood.pressure.12-13.mm.Hg.over.four. years.can.reduce: Overall Deaths Coronary Heart Cardiovascular Disease Disease Reducing.serum.cholesterol.levels.by.10.percent.. can.reduce: Heart Attacks Stroke
Stroke
13%
21% 25% 30% 30%
37%
Source: Centers for Disease Control and Prevention (2009) Chronic Disease Prevention and Health Promotions.
60
Screening for and Managing Cardiovascular Disease
Among those with cardiovascular disease, 89 percent receive proper cholesterol screening, while only 63 percent of those at risk have reduced their blood pressure to recommended levels.
Cholesterol Screening*
High Blood Pressure Management
87.5%
88.2%
88.9%
59.7%
62.2%
63.4%
2006
2007
2008
2006
2007
2008
Percentage of:
Members.aged.18.to.75.who.were.discharged.for.a.heart.condition.. who.received.an.LDL-C.screening
Hypertensive.members.age.18.to.85.whose.blood.pressure.was. controlled.to.less.than.140/90.mm.Hg.during.the.past.year
*Specific to patients with cardiovascular conditions. Note: Measures include only commercially insured members and exclude Medicare and Medicaid members unless stated. LDL-C is low density lipoprotein cholesterol. Source: National Committee for Quality Assurance. The State of Healthcare Quality Report, 2007-2009.
61
Prevalence of Cancer
Cancer is the number two leading cause of death in the U.S. The prevalence of cancer has gradually declined.
Cancer
Overall Prevalence of Cancer per 100,000 Prevalence of Cancer by Origin per 100,000 176.0 163.1 469.3 456.9 456.0 447.5 439.9 131.6 122.6 122.7 163.3 148.6 121.9 155.1
119.6
59.5
57.7
55.8
53.2
51.1
8.3 2002 2003 2004 2005 2006 2002
8.1 2003
7.7 2004
7.7 2005
7.3 2006
Colorectal (Male) Breast (Female)
Prostate (Male) Cervical (Female)
Source: Centers for Disease Control and Prevention (2009) Health, United States, 2008.
62
Impact of Cancer Screening
Routine cancer screening can reduce cancer mortality rates by up to 60 percent.
Cancer
Routine.colorectal.cancer. screening.can.reduce.the. number.of.people.who.die. from.colorectal.cancers.by:
Getting.a.mammogram.every. 1-2.years.for.women.age.40. and.over.can.reduce.mortality. rates.by:
After.implementation.of. screening.program,.rates.. of.cervical.cancer.dropped. up.to:
20%
60%
20% 25%
During a 10-year period
60%
Source: Centers for Disease Control and Prevention (2009).
63
Preventive Screening for Cancer
Although more people are getting the necessary screening for cancer, there is room for improvement.
Cancer
Breast Cancer 81.0%
Cervical Cancer 81.7% 80.0%
Colorectal Cancer
69.9%
69.1%
70.2%
54.5%
55.6%
58.7%
2006 Measure Percentage of:
2007
2008
2006
2007
2008
2006
2007
2008
Women.aged.40.to.69.who.had.at.least.one. mammogram.in.the.past.two.years
Women.aged.21.to.64.who.had.at.least.one.Pap. test.in.the.past.three.years
Adults.aged.50.to.80.who.had.appropriate. screening.for.colorectal.cancer
64
Physical Activity Levels in Children and Adults
Children and adults are not getting enough exercise.
Inactivity and Obesity
Percentage of Youths Meeting Physical Activity Guidelines by Age
Percentage of Adults who are Active or Inactive
49%
40.5%
40.5%
39.5%
39.1%
35% 29.5% 30.2%
31.0%
30.8%
12% 3% 6-11 Male 12-15 Female
10% 5% 16-19 1998 2005 2006 2007
Inactive
Regularly Active
Note: Those that are classified as inactive report no sessions of light/moderate or vigorous leisure-time activity of at least 10 minutes duration, while those who are classified as performing regular activity report three or more sessions per week of vigorous activity lasting at least 20 minutes or five or more sessions per week of light/moderate activity lasting at least 30 minutes in duration. Figures do not add up to 100 percent, the balance remaining are those individuals who report engaging in some physical activity. Source: Troiano R, Berrigan D, Dodd K, et al., Medicine & Science in Sports & Exercise (2008); Centers for Disease Control and Prevention (2009) Health, United States, 2008.
65
Children and Adults Considered Overweight
An increasing number of children and adults are considered overweight.

Percentage of Adults Age 20 - 74 with a BMI Greater than 25** 65.7% 17.5% 15.8%16.0% 17.0% 17.0% 17.6% 44.9% 11.3% 10.5% 13.4% 55.9% 31.3% 32.9% 35.1% 66.3% 67.3%
Percentage of Children and Adolescents Considered Overweight by Age Group*
23.2%
31.5%
32.7%
34.4%
33.4%
32.2%
1998-1994
1999-2002
2001-2004
2003-2006
1960-1962 1988-1994 2001-2002 2003-2004 2005-2006
Ages 6 - 11
Ages 12 - 19
Overweight (25 < BMI < 30)
Obese (BMI > 30)
*In children, overweight is defined as a BMI at or above the 85th percentile and lower than the 95th percentile. **In adults, overweight is defined as having a BMI greater than 25 but less than 30. Data include overweight and obese individuals. Note: Data are age adjusted. Source: Centers for Disease Control and Prevention (2009) NHANES.
66
Prevalence of Obesity Among U.S. Adults by State
In 2008, more than half of U.S. states had a prevalence of obesity greater than 26 percent. All states had a lower prevalence in 2000.
1994
2000
2008
No data
<14.0%
14.0 - 17.9%
18.0 - 21.9%
22.0 - 25.9%
26.0%
Note: Obesity is defined as having a very high amount of body fat in relation to lean body mass, or Body Mass Index (BMI) of 30 or higher. Source: Centers for Disease Control and Prevention (2009). Behavioral Risk Factor Surveillance System (BRFSS) www.cdc.gov/brfss/.
67
Increase in Adult Per Capita Medical Spending Attributable to Obesity, By Insurance Status and Type of Service, 2006 (in 2008 Dollars)
Utilization Rates and Medical Expenditures for Children with Private Insurance
Studies document a substantial increase in medical and prescription drug spending due to obesity.
Obese children are substantially more likely to visit a physician, be hospitalized and incur higher annual healthcare utilization costs.
Insurance. Category
Type.of.Service Inpatient.
Spending. Increase.($) 95b.(296). 693a.(128). 608 .(65).

a
Percent.Increase 4.4b.(13.0). 40.1a.(8.4). 72.7a.(10.3). 39.2b.(34.2). 14.8b.(12.8). 60.6a,b.(24.2). 90.3a.(23.9). 37.9a.(6.6). 81.8a.(12.4). 45.5a.(12.0). 26.9a.(4.7). 80.4a.(8.3). 26
44
5.6%
$3,547
Medicare
Non-inpatient. Rx.drug. Inpatient.
213b.(153). 175b.(172). 230a,b.(80). 443a.(85). 398a.(60). 284 .(41).

a
Medicaid
$1,346 1.3%
Private
420a.(93). 444a.(76). 568a.(59).
All.Payers
Non-inpatient. Rx.drug.
Physician Visits per Year
Hospitalization Rates per Year Obese Non-Obese
Annual Healthcare Utilization Costs
Notes: Bootstrapped standard errors are shown in parentheses. Obese is body mass index (BMI) 30 kg/m2. Dollar values were updated to 2008 using the gross domestic product price index provided by the Bureau of Economic Analysis, U.S. Department of Commerce. a Increased spending estimate is significantly greater than zero (p < 0.05). b Relative standard error is greater than 0.3, indicating that the estimate is unstable. Authors calculations based on data from the 2006 Medical Expenditure Panel Survey. Source: Finkelstein, E., et al (2009) Annual Medical Spending Attributable to Obesity: Payer and Service-specific Estimates. Health Affairs. Pg 822-831 July 27 2009 Web Exclusive , Healthcare.Trends.in.America:.A.Reference.Guide.from.BCBSA.(2010.Edition)
Source: Thomson Reuters. Childhood obesity: Medicaid versus private insurance. Accessed June 9, 2009.
68
Screening and Managing Obesity and Promoting Physical Activity
Only about 25 percent of people are documenting their BMI. Even a slight improvement in physical activity levels and BMI leads to better health and can result in significant savings.
Percentage.of.people.who.had.their. BMI.documented:
A.sustained.10.percent.weight.loss.will. reduce.an.overweight.persons.lifetime. medical.costs.by: $5,300
If.10.percent.of.adults.began.a.regular. walking.program: $5.6
27%
$2,200
From lower costs associated with hypertension, type 2 diabetes, heart disease
2008
2008
Savings in Heart Disease Costs in Billions
Note: Measures include only commercially insured members and exclude Medicare and Medicaid members unless stated. Source: National Committee for Quality Assurance. The State of Healthcare Quality Report, 2007-2009, Centers for Disease Control and Prevention (2009).
69
Obesity and Diabetes
Physical inactivity and obesity also are correlated with increasing diabetes diagnoses and prevalence.
Diabetes
U.S. Adults Who Were Obese (BMI 30 kg/m2) 1994 2008
No data
<14.0%
14.0 - 17.9%
18.0 - 21.9%
22.0 - 25.9%
>26.0%
U.S. Adults Who Had Diagnosed Diabetes 1994 2008
No data
<4.5%
4.5 - 5.9%
6.0 - 7.4%
7.5 - 8.9%
>9.0%
Note: Obesity is defined as having a very high amount of body fat in relation to lean body mass, or Body Mass Index (BMI) of 30 or higher. Data on prevalence of diabetes is age adjusted. Source: Centers for Disease Control and Prevention, Division of Diabetes Translation (2009) National Diabetes Surveillance System.
70
Prevalance of Diabetes Among Children and Adults
The prevalence of diabetes in adults and children is on the rise.
Diabetes
Prevalence of Diabetes per Diabetes per 1,000 Children Age 10 - 19* 4.4 4.6 4.7
U.S. Population Age 18 and Over with Diagnosed Diabetes in Millions** 8.3% 7.8% 7.7%
3.2
3.3
3.4 7.0%
7.4%
15.1
16.2
17.1
17.3
18.7
Age 10-14 2005 2006
Age 15-19 2007
2004
2005
2006
2007
2008
Number with Diabetes
Percentage with Diabetes
*Data include commercially insured children and young adults age 10 to 19 with Type 1, Type 2 and combination type diabetes. **Data include respondents who were asked if they had ever been told by a doctor or other health professional that they had diabetes (or sugar diabetes; female respondents were instructed to exclude pregnancy-related diabetes). Responses from persons who said they had borderline diabetes were treated as unknown with respect to diabetes. Source: BHI (2009); Centers for Disease Control and Prevention, National Center for Health Statistics (2008) National Health Interview Survey (NHIS) BHI is a registered trademark of the Blue Cross and Blue Shield Association. The information contained herein is proprietary and was derived from claims information submitted by Member Plans of the Blue Cross and Blue Shield Association. 2009 BHI All Rights Reserved. No reproduction without permission.
71
Preventing and Managing Diabetes
Increased physical activity and adherence to care programs, such as foot care and blood pressure control, reduces the risk for diabetes-related complications.
Diabetes
Foot.care.programs.that.include. regular.examinations.and.patient. education.could.prevent.up.to: Among.pre-diabetics,.a.7-percent. weight.loss.and.2.hrs.of.physical. activity.per.week.can.reduce:
Onset of Type 2 Diabetes
Proper.blood.pressure.control.among. diabetes.reduces.risk.of:
Heart Disease and Stroke Eye, Kidney and Nerve Disease
85%
35%
33%
50% 58%
Diabetes-Related Amputations
72
Screening for, Monitoring and Managing Diabetes
Most diabetics receive routine screening tests, however, less than half receive proper medical attention to manage comorbid conditions.
Diabetes
Blood Pressure Control (<130/80)
Blood Sugar Testing 87.5% 88.1% 89.0%
Cholesterol Screening
Monitoring Nephropathy
Cholesterol Control
83.4%
83.9%
84.8%
79.7%
80.6%
82.4%
43.0%
43.8%
45.8% 29.2% 32.1% 33.4%
2006 Measure Percentage of people age 18 to 75 with diabetes who had:
2007
2008
2006
2007
2008
2006
2007
2008
2006
2007
2008
2006
2007
2008
Blood.sugar.. (HbA1c).test
Cholesterol.. (LDL-C).test
Medical.attention.. for.kidney.disease
Medical.attention.to.. control.LDL-C.levels
Medical.attention.to.. control.blood.pressure
Note: Measures include only commercially insured members and exclude Medicare and Medicaid members unless stated. LDL-C is low density lipoprotein cholesterol. Source: National Committee for Quality Assurance. The State of Healthcare Quality Report, 2007-2009.
73
Prevalance of Smoking Among High School Students and Adults
One in five high school students and adults smoke.
Smoking
Prevalence of Smoking Among High School Students 26.7% 24.4% 25.0% 23.2% 20.0% 20.8% 20.8% 20.8% 20.8% 19.7% Prevalence of Smoking Among Adults Aged 18 Years and Over
2002
2003
2004
2005
2007
2004
2005
2006
2007
2008*
*Data as of June 2008. Note: Estimates for this Healthy People 2010 Leading Health Indicator are age adjusted using the projected 2000 U.S. population as the standard population and using five age groups: 18 24 years, 25 34 years, 35 44 years, 45 64 years, and 65 years and over. Source: Centers for Disease Control and Prevention (2009).
74
Impact of Smoking
Smoking and second-hand smoke is associated with lives lost and increased annual healthcare costs.
Smoking
Between.2000.-.2004. cigarette.smoking.was. associated.with: Cigarette.smoking. results.in: Cigarette.and.secondhand.smoking.related. deaths:
$193 49 Due to Direct Medical Costs
From Second-hand Smoke
$96
5.1M 443 From Smoking
$97
Due to Lost Productivity
Annual Health Related Costs in Billions
Years of Potential Life Lost Annually
Annual Deaths in Thousands
75
Monitoring and Advising Against Smoking
More than 75 percent of physicians are advising smokers to quit, but only about half are discussing smoking cessation strategies.
Smoking
Advising Smokers to Quit 73.8% 75.8% 76.7% Discussing Smoking Cessation Strategies Discussing Smoking Cessation Medications
43.2%
48.0%
49.7% 43.9%
50.9%
54.4%
2006 Percentage of people age 18 and older who are current smokers, seen during the year by a practitioner and:
2007
2008
2006
2007
2008
2006
2007
2008
Received.advice. to.quit.smoking
For.whom.smoking.cessation. methods.or.strategies.were. recommended.or.discussed.
For.whom.smoking.cessation. methods.or.strategies.were. recommended.or.discussed.
76
Changing Care Delivery Models

Key.Healthcare.Issues.................................................................................................. 79 Consumers.Willingness.to.Utilize.Alternative.Methods.. of.Accessing.Healthcare. ............................................................................................. 80 . Employer.Strategies.for.the.Next.Five.Years............................................................. 80 Number.of.Retail.Clinics.in.the.U.S.. .......................................................................... 81 . Percentage.of.Consumers.Receiving.Health.Services.. in.the.Last.12.Months.by.Site.of.Care......................................................................... 81 Patient-Centered.Medical.Homes.(PCMH)................................................................. 82 Blue.Cross.and.Blue.Shield.PCMH.Demonstrations................................................. 83 Familiarity.with.PCMH.................................................................................................. 83 International.and.Domestic.Medical.Tourism............................................................ 84 Fully.Operational.HIE.Initiatives.................................................................................. 85 Potential.Savings.from.HIT-enabled.Efficiencies...................................................... 86 Percentage.of.Office-Based.Physicians.Using.EMRs/EHRs..................................... 87 Percentage.of.Consumers.Using.PHRs. ..................................................................... 88 . E-Prescription.Statistics............................................................................................... 88
Section
77
Summary
In improving our healthcare system, a number of new models are being explored to deliver better, safer and higher quality care more efficiently and more affordably. These new care delivery models include alternative provider settings and the use of online interfaces to connect healthcare practitioners to each other and to their patients. A few examples of new care delivery models: Patient-Centered Medical Homes promote adherence to evidence-based care, provider performance measurement and quality improvement. They also foster greater patient engagement in their care decisions. New health information technology such as electronic medical/health records, eConsults/Telemedicine, ePrescribing and health information exchanges. The number of retail clinics is approaching 1,200 a four-fold increase in a two-year period.
There is growing awareness among employers and consumers of the potential benefits from new care delivery models. Employers see potential savings from new care models 39 percent believe patient-centered medical homes may lead to long-term savings. Among consumers, half of the population is willing to use the Internet to access healthcare and 36 percent say they would use retail clinics. To date, however, only 8 percent have used a retail clinic and only 5 percent have consulted their physician online. In addition, the use of health information technology can mean better, safer care with the ability to transmit patient health information and to accurately collect/update information online and added operational efficiencies to hold down costs.
78
Changing Care Delivery Models National Healthcare Trends
Key Healthcare Issues
Alternative settings and technology-based solutions are emerging to address key healthcare issues.
Access to Healthcare In 2008, more than 46M Americans did not have health insurance 46M
Healthcare Spending Healthcare spending is projected to be nearly $2.6 trillion or 17 percent of GDP in 2010 $2.6T
Quality and Safety Improvements in healthcare quality and safety can yield up to $400 million in healthcare savings $402B
Consumer Health Healthcare costs attributable to cardiovascular disease, cancer, diabetes, obesity and poor lifestyle choices approach $1 trillion $1T
Potential Solutions
Alternative Settings Retail.and. Worksite.Clinics Patient-Centered.Medical. Home.(PCMH) Medical.Tourism Health.Information. Exchange.(HIE)
Technology Solutions Electronic.Medical. Records.(EMR) e-Consults.and. e-Prescribing
Source: U.S. Census Bureau (2009) Historical Health Insurance Tables, Table HIA-2; Centers for Medicare and Medicaid Services (2010); PricewaterhouseCoopers Health Research Institute (2009) The Price of Excess: Identifying Waste in Healthcare Spending; National Institutes of Health, National Heart, Lung and Blood Institute Fact Book, Fiscal Year 2003, 2007 and 2008.
79
Consumers Willingness to Utilize Alternative Methods of Accessing Healthcare
Employer Strategies for the Next Five Years
Consumers are showing interest in using alternative methods, such as using the Internet or visiting retail and worksite clinics, to access and receive care.
Employers are looking to implement strategies focused on innovative methods to deliver healthcare, such as retail clinics, medical homes and medical tourism.
Alternative Settings
Alternative Settings
Via Internet or other computer technology Telephone consultation Clinical trials/research Worksite clinic Retail clinic Shared medical appointments Mobile device (Text Messages) 28% 21% 37% 36%
50% 50% 46%
Facilitating creation of personal health records Promoting the use of retail clinics
9% 7% 35% 26% 30%
65% 49% 56%
74%
Treating Web-based consultations as eligible expenses 3% Encouraging physician development of medical homes 4% Off-shoring major surgery 6% 7% 1% Already Using Strategy
38%
Interested / Very Interested
Source: PriceWaterhouseCoopers (2009) Top 10 Health Industry Issues in 2010: Squeezing the Juice Out of Healthcare.
Source: Mercer, Inc. (2009) National Survey of Employer-Sponsored Health Plans: 2008 Survey Report.
80
Number of Retail Clinics in the U.S.
Percentage of Consumers Receiving Health Services in the Last 12 Months by Site of Care
The number of retail clinics in the U.S. quadrupled between 2006 and 2008.
Despite growth, new access models are still in a nascent stage. Only 8 percent of Americans have used retail clinics, 5 percent have used e-Consults and 4 percent have used worksite clinics.
Retail Clinics
Retail Clinics
1,137 979 815
Visit to a physician's office Emergency room visit At a walk-in health clinic based within a retail location Online or telephone-based consultation At a health clinic based at my work location 22%
79%
480 251
8% 5% 4%
Dec 2006
Jun 2007
Dec 2007
Jun 2008
Dec 2008
Source: Merchant Medicine LLC (2009).
Note: Survey is based on U.S. consumers Source: North American Technographics, Healthcare Online Survey, Q1 2009 (US).
81
Patient-Centered Medical Homes (PCMH)
Patient-centered medical homes promote greater patient involvement and interaction with primary care physician and use of Health Information Technology (HIT).
Patient-Centered Medical Homes
Features
Benefits
Based.on.ongoing.relationship.between.patient.and.physician Personal.physician.provides.medical.care.and.assumes.responsibility.. for.managing.care.across.the.entire.system Responsibility.spans.the.patients.lifetime Integration.of.patients.family.and.social.network
Adheres.to.evidence-based.care Engages.in.provider.performance.measurement.and.quality.improvement Fosters.active.patient.involvement.in.care.decisions Encourages.appropriate.use.of.HIT.to.aid.clinical.decisions Enhances.access.to.care
Source: Patient Centered Primary Care Collaborative Web Site; Blue Cross and Blue Shield Association.
82
Blue Cross and Blue Shield PCMH Demonstrations
Familiarity with PCMH
More than half of Blue Cross and Blue Shield Plans have PCMH initiatives under way.
Employer familiarity with PCMH is low. However, they are viewed as a potential source of long-term savings.
Percentage of employers who are very familiar with PCMH
Percentage of employers indicating potential for long-term cost savings from PCMH
39% 7%
32%
Pilots in progress Pilot activity in early stages of development
Pilots in planning phase for 2010 implementation Multi-stakeholder demonstration
10% Somewhat Agree Strongly Agree
Note: Data include Blue Cross and Blue Shield Plan Pilots as of January 2010. Source: Blue Cross and Blue Shield Association (2010)
Source: Blue Cross and Blue Shield Association (2009) Business Decision-Maker Survey.
83
International and Domestic Medical Tourism
Consumers are more likely to travel to access care if recommended by a physician or if there are significant savings; however, only 8 percent have actually done so.
Medical Tourism
International Medical Tourism Americans Traveling Abroad for Medical Care
Domestic Medical Tourism Percentage of Consumers Who:
750,000 648,000 540,000 Would travel outside of immediate area for care if physician recommended it or for 50% savings** 40%
Sought healthcare outside of immediate community
8%
2007
2008
2009 (p)*
*Projected by Deloitte. **Implies that the consumer would save 50 percent or more and be assured the quality was equal or better than in the U.S. Source: Deloitte Center for Health Solutions (2009) Medical Tourism: Updates and Implications.
84
Fully Operational HIE Initiatives
The number of fully operational Health Information Exchanges (HIEs) rose 40 percent from the previous year but the number remains low. Seventy percent of HIEs report cost savings since start of operation.
Health Information Technology

57
HIE
42 40
HIE.provides.a.platform.for.providers.to. exchange.and.access.information.among.. each.other.and.with.patients.through.EMRs. and.Personal.Health.Records.(PHRs)
32 29 25 26
Benefits of HIE
Electronically.transports.clinical.information. across.disparate.healthcare.information. systems Maintains.the.integrity.of.the.information.. being.exchanged Potential.savings.in.reduced.staff.time,. redundant.tests,.cost.for.chronic.care.. and.medication.errors

2005 2006 2007 2008 2009
Number of Operational Initiatives
Number of Operational Initiatives Reporting Cost Savings
Sources: eHealth Initiatives Annual Survey of Health Information Exchange Activities at the State, Regional and Local Levels, 2005-2009; Agency for Healthcare Research and Quality (2008) Personal Health Records to Improve Health Information Exchange and Patient Safety .
85
Potential Savings from HIT-enabled Efficiencies
HIT-generated efficiencies expected to yield fewer errors in treatment, resulting in long-term cost savings.
Initiative e-Prescribing
Application Goal
Investment $7.7..$13.0B.
Possible Savings $10.2..$22.6B
Decreased.Rx.errors.and. adverse.drug.events.for. medication.management Decreased.gaps.in.care. via.real.time.sentinel. monitoring.of.clinical.data Medical.malpractice. savings
Electronically-enabled.care. coordination.
$25.9..$35.8B
$62.7..$96.5B
Total
$33.6 $48.8B
$72.9 $119.1B
Net savings
$39.3 $70.3B
Source: Deloitte (2009) Reducing Costs While Improving Care in the U.S. Health System.
86
Percentage of Office-Based Physicians Using EMRs/EHRs
More than 40 percent of office-based physicians are using EMR or Electronic Health Record (EHR) systems, but only 6 percent are using fully functional systems.
43.9% 41.5% 34.8% 29.2% EMR/EHR Functionality of Basic Systems:

20.5% 16.7%
Patient.demographic.information Patient.problem.lists.and.clinical.notes Viewing.imaging.and.laboratory.results.. and.orders.for.prescriptions
Functionality of Fully Functional System:
10.5%
11.8% 6.3%
4.4%
All.basic.functionalities Medical.history.and.follow-up Orders.for.tests.and.prescriptions.electronically Warnings.of.potential.drug.interactions.and. highlights.of.out-of-range.tests.results Reminders.for.evidence-based.interventions
3.1%
3.8%
2006
2007
2008
2009* Basic System
Any EMH/EHR System
Fully Functional System

*Preliminary data. Source: Centers for Disease Control and Statistics (2009) National Center for Health Statistics. Electronic medical record/electronic health record use by office-based physicians: United States 2008, preliminary 2009.
87
Percentage of Consumers Using PHRs
E-Prescription Statistics
Nearly one-third of consumers report having a PHR.
In 2009, the number of e-Prescribing users exceeded 150,000, doubling from the previous year. The number of prescriptions routed electronically in 2009 nearly tripled from 2008.
156
My health insurance plan WebMD Microsoft HealthVault Google Health Other I don't know No answer I do not have a PHR 6% 52% 2% 1% 1% 5% 14% 56% 22% 6%
Benefits of E-Prescribing

191 74 35
More.complete. medication.history Displays.economic. alternatives No.illegible. handwriting Reduces.pharmacy. callbacks More.convenient.. for.patients Reduces.time.spent. on.refills
31 percent of consumers report having a PHR account
36
68 13 5 55 2008
156
29 24 2007
2009
New Prescriptions Routed Electronically (In Millions) Renewal Prescriptions Routed Electronically (In Millions) Active Prescribers Using ePrescribing (In Thousands)
Source: PHRs: Scant Penetration And Lots Of Confusion, Forrester Research, Inc., Nov. 4, 2009.
Note: E-prescribing transactions or messages include viewing prescription benefit and history online, as well as routing prescriptions online. Source: Surescripts and the 2009 National Progress Report on E-prescribing.
88
89
Methodology
The 2010 edition of Healthcare Trends in America contains data from public and private sources. When necessary, permission to reuse, reprint and republish data and information was obtained from the original source. Permission granted does not extend beyond the Reference Guide, and reuse and republication of information contained herein may require permission from the original source.
Data included in the Reference Guide reflect the latest available published results based on the original source data. When possible, charts reflect the most recent five-year trend either for each of the last five years or from the first and last years of the five-year period. If a five-year trend was not available, trends show the most recent data.
90
Glossary of Abbreviated Terms
ACS American.College.of.Surgeons AHRQ .Agency.for.Healthcare.Research.and.Quality ASMBS .American.Society.for.Metabolic.and.Bariatric.Surgery BCBSA .Blue.Cross.and.Blue.Shield.Association BDC Blue.Distinction.Center BHI .Blue.Health.Intelligence BMI .Body.Mass.Index BRFSS .Behavioral.Risk.Factor.Surveillance.System CA-UTI..Catheter-Associated.Urinary.Tract.Infections CLABSI .Central.Line-Associated.Bloodstream.Infections CMS .Centers.for.Medicare.and.Medicaid.Services CPI .Consumer.Price.Index. EHR .Electronic.Health.Record EMR .Electronic.Medical.Records ER .Emergency.Room FEHBP .Federal.Employees.Health.Benefits.Program GDP .Gross.Domestic.Product HAI .Hospital-Associated.Infection HbA1c .Hemoglobin.A1c HDHP .High.Deductible.Health.Plan HDHP/SO .High.Deductible.Health.Plan.with.Savings.Option HIE .Health.Information.Exchange HIT .Health.Information.Technology
HMO .Health.Maintenance.Organization HRA .Health.Reimbursement.Arrangement HSA .Health.Savings.Account ICU .Intensive.Care.Unit JCAHO .The.Joint.Commission.on.the.Accreditation.of.Healthcare.Organizations LDL-C .Low.Density.Lipoprotein.Cholesterol MHA .Michigan.Health.and.Hospital.Association NHE .National.Healthcare.Expenditure NHIS .National.Health.Interview.Survey MM HG .Millimeters.of.Mercury NQF .National.Quality.Forum P4P .Pay-for-Performance PCMH .Patient-Centered.Medical.Home PCP .Primary.Care.Provider PHR .Personal.Health.Record POS .Point.of.Service PPO .Preferred.Provider.Organizations QI .Quality.Improvement RDS .Retiree.Drug.Subsidy RED .Re-Engineered.Discharge RFI .Request.for.Information TRD .Traditional.Health.Plan VAP..Ventilator-Associated.Pneumonia
91
Index of Tables
U.S..Population.with.Health.Insurance.in.Millions...................................................... 5 Coverage.by.Type.of.Health.Insurance......................................................................... 6 Employers.Offering.Health.Benefits............................................................................. 7 Employer-Sponsored.Health.Plan.Enrollment............................................................. 8 Enrollment.in.COBRA..................................................................................................... 9 Account.Implementation.of.Benefit.Changes.as.a.Result.. of.Current.Economic.Environment.............................................................................. 10 Enrollment.in.Medicaid.and.Medicare........................................................................ 11 Medicare.Advantage.Enrollment.in.Millions. ............................................................ 12 . Percentage.of.Uninsured.by.Income.Level................................................................ 13 Percentage.of.Uninsured.by.State.............................................................................. 14 Breakdown.of.the.Uninsured....................................................................................... 15
Components.of.Gross.Domestic.Product.(GDP)....................................................... 19 . Healthcare.Spending.in.Billions.................................................................................. 19 International.Healthcare.Spending.as.a.Percentage.of.GDP. .................................. 20 . Growth.Rates.of.Healthcare.Spending,.Wages.and.Salaries,.. and.the.CPI..................................................................................................................... 21 The.Nations.Healthcare.Dollar. .................................................................................. 21 . Percentage.Spent.on.Healthcare.by.Source.of.Funds.............................................. 22 Change.Between.2004.and.2007.in.Total.Costs.for.Hospital.Stays......................... 22 Percentage.Change.in.Healthcare.Utilization.and.Costs.......................................... 23 Physician.Office.Visits.................................................................................................. 24 Hospital.Employees.in.Millions.and.Percentage.of.Hospitals.. with.Physician.Affiliations.by.Organization............................................................... 25 Annual.Growth.in.Drug.Spending. ............................................................................. 26 . Generic.Prescriptions.as.a.Percentage.of.Total.Scripts,.2006.-.2008...................... 27 Average.Consumer.Pharmacy.Copayments.by.Tier................................................. 27 Generic.Drug.Approvals............................................................................................... 28 Average.Annual.Premium.for.Family.Coverage........................................................ 29 Hospital.Payment-to-Cost.Ratios.for.Medicare,.Medicaid.. and.Private.Payers........................................................................................................ 30 Percentage.of.Members.Out-of-Pocket.Cost.Sharing.by.Product.Line,.. 2006.-.2008..................................................................................................................... 30 Actions.Organizations.Are.Taking.Regarding.Their.Healthcare... Programs.Given.Recent.Events.in.Economy. ............................................................ 31 . Private.Health.Plan.Administrative.Expenses.as.a.Percentage.. of.Premiums.................................................................................................................. 32 Savings.and.Recoveries.from.Fraud.Investigations.in.Millions. ............................. 32 .
92
Index of Tables
Potential.Savings.from.Improvements.in.Healthcare.Quality.and.Safety.............. 35 Sentinel.Events. ............................................................................................................ 36 . Variations.in.Treating.Patients. ................................................................................... 37 . Knee.and.Hip.Replacement.Surgery.per.10,000.Members.in.2007.by.Region....... 38 Inappropriate.Use.of.Antibiotics................................................................................. 39 Examples.of.MHA.Keystone.Center.Collaborative.................................................... 40 AHRQ/Boston.Medical.Center.Project.RED.(Re-Engineered.Discharge)................ 41 Percentage.of.Hospital.Patients.Receiving.Evidence-Based.Care.......................... 42 . Blue.Distinction.Centers .Designations..................................................................... 43 Patient.Outcomes.at.Blue.Distinction.Centers .........................................................44 Average.Cost.of.Initial.Bariatric.Procedure................................................................ 45 Clinical.Quality.Information.Needed.When.Selecting.. a.Physician/Facility....................................................................................................... 46 Effective.Policy.Strategies.to.Control.Costs.while.Maintaining.. or.Improving.Quality.................................................................................................... 46 . Initiatives.Aimed.to.Increase.Quality.of.Care............................................................ 47 Payment.Policies.Involving.Never.Events.................................................................. 48 Pay-for-Performance.(P4P).Programs. ....................................................................... 49 . Components.in.Provider.Measurement.for.P4P.Programs...................................... 50 Percentage.of.P4P.Programs.Reporting.Improvement............................................. 51 CMS.Hospital.P4P.Demonstration.Average.Composite.Quality.Score................... 52
Leading.Causes.of.Death.in.Thousands..................................................................... 55 Direct.and.Indirect.Costs.Related.to.Disease.and.Poor.Lifestyle.. Choices.in.Billions......................................................................................................... 56 Increase.in.Visiting.Physicians.Annually.Between.2006.and.2008.. ....................... 57 . Employer.Strategies.for.Promoting.Primary.Care.................................................... 57 . Adults.Age.18.and.Over.with.Cardiovascular.Disease.in.Millions........................... 58 Hospital.Discharges.for.Cardiovascular.Disease...................................................... 59 . Managing.Cardiovascular.Disease. ............................................................................ 60 . Screening.for.and.Managing.Cardiovascular.Disease.............................................. 61 Prevalence.of.Cancer.................................................................................................... 62 Impact.of.Cancer.Screening........................................................................................ 63 . Preventive.Screening.for.Cancer. ............................................................................... 64 . Physical.Activity.Levels.in.Children.and.Adults........................................................ 65 Children.and.Adults.Considered.Overweight............................................................ 66 Prevalence.of.Obesity.Among.U.S..Adults.by.State................................................. 67 Increase.in.Adult.Per.Capita.Medical.Spending.Attributable.to.Obesity,.. By.Insurance.Status.and.Type.of.Service,.2006.(in.2008.Dollars)........................... 68 Utilization.Rates.and.Medical.Expenditures.for.Children.. with.Private.Insurance.................................................................................................. 68 Screening.and.Managing.Obesity.and.Promoting.Physical.Activity...................... 69 Obesity.and.Diabetes................................................................................................... 70 Prevalance.of.Diabetes.Among.Children.and.Adults................................................ 71 Preventing.and.Managing.Diabetes............................................................................ 72 Screening.for,.Monitoring.and.Managing.Diabetes.................................................. 73 Prevalance.of.Smoking.Among.High.School.Students.and.Adults.. ...................... 74 . Impact.of.Smoking........................................................................................................ 75 Monitoring.and.Advising.Against.Smoking............................................................... 76
93
Index of Tables
Key.Healthcare.Issues.................................................................................................. 79 Consumers.Willingness.to.Utilize.Alternative.Methods.. of.Accessing.Healthcare. ............................................................................................. 80 . Employer.Strategies.for.the.Next.Five.Years............................................................. 80 Number.of.Retail.Clinics.in.the.U.S.. .......................................................................... 81 . Percentage.of.Consumers.Receiving.Health.Services.. in.the.Last.12.Months.by.Site.of.Care......................................................................... 81 Patient-Centered.Medical.Homes.(PCMH)................................................................. 82 Blue.Cross.and.Blue.Shield.PCMH.Demonstrations................................................. 83 Familiarity.with.PCMH.................................................................................................. 83 International.and.Domestic.Medical.Tourism............................................................ 84 Fully.Operational.HIE.Initiatives.................................................................................. 85 Potential.Savings.from.HIT-enabled.Efficiencies...................................................... 86 Percentage.of.Office-Based.Physicians.Using.EMRs/EHRs..................................... 87 Percentage.of.Consumers.Using.PHRs. ..................................................................... 88 . E-Prescription.Statistics............................................................................................... 88
94
Bibliography
Agency.for.Healthcare.Research.and.Quality.(2008).Personal.Health.Records.to. Improve.Health.Information.Exchange.and.Patient.Safety.. http://www.ahrq.gov/downloads/pub/advances2/vol4/advances-fricton_21.pdf. Agency.for.Healthcare.Research.and.Quality.(2009).Project.RED.(Re-Engineered. Discharge).Toolkit.http://www.innovations.ahrq.gov/content.aspx?id=2180. Agency.for.Healthcare.Research.and.Quality,.Center.for.Delivery,.. Organization,.and.Markets,.Healthcare.Cost.and.Utilization.Project,.. Nationwide.Inpatient.Sample,.2004.and.2007.http://www.hcup-us.ahrq.gov/ American.Hospital.Association.and.Avalere.Chartbook.2009:.. Trends.Affecting.Hospitals.and.Health.Systems.. http://www.aha.org/aha/research-and-trends/chartbook/index.html. American.Society.for.Metabolic.and.Bariatric.Surgery.(ASMBS). http://www.asmbs.org/. American.College.of.Surgeons.(ACS).http://www.facs.org/. BHI.(2009) Blue.Cross.and.Blue.Shield.Association.(2009).National.Account.Decision-Maker. Survey Blue.Cross.and.Blue.Shield.Association.(2009).Transparency.Survey Blue.Cross.and.Blue.Shield.Association.http://www.bcbs.com/. Bureau.of.Economic.Analysis,.U.S..Department.of.Commerce.(2010). http://www.bea.gov/. Center.for.Drug.Evaluation.and.Research,.Food.and.Drug.Administration.(2010). http://www.fda.gov/cder/ogd/approvals/default.htm. Centers.for.Disease.Control.and.Prevention.(2009).Chronic.Disease.Prevention. and.Health.Promotions.http://www.cdc.gov/chronicdisease/index.htm Centers.for.Disease.Control.and.Prevention.(2009).National.Health.Interview.. Survey.2008.http://www.cdc.gov/nchs/nhis.htm. Centers.for.Disease.Control.and.Prevention.(2008).National.Health.Interview.. Survey.2007.http://www.cdc.gov/nchs/nhis.htm Centers.for.Disease.Control.and.Prevention.(2007).National.Health.Interview.. Survey.2006.http://www.cdc.gov/nchs/nhis.htm Centers.for.Disease.Control.and.Prevention.(2006).National.Health.Interview.. Survey.2005.http://www.cdc.gov/nchs/nhis.htm
Centers.for.Disease.Control.and.Prevention.(2005).National.Health.Interview.. Survey.2004.http://www.cdc.gov/nchs/nhis.htm Centers.for.Disease.Control.and.Prevention.(2009).NHANES.. http://www.cdc.gov/nchs/nhanes.htm. Centers.for.Disease.Control.and.Prevention,.Division.of.Diabetes.Translation. (2009).National.Diabetes.Surveillance.System.www.cdc.gov/diabetes Centers.for.Disease.Control.and.Prevention,.National.Center.for.Health.Statistics. (2009).National.Heart,.Lung.and.Blood.Institute.(2009).http://www.cdc.gov/Nchs/ Centers.for.Disease.Control.and.Prevention,.National.Center.for.Health.Statistics. (2008).National.Health.Interview.Survey.(NHIS).. http://www.cdc.gov/NCHS/nhis.htm Centers.for.Disease.Control.and.Prevention.(2009)..Behavioral.Risk.Factor.. Surveillance.System.(BRFSS).http://www.cdc.gov/brfss/. Centers.for.Disease.Control.and.Prevention..Health.(2010).United.States,.2009. http://www.cdc.gov/nchs/data/hus/hus09.pdf. Centers.for.Disease.Control.and.Prevention..Health.(2009).United.States,.2008. http://www.cdc.gov/nchs/data/hus/hus08.pdf. Centers.for.Disease.Control.and.Prevention..Health.(2003).United.States,.2003. http://www.cdc.gov/nchs/data/hus/hus03.pdf. Centers.for.Disease.Control.and.Statistics.(2009).National.Center.for.Health. Statistics..Electronic.medical.record/electronic.health.record.use.by.office-based. physicians:.United.States.2008,.preliminary.2009. http://www.cdc.gov/nchs/data/hestat/emr_ehr/emr_ehr.pdf. Centers.for.Medicare.and.Medicaid.Services.(2008).Roadmap.for.Implementing. Value.Driven.Healthcare.in.the.Traditional.Medicare.Fee-for-Service.Program. http://www.cms.hhs.gov/QualityInitiativesGenInfo/downloads/VBPRoadmap_ OEA_1-16_508.pdf. Centers.for.Medicare.and.Medicaid.Services.(2009).http://www.cms.hhs.gov/. Centers.for.Medicare.and.Medicaid.Services.(2010).http://www.cms.hhs.gov/ Centers.of.Disease.Control.and.Prevention.(2008).National.Health.Statistics.. Reports,.Number.3.http://www.cdc.gov/nchs/data/nhsr/nhsr003.pdf. Commonwealth.Fund.Healthcare.Opinion.Leaders.Survey,.April.2009.. http://www.commonwealthfund.org/Content/Surveys/2009/April/Health-CareOpinion-Leaders-Survey-on-Slowing-the-Growth-of-Health-Care-Costs.aspx.
95
Bibliography
Congressional.Budget.Office.(2009).http://www.cbo.gov/. Dallas.Business.Journal.(2008).Medicare,.Insurers.to.Stop.Reimbursing.for.Errors.. October.17,.2008.http://www.bizjournals.com/dallas/stories/2008/10/20/story15.ht ml?b=1224475200%5E1718641&brthrs=1 Deloitte.(2009).Reducing.Costs.While.Improving.Care.in.the.U.S..Health.System. http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/ us_chs_healthcare_pyramiddeck_140109(1).pdf Deloitte.Center.for.Health.Solutions.(2009).Medical.Tourism:.Updates.and.. Implications.http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/ Documents/us_chs_MedicalTourism_111209_web.pdf. Douglas.B..Sherlock,.CFA,.Administrative.Expenses.of.Health.Plans.(2009). Drug.Trend.Report:.Humanomics...2007.Medco.Health.Solutions,.Inc.. http://www.medcohealth.com/medco/corporate/home.jsp. Drug.Trend.Report:.Personalizing.Healthcare...2006.Medco.Health.Solutions,.Inc.. http://www.medcohealth.com/medco/corporate/home.jsp. Drug.Trend.Report:.Predictions...2008.Medco.Health.Solutions,.Inc.. http://www.medcohealth.com/medco/corporate/home.jsp. Drug.Trend.Report:.The.Great.Healthcare.Debates...2009.Medco.Health.. Solutions,.Inc..http://www.medcohealth.com/medco/corporate/home.jsp. eHealth.Initiatives.Annual.Survey.of.Health.Information.Exchange.Activities.at. the.State,.Regional.and.Local.Levels,.2009.http://www.ehealthinitiative.org/sites/ default/files/file/2009%20Survey%20Report%20FINAL.pdf. eHealth.Initiatives.Annual.Survey.of.Health.Information.Exchange.Activities.at.the. State,.Regional.and.Local.Levels,.2008.http://www.ehealthinitiative.org/previoushie-survey-results.html eHealth.Initiatives.Annual.Survey.of.Health.Information.Exchange.Activities.at.the. State,.Regional.and.Local.Levels,.2007.http://www.ehealthinitiative.org/previoushie-survey-results.html eHealth.Initiatives.Annual.Survey.of.Health.Information.Exchange.Activities.at.the. State,.Regional.and.Local.Levels,.2006.http://www.ehealthinitiative.org/previoushie-survey-results.html eHealth.Initiatives.Annual.Survey.of.Health.Information.Exchange.Activities.at.the. State,.Regional.and.Local.Levels,.2005.http://www.ehealthinitiative.org/previoushie-survey-results.html
Finkelstein,.E.,.et.al.(2009).Annual.Medical.Spending.Attributable.to.Obesity:. Payer.and.Service-specific.Estimates..Health.Affairs..Pg.822-831.July.27,.2009.Web. Exclusive.http://content.healthaffairs.org/cgi/reprint/hlthaff.28.5.w822v2. Forrester.Research,.Inc..North.American.Technographics,.Healthcare.Online. Survey,.Q1.2009.(US) HealthCore.Inc..2009.evaluation.of.Bariatric.Surgery.BDCs:.WellPoint.data Health.Insurance.Coverage.of.the.Total.Population,.states.(2007-2008),.U.S.. (2008) ,.statehealthfacts.org,.The.Henry.J..Kaiser.Family.Foundation,.2009.. http://www.statehealthfacts.org/. Employer.Health.Benefits.2009.Annual.Survey, .(#7936),.The.Henry.J..Kaiser. Family.Foundation.&.HRET,.September.2009.http://ehbs.kff.org/pdf/2009/7936.pdf. The.COBRA.Subsidy.and.Health.Insurance.for.the.Unemployed ,.(#7875-02),.. The.Henry.J..Kaiser.Family.Foundation,.December.2009... http://www.kff.org/uninsured/upload/7875-A.pdf. The.Medicare.Prescription.Drug.Benefit..An.Updated.Fact.Sheet ,.(#7044-10).. The.Henry.J..Kaiser.Family.Foundation,.November.2009... http://www.kff.org/medicare/7044.cfm. The.Joint.Commission.(2009).Improving.Americas.Hospitals:.The.Joint.Commissions.Annual.Report.on.Quality.and.Safety.http://www.jointcommission.org/NR/ rdonlyres/22D58F1F-14FF-4B72-A870-378DAF26189E/0/2009_Annual_Report.pdf. The.Joint.Commission.(2009).Sentinel.Event.Statistics.as.of.Sept..30,.2009.. http://www.jointcommission.org/NR/rdonlyres/377FF7E7-F565-4D61-9FD2593CA688135B/0/SE_Stats_9_09.pdf. The.Leapfrog.Group,.Leapfrog.Hospital.Survey.Report,.2009. http://www.leapfroggroup.org/home. Lembitz,.A.et.al..(2009).Clarifying.Never.Events.and.Introducing.Always. Events. .Patient.Safety.in.Surgery..December.2009.http://www.pssjournal.com/ content/3/1/26. Med-Vantage.2009.National.P4P.Survey..BlueCross.BlueShield.Plan.Responses. Med-Vantage,.Inc.,.The.Leapfrog.Group.and.Integrated.Healthcare.Association. (IHA)..2008.Surveys.of.P4P.and.Transparency.Programs..http://medvantage.com/ pdf/MV_2008_Surveys_Executive_Summary_20090908.pdf. Mercer,.Inc..(2009).National.Survey.of.Employer-Sponsored.Health.Plans:.2008. Survey.Report.http://www.mercer.com/home.htm.
96
Bibliography
Merchant.Medicine.LLC.(2009).http://www.merchantmedicine.com/. MHA.Keystone.Center.for.Patient.Safety.and.Quality.(2009).Setting.the.Healthcare. Agenda..2009.Annual.Report.http://www.mhakeystonecenter.org/. documents/2009_mha_keystone_center_annual_report.pdf. 2009.Milliman.Evaluation.of.Bariatric.Surgery.Blue.Distinction.Centers National.Business.Group.on.Health.(2009).Congress.Extends.Federal.. COBRA.Subsidies National.Committee.for.Quality.Assurance..The.State.of.Healthcare.Quality.. Report,.2009.http://www.ncqa.org/Portals/0/Newsroom/SOHC/SOHC_2009.pdf. National.Committee.for.Quality.Assurance..The.State.of.Healthcare.Quality.. Report,.2008.http://www.ncqa.org/Portals/0/Newsroom/SOHC/SOHC_08.pdf. National.Committee.for.Quality.Assurance..The.State.of.Healthcare.Quality.. Report,.2007.http://www.ncqa.org/Portals/0/Publications/Resource%20Library/ SOHC/SOHC_07.pdf. National.Institutes.of.Health,.National.Heart,.Lung.and.Blood.Institute.Fact.Book,. Fiscal.Year.2008.http://www.nhlbi.nih.gov/about/factpdf.htm. National.Institutes.of.Health,.National.Heart,.Lung.and.Blood.Institute.Fact.Book,. Fiscal.Year.2007.http://www.nhlbi.nih.gov/about/factpdf_archive.htm National.Institutes.of.Health,.National.Heart,.Lung.and.Blood.Institute.Fact.Book,. Fiscal.Year.2003.Link.(Archives).http://www.nhlbi.nih.gov/about/factpdf_archive.htm. Patient.Centered.Primary.Care.Collaborative.Web.Site.http://www.pcpcc.net/. PHRs:.Scant.Penetration.And.Lots.Of.Confusion,.Forrester.Research,.Inc.,.. November.4,.2009 PricewaterhouseCoopers.Health.Research.Institute.(2009).The.Price.of.Excess:. Identifying.Waste.in.Healthcare.Spending.http://www.pwc.com/us/en/healthcare/ publications/the-price-of-excess.jhtml. PricewaterhouseCoopers.(2009).Top.10.Health.Industry.Issues.in.2010:.Squeezing. the.Juice.Out.of.Healthcare.http://www.pwc.com/us/en/healthcare/publications/ top-ten-health-industry-issues-in-2010.jhtml. Surescripts.and.the.2009.National.Progress.Report.on.E-prescribing.http://www. surescripts.com/downloads/NPR/national-progress-report.pdf.
Thomson.Reuters..Childhood.obesity:.Medicaid.versus.private.insurance... Accessed.June.9,.2009 Towers.Watson.and.National.Business.Group.on.Health.(2009).The.Keys.to.. Continued.Success:.Lessons.Learned.from.Consistent.Performers..14th.Annual. Employer.Survey.on.Purchasing.Value.in.Healthcare Troiano.R,.Berrigan.D,.Dodd.K,.et..al.,.Medicine.&.Science.in.Sports.&.Exercise. (2008) U.S..Census.Bureau.(2009).Historical.Health.Insurance.Tables,.Table.HIA-2.. http://www.census.gov/hhes/www/hlthins/historic/index.html. U.S..Census.Bureau..Income,.Poverty,.and.Health.Insurance.Coverage.in.the. United.States.(2008).http://www.census.gov/prod/2009pubs/p60-236.pdf. U.S..Census.Bureau..Income,.Poverty,.and.Health.Insurance.Coverage.in.the. United.States.(2007).http://www.census.gov/prod/2008pubs/p60-235.pdf. U.S..Census.Bureau..Income,.Poverty,.and.Health.Insurance.Coverage.in.the. United.States.(2006).http://www.census.gov/prod/2007pubs/p60-233.pdf. U.S..Census.Bureau..Income,.Poverty,.and.Health.Insurance.Coverage.in.the. United.States.(2005).http://www.census.gov/prod/2006pubs/p60-231.pdf. U.S..Census.Bureau..Income,.Poverty,.and.Health.Insurance.Coverage.in.the. United.States.(2004).http://www.census.gov/prod/2005pubs/p60-229.pdf. U.S..Department.of.Labor,.Bureau.of.Labor.Statistics.(2009).http://www.bls.gov/. UBS.Investment.Research.(2009).Managed.Care..UBS.COBRA.Tracker World.Health.Organization.(2009). http://www.who.int/nha/country/nha_ratios_and_percapita_levels_2002-2006.pdf.
97
Please.insert.the.attached.CD-ROM.in.the.CD.drive.of.your.computer. to.access.an.interactive.PDF.version.of.the.2010.edition.of.Healthcare Trends in America..Double-click.the.PDF.icon.titled.2010.Healthcare. Trends.in.America.to.launch.the.interactive.version. The Reference Guide.provides.a.comprehensive.picture.of.key.concerns. and.emerging.issues.in.healthcare..The.interactive.version.enables.you.. to.quickly.and.easily.locate.the.topics.of.greatest.interest.to.you.and. launch.PowerPoint.presentation.slides.of.the.information.for.your.use.. by.double-clicking.on.the.relevant.chart.or.graph..These.slides.can.. be.saved.to.your.computer.for.future.reference..To.print.pages.directly.. from.the.interactive.version,.click.the.Print.button.located.at.the.. bottom.of.each.screen. Navigation Multiple.navigation.paths.include:
n..a.detailed.subject-matter.index.with.links.to.specific.pages n..a.clickable.table.of.contents n... .navigation.bar.with.section-specific.tabs.across.the.top.of.each.page a
By.offering.different.ways.to.move.through.the.information,.the.interactive.version.of.the Reference Guide.encourages.faster.access.to.content,. while.minimizing.the.steps.needed.to.find.specific.items..You.also.can. move.back.and.forth.through.the.document.one.page.at.a.time.by.using. the.arrows.located.in.the.bottom.right-hand.corner.of.each.screen. System Requirements Adobe.Acrobat.Reader.version.6.0.or.later Microsoft.PowerPoint.2000.or.later
225 North Michigan Avenue Chicago, Illinois 60601-7680 www.BCBS.com
R30-10-063

Healthcare Trends in America

Uploaded by

Copyright:

Available Formats

Healthcare Trends in America

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Healthcare Trends in America

Uploaded by

Copyright:

Available Formats

Healthcare Trends in America

A Reference Guide from BCBSA 2010 Edition

Blue Cross and Blue Shield Association

Improving Access to Health Coverage

Improving Access to Health Coverage

Blue Cross and Blue Shield Association

Improving Access to Health Coverage

Improving Access to Health Coverage

U.S. Population with Health Insurance in Millions

Percentage.with.Health.Insurance Persons with Employer-Sponsored Coverage

Persons with Health Insurance

Blue Cross and Blue Shield Association

Improving Access to Health Coverage

Coverage by Type of Health Insurance

Any Private Plan*

Any Government Plan

Medicare Employment-Based 58.5% 60.5% Medicaid

8.9% 9.5% Military Healthcare**

Improving Access to Health Coverage

Employers Offering Health Benefits

Employer-Sponsored Insurance Coverage

33% 31% 28%

Number of Workers per Firm 2005 2009

Blue Cross and Blue Shield Association

Improving Access to Health Coverage

Employer-Sponsored Health Plan Enrollment

Employer-Sponsored Insurance Coverage

Improving Access to Health Coverage

Employer-Sponsored Insurance Coverage

Est. Unemployed Population 15.3 million

Oct-08 Jun-09 Feb-09 Aug-09 Dec-08 Dec-09 Apr-09 Oct-09

Blue Cross and Blue Shield Association

Improving Access to Health Coverage

Account Implementation of Benefit Changes as a Result of Current Economic Environment

Employer-Sponsored Insurance Coverage

19% 20% 6% 4% 6% 5% 4% 7% 13% 12% 11% 10% 9%

Improving Access to Health Coverage

Enrollment in Medicaid and Medicare

25.9 17.4 11.0

Stand-alone PDP 17.5M 2007 2008

Blue Cross and Blue Shield Association

Improving Access to Health Coverage

Medicare Advantage Enrollment in Millions

10.1 8.8 7.7

Improving Access to Health Coverage

Percentage of Uninsured by Income Level

Uninsured by Income Level (2008 Uninsured: 46.3M) 13.7M 14.9M

2004 Overall.Percentage.of. Uninsured Average.. Unemployment.Rate 14.9% 5.5%

2005 15.3% 5.1%

2006 15.8% 4.6%

2007 15.3% 4.6%

2008 15.4% 5.8%

Blue Cross and Blue Shield Association

Improving Access to Health Coverage

Percentage of Uninsured by State

17.5% or higher 15.5% to 17.4% 12.4% to 15.4%

Improving Access to Health Coverage

Breakdown of the Uninsured

2008 Uninsured: 46.3M

By Age Asian 5% 35 - 44 17% 45 - 64 24% 65 and Older 1%