1. Health Care Challenges and
Opportunities for Primary Care
in West Virginia
James Becker, MD
Medical Director
WV DHHR, Bureau for Medical
Services

3. “We are all faced with a series of
great opportunities – brilliantly
disguised as insoluble problems.”
-- John W. Gardner

4. The evolution of systems
Plateau
Decline
Growth
Investment
Excerpt from “The Age of Paradox,” Charles Handy, 1994

5. National Health Expenditures per Capita, 1960-
2009
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at
http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; file
nhegdp09.zip).

6. National Health Expenditures and Their Share of
Gross Domestic Product, 1960-2009
Dollars in Billions:
5.2% 7.2% 9.2% 12.5% 13.8% 14.5% 15.4% 15.9% 16.0% 16.0% 16.1% 16.2% 16.6% 17.6%
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at
http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; file nhegdp09.zip).

7. Projected National Health Expenditures:
In Billions and as Percent of GDP
$4,500 $4.48 Trillion 19.5%
19.3% GDP
$4,000
19.0%
$3,500
18.5%
$3,000
$2.57 Trillion
$2,500 17.3% GDP 18.0%
% GDP
Billions
$2,000 17.5%
$1,500
17.0%
$1,000
16.5%
$500
$0 16.0%
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
2008 version of the National Health Expenditures (NHE) released in January 2010

8. Average Annual Health Insurance Premiums and Worker
Contributions for Family Coverage, 2001–2011

9. Market Shifts to Greater
Government Subsidization
Medicare, Medicaid, individual and small group markets
% of % of
Total 306M Total
296M
127
126 41%
Large Group Risk & ASO
58% Small Group
Segments impacted
Individual by Exchange/Other
26
32 Uninsured Government
26 Medicaid
Subsidies by 2015
15
20 Medicare
41
59%
58
42% 39
43 49
Source: Booz & Co. research (Total Population,
Commercial & Individual); Cowen & Goldman
2010 Population 2015 Population Sachs estimates (Government splits)

10. U.S. vs. OECD: U.S. Higher
Drug Costs
*Manufacturer price; ** Assumes 15% rebates from manufacturers to payors and PBMs; *** Average of U.K., Germany, Italy, France, and Spain
Source: IMS Health; McKinsey Global Institute analysis

11. US vs. OECD:
Hospital Stays / Costs
Fewer and shorter hospital stays are offset by higher unit cost
Source: OECD, McKinsey
Global Institute Analysis

12. AGING OF THE BABY BOOM
GENERATION
78 million people
30 percent of U.S. population
Unfunded liability in Medicare = $70 Trillion

13. System Objectives
The Triple Aim
(Institute for Healthcare Improvement)
1. Improve population health
2. Reduce per capita cost
3. Improve patient experience
 Outcome
 Safety
 Satisfaction

14. Chronic Disease*
People with chronic diseases → 70% HC spending
 Diabetes
 Coronary Artery Disease
 Congestive Heart Failure
 Asthma
 Mental health / chemical dependency
* George Halvorson Health Care Reform Now

15. Distribution of Health Care Expenditures*
1% of population → 35% of HC spending
5% of population → 60% of HC spending
10% of population → 70% of HC spending
* George Halvorson Health Care Reform Now

16. Health Field Model
Influence Factors on Health Status
Social 15% Environmental 5%
Human Biology 30%
Lifestyle & Behavior 40% Medical Care 10%
Source: McGinnis J.M., Williams-Russo, P., Knickman, J.R. (2002). Health Affairs, 21(2), 83

17. B
The Second Curve
Scenario B

18. WHERE THE RUBBER
MEETS THE ROAD
Cost continues to escalate
 Acute care system lacks capacity to absorb
 2011 Baby Boomers Eligible for Medicare
 Increase national debt
 Increasing access problem for the elderly
 Public dissatisfaction with care quality and
coordination

19. Where are the solutions?
• Development of a model that creates a Health Community.
• Improved data collection systems that allow analysis of
outcomes rather than just collecting process measures
• Prevention, wellness and medical care that are integrated to
create a true health system.
• A reimbursement model that rewards healthy outcomes
• Integration of behavioral and physical health

20. Profile of WV Medicaid
 400,000 Medicaid member
 We will expand by 170,000 new members
 Medical costs in 2010 were $2.5 billion
 We have had several years of surplus
 We face a short fall in 2013
 Reimbursement for most services is at 72-
75% of Medicare
 50% of members are in managed care

21. Major Challenges
 Expanded population
 Higher cost for services
 New therapies
 Requirement to cover more conditions
 Mental health parity
 Risky
lifestyle issues (substance abuse)
 Readmissions, HCACs, Never events

22. Facts about our duals..
 There are just under 50,000 West Virginia
dual eligible members. That’s 12% of
Medicaid eligibles.
 Ofthe $2.5 billion in SFY 2010 medical
expenditures $420 million Medicaid dollars
are attached to the care of duals.
 71% of that amount is spent caring for
those over 65 years of age.

23. Facts about duals..
 40% of the duals had a hospital admission in
2010.
 28% had more than one admission.
 32,000 dual eligible members (66%) had care
from a specialist in 2010 but no care claim by
a PCP.
 20% of the dual population had at least one
nursing home stay in 2010.

24. West Virginia’s foster care
children….
 Medicaid covers 8,500 children in foster
care.
 600 of those children have asthma.
 Many have behavioral, developmental or
psychiatric diagnoses. 60% are labeled as
“oppositional defiant disorder”
 Medication profile: stimulants, AAPs,
mood meds

25. What are we doing in WV?
 Data to guide decisions
 Data warehouse, APCD, benchmarks
 Many care coordination efforts
 Health homes, PCMH, care integration
 Usingevidence to guide decisions
 Working with stakeholders
 FQHCs, comprehensives, private payers

26. The importance of coordinated
effort!

27. What else?
 Major pharmacy efforts on opiates, psych
meds, high dollar oncology products
 EHR, incentives, ePrescribing, meaningfull
use, Health Information Technology
 WV is creating a Health Insurance
Exchange

29. This is clearly a time of challenge
and opportunity for primary care
physicians as we move forward
improving health and the health
care system. Primary care needs
to lead the way.