The Science of Healthcare Delivery:
A Glimpse Into the Future
David Adelson, MD, MS Jeffrey Alderman, MD, MS
“The problems of health care throughout the world are not primarily ones of
medical knowledge or even political will—they are problems of effective management and execution.”
-Jim Yong Kim, 17th President of
Dartmouth College
Health is a state of complete
physical, mental, and social
well-being
It is not the mere absence of disease
or infirmity
Defining Health
•
Income and Social Status
•
Education
•
Physical Environment
•
Employment and Working Conditions
•
Social Support
•
Culture, Customs and Traditions
•
Genetics
•
Personal Behavior/Coping
•
Medical Care
Determinants of Health
Centers for Disease Control, www.cdc.gov
•
With advances in technology, we are living
longer, but with a greater burden of disease
•
The share of people living with poorer
health is rising
•
45,000 preventable deaths are associated
with lack of health insurance annually –
equivalent of 1 Boeing 737 jet crashing
every day.
-American Journal of Public Health, 2006 -Harvard University School of Public Health
Wages & Inflation have not kept pace with
Health Care Spending
“20 to 30 percent of
health spending is
‘waste’ that yields no
benefit to patients.”
- Don Berwick, M.D. 12/3/11
•
Poor health and high healthcare spending
are primary threats to the American
economy and our way of life.
•
Medical Debt is the greatest source of
personal (and corporate) bankruptcy
•
Variation is widespread, raising costs and
reducing quality
Himmelstein, et al. Health Affairs, Feb 2005TRIPLE AIM
Higher Quality Healthcare Better Experience of Care Decreased Costs of CareBuilding a Better Healthcare System
Creating Value Requires a Three Prong Approach•
Shifting away from payment models that reward
reactive care towards ones that promote
proactive and preventive care
•
Paying for Value: Better outcomes at lower costs
– What is the system’s cost and quality performance
across the entire patient experience?
• From primary to specialist care
• From prescription drug to diagnostic service utilization • From acute to post acute care
Strategy for Change
Quality + Satisfaction
Value =
Cost
Michael Porter & Elizabeth Tiesberg, 2010
Quality + Satisfaction
Value =
Cost
• More than just lowering costs…
• More than just adding/subtracting care…
• Raising the quality of care
• Offering it to as many people as possible • Affordable prices
• Welcoming environment
• Promotes the development of positive self-care behaviors
Michael Porter & Elizabeth Tiesberg, 2010
•
Value based competition will drive the
improvement of the healthcare system
•
Organize Integrated Practice Units across
facilities, around patient medical conditions
•
Measure outcomes and costs for every
patient
•
Payments should be bundled across the
entire cycle of care
•
Care must be scalable, and integrated across
multiple facilities
•
Expand successful practice units across
geographical regions
•
Move away from fee-for-service toward new
methods of reimbursement
•
Align provider incentives to outcomes
•
Examples:
– Bundled payments – Global Capitation
– Accountable care organizations – Pay for performance
•
One Size does not Fit All
– Deductibles & co-payments decreases use of all
types of services
– People avoid essential AND non- essential care
– But if there is NO cost-sharing, people use more of
both necessary AND unnecessary care
•
People’s incomes matter
– Cost-sharing hits sicker and lower income people
harder
– Encourages avoidance of all care
•
Smart
cost-sharing
– Does not discourage important, essential care
• annual check-ups, immunizations
– Does not discourage use of necessary medications – Encourages appropriate consideration of pros and
cons of potentially unnecessary procedures that do not have proven benefit and can be wasteful to the system
Fee for Service
ACO/CPCI
Capitation
Incentive to Limit Care Incentive to Overtreat
Incentive to Deliver Quality Care
•
New provider organizational structure
–
Medicaid & Medicare authority
•
Provider takes on insurance risk
•
Shared savings between payer & provider
•
Capitated reimbursements from payer to
ACO
•
Savings is split among providers within ACO
•
“TDABC” time driven activity based costing
– Method created by Robert Kaplan & MichaelPorter
– New approach that measures cost as patient
level for a given condition over a full cycle of care and compares those costs to outcomes
– As providers & payers better understand costs,
they will be positioned to achieve a true “bending of the cost curve”
Collaboration between patients and caregivers to
come to an agreement about a health care decision. The Provider Helps
Patients:
• Understand the likely
outcomes of various options
• Think about what is
personally important about the risks and
benefits of each option
• Participate in decisions
about medical care
Studies have shown that Chronic Disease
Management Programs (CDMP) can reduce the incidence, complications and cost from many illnesses (CHF, DM, Asthma)
Robust CDMP’s prevent avoidable ED visits, increase life-satisfaction, prevent the need for invasive
surgeries, and improve mortality
Reengineering Chronic Disease Management
1. Cohen, J.T., P.J. Neumann, and M.C. Weinstein, N Engl J Med, 2008. 358(7): p. 661-3 2. Villagra, V.G. and T. Ahmed, Health Aff (Millwood), 2004. 23(4): p. 255-66.
Care coordination is an approach to health care in which patient's needs are coordinated with the assistance of a Care Manager
The Care Manager provides information to the patient and the patient's caregivers, and works with the
patient to make sure that the patient gets the most appropriate treatment.
Reduces unnecessary duplication, testing and acute-care utilization.
This process saves money on health care costs and improves the quality of care.
“In Camden, New Jersey, one per cent of patients account for a third of the city’s medical
costs…”
Camden, NJ - Non-urgent use of Emergency room by census tract
Comprehensive primary health care for a fixed per member per month fee.
Iora – Disrupting the
THE NEW MODEL FOR
CARE AND EDUCATION
Shared Savings Infrastructure –
e.g. Comprehensive Primary Care Initiative
Health Workforce Development e.g. Summer Institute, Teaching Health Center, Residency Program, Physician Assistant – Medical Student
and Resident Physician Training Expansion and full immersion in new models of team / medical home care,
training expansion grant
Care Coordination - e.g. Health Access Network Program with
Oklahoma Medicaid – 70,000 patients
Vulnerable Populations e.g. Child Abuse Team – HARUV, IMPACT Team for Mental Illness, Palliative Care team for chronic illness, Heart Intervention Program
for MI and Stroke Prevention Patient Centered Medical Homes –
Medicare, Oklahoma Medicaid, Blue Cross contracts, Bedlam student led clinics, PAL PCMH at Morton Clinic Medical Informatics and Health Information Exchange Development
e.g. Beacon Communities Grant, Pentaho for Population Health
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NIH PROMIS
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Vision-Mission:
•
Vision
– The Patient-Reported Outcomes Measurement Information
System (PROMIS®), funded by the National Institutes of
Health, aims to provide clinicians and researchers access to efficient, precise, valid, and responsive adult- and
child-reported measures of health.
•
Mission
– PROMIS uses measurement science to create an efficient
state-of-the-art assessment system for self-reported health.
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Evolving concept of health
DOMAIN
vs.
DISEASE
SPECIFIC
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DOMAINS
A
domain
is the specific feeling,
function, or perception you
want to measure.
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Domains & Diseases: Hypotheses
• Diseases are combinations of different
domains
– fatigue, physical function, anxiety, pain…
• Capturing multiple domains may be
optimal way to assess diseases
• Core-common PRO domains are
universally applicable across diseases
(common or rare), ages and ethnicities
Anxiety Prostaglandins Interleukins Chemokines Sleep
PROs
Mechanisms
Pain Phys Fn Social Fatigue• Team Based Care and Care Coordination
– (no longer just one doctor, one patient and one room)
• Leveraging HIT to care for Patient Populations • ACA – more people (but not everyone) insured • Standardization of Care to Reduce Variation
• Health Systems Measured by (and competing) on
Quality
• Innovations that incorporate all three arms of the
Triple Aim
• Shared Decision-Making
• New Payment Systems: Less Fee-for-Service, more
Risk-Based Contracting
• Increased scrutiny of care delivered close to the
End-of-Life, with more emphasis on Share Patient, Family, and Provider Goals and Values
• Doctor Leads (but may not coordinate) a Team of Health
Care Professionals
• Acute Sensitivity to the Cost of Care • Sensitivity to Disparate Populations
• More Loan payback through Service Scholarships • More Headaches!
