iHT² Health IT Summit in New York 2012 - Opening Keynote "The Changing Health Environment in Health Reform"
1. The Changing Environment
in Health Reform
John R Lumpkin MD MPH
SVP & Health Care Director
Robert Wood Johnson Foundation
2. Victory awaits him who has everything in order – luck people call it. Defeat is
certain for him who has neglected to take necessary precautions in time; this is
called bad luck
Roald Amundsen, Norwegian polar explorer
3. Why was health reform on the
National agenda in 2009?
The same reason why health reform is
on today’s agenda:
4.
5. Insurance Matters
• Medicaid expansion
• 90,000 applied
• 10,000 enrolled via lottery
• Outcomes
• Higher use of preventive services
• Better physical and mental health
• Less medical related debt
6. The system was/is broken:
Insurance market concerns
• Pre-existing conditions
• Denial of coverage
• Retroactive denial of coverage
• Excessive rating gradients
• Annual and lifetime limits
7. Basics of Health Reform
Insurance Market reforms
Insurance works best if the risk pool
is large
Allowances for the working poor
8. 2014 Coverage Expansion
• Protects consumers in the insurance market
• Requires individuals to purchase insurance
• Requires employers to purchase insurance
• Creates health insurance exchanges
• Provides subsidies
• Expands Medicaid
9. Coverage Expansion Categories
Medicaid Premium
Expansion Subsidy
138% 400%
Medicaid
Subsidy
$29,326 $88,000
Family Family of
Of Four Four
0 100 200 300 400 500
Federal Poverty Level
10. Supreme Court Decision
• Individual
mandate
constitutional
• Medicaid
expansion
constitutional,
but now a state
option
11. Supreme Court Decision
Supreme Court decision
Total Expansion = 32 Million
Exchange
Medicaid 15M
17M
Sources: Urban Institute analysis, HIPSM 2011.
12. The Future is already here, it is not
very evenly distributed.
William Gibson - 1993
13. Average Annual Contributions to Premiums for Family
Coverage, 1999-2011
$15,073*
$13,770*
$13,375*
$12,680*
$12,106*
$11,480*
$10,880*
$9,950*
$9,068*
$8,003*
$7,061*
$6,438*
$5,791
* Estimate is statistically different from estimate for the previous year shown (p<.05).
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2011.
14. Cumulative Percent Change in National Health Expenditures, by
Selected Sources of Funds, 2000-2010
Medicare
Medicaid
Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health
Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source
of funds, CY 1960-2010; file nhe2010.zip).
15. Healthy Life Expectancy at Age
60, 2007
Developed by the World Health Organization, healthy life expectancy is based on
life expectancy adjusted for time spent in poor health because of disease and/or injury
Years
30
Women Men
22
21 21 21 21 20
20 20 20 20 20 20 20 20 19 19 19
20 18 18 18 19 19 19 19
18 18 18 18 18
17
16 17 18 17 16 17 17 17 18 17 17 17
16 16 16
15
10
0
ria
es
ly
n
m
ay
l
s
lia
k
m
ce
n
d
y
ic
d
da
nd
e
en
d
nd
ga
nd
ar
an
ai
ec
an
an
pa
an
Ita
iu
do
bl
st
at
ra
an
rw
na
la
ed
Sp
rtu
nm
la
la
pu
lg
m
re
nl
el
Ja
St
Au
al
st
Ire
ng
er
Fr
No
Sw
Ca
er
Ic
er
Be
Fi
G
Po
Ze
Au
De
Re
d
it z
Ki
th
G
ite
w
Sw
Ne
d
h
Un
Ne
ec
ite
Cz
Un
Data: Provided by C. Mathers. Unpublished data set consistent with HALE estimates published in
World Health Statistics 2009 (Geneva: World Health Organization).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
16. Mortality Amenable to Health Care
Deaths Avoidable Through Health Care:Nolte & McKee – Health Affairs August 29, 2012
17. EXHIBIT 16
Medical, Medication, and Lab Errors
Percent of adults reported medical mistake, medication error, or lab error in past two years
40
32
30 28
26
22 23
20 18 19
16
10
0
NETH FRA GER UK NZ CAN AUS US
Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or
had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New
Zealand; UK=United Kingdom; US=United States.
Data: 2008 Commonwealth Fund International Health Policy Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
18. Test Results or Records Not Available at Time of Appointment
Percent of adults reported test results or records were not available at time of appointment
in past two years
30
23
20 18 18
15 15 15
13
10 9
0
NETH GER AUS FRA UK CAN NZ US
Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or
had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New
Zealand; UK=United Kingdom; US=United States.
Data: 2008 Commonwealth Fund International Health Policy Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
19.
20.
21.
22.
23. We have run out of money, it
is time to start thinking.
Ernest Rutherford (1871-1937)
Nobel Laureate
24. Six Drivers of Excess Cost
Six Drivers of Excess Cost
Driver Examples Excess cost
Unnecessary services Defensive medicine, overuse $210 B
Inefficient services Mistakes, duplication $130 B
Excess administrative Administrative inefficiencies
$190 B
costs by payers and providers
Prices higher than
Prices that are too high $105 B
competitive benchmarks
Missed prevention Missed screenings and
$55 B
opportunities condition monitoring
Fraud Payer, provider, patient fraud $75 B
Source: Institute of Medicine
Better Care at Lower Cost
September, 2012
38. Accountable Care Organizations
Ability to provide care and manage patients
across the continuum of care
Capability to prospectively plan budgets and
resource needs
Sufficient size to support comprehensive, valid,
and reliable performance measurement
• 33 measures
• Patient experience
• Care coordination/safety
• Preventive health
• At-risk populations
40. Clinical Re-Engineering
• Improved care coordination and communication
• Improved access – physician extenders – email – phone call etc.
• Prevention and early diagnosis
• ED and Immediate Care Center visits
• Increase generic medication utilization
• Hospital re-admissions and multiple ED visits
• Improved management of complex patients
• Care Coordination
• High Resource Utilizers
43. Current practice depends upon the clinical
decision-making capacity and reliability of
autonomous individual practitioners, for classes
of problems that routinely exceeds the bounds of
unaided human cognition
Daniel R. Masys, M.D.
2001 IOM Annual Meeting
44. Complexity
Clinical Complexity
• Physicians in private practice interact with as many as 229 other
physicians in 117 different practices just for their Medicare patient
population
• ICU clinicians have 180 activities per patient per day
• Chronic disease: a 79 year old patient with osteoporosis,
osteoarthritis, type 2 diabetes, hypertension, and chronic
obstructive pulmonary disease: 19 medications per day
45. The Vision
New Tools
• Computing Power
• Connectivity
• Improvements in organizational capabilities
• Collaboration between teams of clinicians and with
patients
46.
47. The Future
Big data
• Predictive Modeling
• Next infectious disease hot spot in hospital?
• How will utilization change with Medicaid expansion in ACA?
• How to predict patient demand to minimize use of contract nurses?
Liberated data
Patient generated data
Advanced sensors
49. The Future
Big data
• Predictive Modeling
• Next infectious disease hot spot in hospital?
• How will utilization change with Medicaid expansion in ACA?
• How to predict patient demand to minimize use of contract nurses?
• Hot spotting
Liberated data
Patient generated data
Advanced sensors
56. Key findings
Health IT can improve patient safety in some areas such as
medication safety; however, there are significant gaps in the
literature regarding how health IT impacts patient safety
overall
Safer implementation and use begins with viewing health IT
as part of a larger sociotechnical system
All stakeholders need to work together to improve patient
safety
Slide 55 of 23
57. Current state of health IT
Literature has shown that health IT may lead to safer care
and/or introduce new safety risks
Magnitude of harm and impact of health IT on patient safety
is not well known because:
– Heterogeneous nature of health IT products
– Diverse impact on different clinical environments and
workflow
– Legal barriers and vendor contracts
– Inadequate and limited evidence in the literature
Slide 56 of 23
58. Recommendations: Summary
Current market forces are not adequately addressing the
potential risks associated with use of health IT.
All stakeholders must coordinate efforts to identify and
understand patient safety risks associated with health IT by:
Facilitating the free flow of information
Creating a reporting and investigating system for health IT–
related deaths, serious injuries, or unsafe conditions
Researching and developing standards and criteria for safe
design, implementation, and use of health IT
Slide 57 of 23
59. Deadly Overuse
Disease X
Severe case mortality 50% 100 cases – 50 die
Treatment Y 50% to 25% 100 cases – 25 die
Fatality rate 10% 100 cases – 35 die
New test
10% are severe 100 cases – 5 die
With Treatment 100 cases – 12 die
60. Deadly Overuse
Disease X
Severe case mortality 50% 100 cases – 50 die
Treatment y 50% to 25% 100 cases – 25 die
Fatality rate 10% 100 cases – 35 die
New test
10% are severe 100 cases – 5 die
With Treatment 100 cases – 12 die
Standard diagnosis with treatment 30% reduction
Enhanced diagnosis with treatment 140% increase
Notas do Editor
TEMPLATE FOR POSSIBLE SLIDE
The architects of ACO describe them as needing to have three characteristicsThe ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory and inpatient hospital care and possibly post acute care;The capability of prospectively planning budgets and resource needs; andSufficient size to support comprehensive, valid, and reliable performance measurement. ? The new law authorizes Medicare to contract with Accountable Care Organizations—or ACOs—in order to find ways to deliver high-quality care while, according to the Congressional Budget Office, saving an estimated $5 billion in spending in the first eight years. ACOs don’t exist yet but they are envisioned to be a network of physicians and providers who are incented work together to deliver high quality, high value care. By providing financial incentives to coordinate care and measure performance against scientifically based outcomes, there is every reason to believe that the cost curve could be bent. 8 Health Affairs, Accountable Care Organizations, July 27, 2010.Devers, K., Berenson, R. “Can Accountable Care Organizations Improve the Value of Health Care by Solving the Cost and Quality Quandry?” http://www.rwjf.org/files/research/acobrieffinal.pdf p. 2