game changers in health care for 2014

Game Changers in Health Care for 2014

Steven M. Berkowitz, MDSMB Health Consulting,

Austin, TX512-415-6095

[email protected]

2012- 2013 Clients- Two Lessons Learned

Every System is unique.But… Every System is dealing with the same issues.

So What’s New in Health Care Reform?Same old wine in a brand new bottle?

So What’s New in Health Care Reform?

You can always count on Americans to do the right thing… …after they’ve exhausted all the other possibilities !!” Winston Churchill

People do not change until the pain of staying the same… … exceeds the pain of changing. Anonymous

Medicine is a Team effort….

…..Why do we insist on playing Solo !

The Health Care Team

1990’s-- Market Correction

2013-- Market Reconfiguration

The Evolution of Health Care Reform

Remember, It’s Not Nice to Fool Mother Nature

Health care must follow the same market rules as all other industries

The event is surprise It has an extreme impact After the event occurs, it is rationalized by hindsight

What is a Black Swan?



Examples:

The InternetPersonal computer going to the phone911



Examples:

The InternetPersonal computer going to the phone911Maybe some day……. The Chicago Cubs

Management Goals: Cannot predict event Build robustness against negative events Acknowledge and exploit positive ones


The “Viral” Influence of Transparency The Increasing Trend of Higher Deductible Insurance The information technology system- EMR, ICD-10 New Technology- Personalized Medicine-Genomics

Game Changers for 2014

The increasingly informed consumer will make health care decisions on the basis of VALUE

Value Based Purchasing

The increasingly informed consumer will make health care decisions on the basis of VALUE

The CONSUMER ultimately determines which of the above elements constitute VALUE

Value Based Purchasing

VALUE = Outcomes + Satisfaction Cost

Read all about it !! April 2005

Data Transparency

This is Your Life !!Data Transparency in Action

“What we concluded was that even when hospitals know their performance is not good, that's not sufficient motivation for them to do something. Making it public made a big difference in motivating them to improve.”

Judith Hibbard, Health Affairs 2003

Data Transparency

That which is measured, tends to improve.That which is measured publicly, tends to improve faster.

Core Measures: Heart Attack Heart Failure Pneumonia Surgical Care Improvement

HCAHPS

CMS Core Measures– the Top Decile

Core Measures: Heart Attack Heart Failure Pneumonia Surgical Care Improvement

HCAHPS

Transparency is the best thing that’s happened to quality since antibiotics...

…by decreasing variance and improving results

Data Transparency and Accountability

Percent Who Saw and Acted Upon the InformationChoice of Hospitals

Kaiser Family Foundation, October 2008

Exposure to and Use of Quality Information

If the other guy’s getting better, then you’d better be getting better faster than that other guy’s getting better…

…Or you’re getting worse. Tom Peters

Transparency is the best thing that’s happened to quality since antibiotics...

…by decreasing variance and improving results

As transparency matures, it will rewrite the book on:

Who is your competitor?

Data Transparency and Accountability

Price Transparency

QualityTransparency

The Role of Transparency

Stage IThe “other guy”

Stage IIIThe entire nation ?

Stage IVMedical tourism

Increasin

g Transpare

ncy

Stage IIAll hospitals in Oklahoma

System Strategic PlanningWho is Your Competitor…. The role of Transparency

The Continued Influence of Transparency The Increasing Trend of Higher Deductible Insurance The information technology system- EMR, ICD-10 New Technology- Personalized Medicine-Genomics


Total Health Care Spending

OECD, 2012

Distribution of Health Care Spending

Kaiser HRET, 2013

Total Premium and Percentage paid by Worker

Kaiser HRET, 2013

Kaiser HRET, 2013

Total Premium and Percentage paid by Worker

Kaiser HRET, 2013

Percentage of Plans with $1,000 or $2,000 Deductible

Kaiser HRET, 2013

Average Single Premium Deductible

QualityTransparency

The Role of Transparency

PriceTransparency

Price Transparency:??????

Steve has a URI symptoms and feels bad!Steve has great insurance but a $3,000 deductible

What does he do?

Treatment Options: Approximate*: Out of Pocket Wait Emergency Department $ 300 2-3 hrs Urgent Care 150 1 hr PCP visit 120 1 hr (if available)

Local Pharmacy 80 30 min Self Treat.. rest, OTC meds... 10 ? none

Reflections on Price Transparency

* The actual cost may not be known until the evaluation is completed

The physician’s reimbursement for the visit The nurses reimbursement for the visit The cost of his treatment to the institution Any other contractual relationships◦ Physicians◦ Vendors◦ Any other arrangements with the insurance company

Just tell me: How Much Do I Need to Pay !!

What Steve Does Not Need to Know

Health Care Information Systems-- We are so far behind !!!

1 Zettabyte =

1,000,000,000,000,000,000,000 bytes

= 10007 bytes = 1021 bytes

The Role of Information Systems

More Than Meaningful Use

Health Care of the Future…..

…. We can’t get there from here

…. Without Information Systems !!


EMR and Evidence Based Order Sets are not just another IT initiative….

…. it is a Clinical Transformation to how we will be practicing better medicine in the future.


The EMR will do for health care What the assembly line did for manufacturing


More Than Meaningful Use

Health Care of the Future…..

…. We can’t get there from here

…. Without Information Systems !!


EMR and Evidence Based Order Sets are not just another IT initiative….

…. it is a Clinical Transformation to how we will be practicing better medicine in the future.


For a Given Condition or Disease:

Identify the individual risk for the patient Identify patients most likely to respond beneficially Identify patients most likely to respond adversely– Minimize adverse

complications! Identify the optimal dosage Monitor the progress of the treatment

The Role of Personalized Medicine

Carrier Status◦ Cystic Fibrosis◦ Huntington’s Disease

Risk of Disease◦ Cardiovascular disease◦ Diabetes◦ Alzheimers◦ Breast/ ovarian cancer◦ Colon cancer

Response to Therapy/ Optimal Drug Treatment◦ Cancer◦ Heart Disease◦ Pain Management

Sample Capabilities of Genomic Testing

Original gene mapping-James Watson 2007: $ 1,000,000

Currently: $ 1,000 – 4,000

23 and Me…. 248 health conditions and traits: $99

The Price Barrier Starts to FallThe Race to the $100 Genome

Human genes that produce tumor suppressor proteins BRCA 1and 2 account for about 5-10 percent of all

breast cancers and 15% of ovarian cancers Mutation can be inherited from mother or father Each child has 50% chance if parent has defect

BRCA1 and BRCA 2

BRCA1 BRCA2 Normal

Breast CA 55-65% 45% 12%Ovarian CA 39% 15% 1.4%

Pancreatic CA increased riskProstate CA increased risk

BRCA1 and BRCA 2- Lifetime Cancer Risk

The major enzyme systems involved in drug metabolism-- about 75% of total metabolism

The cytochrome P450 system can either:◦ Metabolize a drug to make it inactive◦ Make a drug active by degrading its precursor

57 human genes code for this process

There are many differences in genetic makeup within the population that for a given drug may lead to:◦ High metabolizer◦ Normal metabolizer◦ Low metabolizer

Response to Drug TherapyThe Role Cytochrome P450

Examples of Drugs Metabolized by P450 System

Common medication widely used to thin blood◦ Treatment of blood clots◦ Stroke prevention in atrial fibrillation◦ Treatment of other hypercoagulable states

The most serious complication is bleeding◦Runs the spectrum from bruising ( usually benign) to

intracranial bleeds (life-threatening)

A Clinical Example- Coumadin

A Clinical Example- Coumadin

Identify the genetic status of the individual patient◦High metabolizer◦ Intermediate metabolizer◦ Poor metabolizer

Adjust the medication and dosage accordingly

A drug that inhibits platelets…. Decreasing the clotting mechanism Indications:

◦ Acute coronary syndrome◦ Stroke◦ Myocardial infarction◦ PCI◦ Peripheral artery disease◦ Post CABG

Not all patients taking plavix achieve the same level of platelet inhibition 20-50% of patients are poor metabolizers Variability in individual response is due to genetic factors, drug

interaction Heterogeneity of response could be due to non compliance

A Clinical Example- Plavix

A Clinical Example- Plavix

Personalized Medicine-- A Game Changer

Treatment based upon statistical evidence

Diagnosis of Established Disease

History Physical Exam Testing

Patient develops symptoms and accesses health care system

Traditional Model

Treatment based upon the individual needs

Likely Diseases Predicted

Testing is done upfront on patient’s DNA

Lifetime Risk of Specific Disease

Unique Response to Medications

Personalized Model

Increasing medical knowledge- research

Increasing speed and power of computers

Enhanced data capture - ICD 10

Unparalelled

Opportunity

to mine data

Increasing individual knowledge- cell phone

Increasing penetration of the Internet

Putting Together IT and GenomicsA Perfectly Perfect Storm

To the world you may be just one person,But to one person you may just be the world.

Unknown

game changers in health care for 2014

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