health policy in 2013 - ucsf cme · more need for hospital/hospitalist alignment new fights over...
TRANSCRIPT
Robert M. Wachter, MD Professor and Associate Chairman, Department of Medicine
Chief, Division of Hospital Medicine University of California, San Francisco
Health Policy in 2013: What It Means to Hospitals and
Hospitalists
Dominant Health Policy Trends
Intense pressure on value – Particularly cost
Shift from individual to population perspective More insured patients with access to [fill
in the blank] The wiring of the healthcare system
What Does This Mean for Hospitals/Hospitalists
Fewer hospital beds/hospitals Better reimbursement/situation for PCPs Ubiquitous IT
– Changing delivery, monitoring, analysis, patient engagement
Intense pressure for value More need for hospital/hospitalist alignment New fights over how to split the dollars
Why We’re Being Pressured to Deliver Value
“The Challenge That Will Dominate Your Career…”
Newton’s First Law of Motion
An object that is at rest will stay at rest unless acted upon by an external force. An object that is in motion will not change
its velocity and direction unless acted upon by an external force.
When It Comes to Changing the System, Physicians Are Still “At Rest”
Tilbert et al. Who is responsible for reducing healthcare costs? (A survey of 2556 US physicians). JAMA 2013
But That Is Wrong: Docs Decide…
Which patients are seen and how frequently Which patients are hospitalized Which tests, procedures, and
surgical operations are done Which technologies are used Which medications are prescribed
Emanuel EJ, Steinmetz A. Will physicians lead on controlling health care costs? JAMA 2013
Hospital Leaders Recognize Importance of MD Alignment
Extremely/Very Important to Our Business Model in Next 3-5 Years
Strategy % Agree Aligning with physicians to integrate them fully in clinical redesign efforts
98%
Aligning with physicians to preserve and expand market share
94%
Improving quality to take full advantage of P4P incentives such as CMS value purchasing
92%
Innovative deployment of health information technology across the continuum of care
92%
Redesigning clinical care processes using Lean, Six Sigma or other workflow redesign methods
88%
KPMG/Harris Study
The CEO’s (Old) Job The doctors brought in the patients, so the
hospital’s customer was the doctors – You don’t call your best customer onto the
carpet for problematic behavior, whether it is: Disruptive Too expensive Poor quality
The 99-1 vote But this is not a viable
strategy in today’s world
After We Sort Out the Incentives and the Motivation, What Then?
Physicians are competitive overachievers Physicians are individualistic and prize
their autonomy Physicians aren’t entirely economic
animals Physicians were taught to care for
individuals, not populations or systems
Report Cards May Catalyze Action
Average GPA of US medical school matriculants: 3.68
Culture is Local
Safety Climate Across 100 Hospitals
Safety Climate Across 49 Units in One Hospital
Pronovost/Sexton, QSHC 2005
We Care Deeply About Our Relative Position
Workers’ satisfaction with their income is negatively related to the amount to which they compare their income Actual
Income Comparison Income
Satisfaction
$70,000 $100,000 Lower $65,000 $45,000 Higher
Clark and Oswald. Satisfaction and comparison income. Journal of Public Economics 1996
My House
After We Sort Out the Incentives and the Motivation, What Then?
Physicians are competitive overachievers Physicians are individualistic and prize
their autonomy Physicians aren’t entirely economic
animals Physicians were taught to care for
individuals, not populations or systems
“The core structure of medicine – how health care is organized and practiced – emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves….We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency… and to designing medicine accordingly….
But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to ‘protocol’ the MRI.”
The Central Tension of Future Medical Practice
Recent guidelines suggest…
Please call the CMO
for approval
What is your reason
for deviation?
Are you some kind of moron?
After We Sort Out the Incentives and the Motivation, What Then?
Physicians are competitive overachievers Physicians are individualistic and prize
their autonomy Physicians aren’t entirely economic
animals Physicians were taught to care for
individuals, not populations or systems
Physicians (Like all Professionals) are Motivated by More than Dollars
Social vs. Market Transactions: The Israeli Daycare Center
“When a social norm collides with a market norm, the social norm goes away for a long time… Money, as it turns out, is very often the most expensive way to motivate people. Social norms are not only cheaper, but often more effective as well.”
Werner R. et al. Health Affairs 2011;30:690-8.
Does P4P Work Better Than Simple Transparency? The Jury is Out
After We Sort Out the Incentives and the Motivation, What Then?
Physicians are competitive overachievers Physicians are individualistic and prize
their autonomy Physicians aren’t entirely economic
animals Physicians were taught to care for
individuals, not populations or systems
Individual Perspective Comes Naturally to MDs
Training and socialization (Fuchs’ “technological imperative”) Moral position as patients’ advocate
(Levinsky’s “Doctor’s Master”) Malpractice fears The weight afforded the unidentified life
(e.g. Oregon’s early rationing stumble)
Costs vs. Benefits: The Big Picture
Benefits
Costs
Day 1
Marginal (or incremental) benefit
Day 2
What to Do Near the “Flat Part of the Curve”?
Benefits
Costs
Individual Perspective: Do this because benefit>risk
Societal/Population Perspective: Don’t do this unless you’ve
paid for everything with better cost:benefit ratios
√ √ √ √ HELP!
?
A Resource Allocation Framework: Encircling a Population
Benefits
Costs
Fuchs V. The doctor’s dilemma: what is “appropriate” care? NEJM 2011
Many interventions are valuable for some patients even if, for the population as a whole, their cost is greater than their benefit…. If the physician is paid on a fee-for-service basis and the patient has open-ended insurance, the scales are tipped in favor of doing as much as possible and against limiting interventions to those that are cost-effective. In that setting, who would benefit from the resources that are saved by practicing cost-effective medicine is not obvious to the physician…. [However] when physicians are collectively caring for a defined population within a fixed annual budget, it is easier for the individual physician to resolve the dilemma in favor of cost-effective medicine. That becomes “appropriate” care. And it is an ethical choice, as defined by philosopher Immanuel Kant, because if all physicians act the same way, all patients benefit.
So, What Should We Do?
Be comfortable w/ new arrangements that drive aligned incentives & population perspective Use comparative data: individual & group level
– Clinically meaningful, well presented – Can look outside, but use mostly local comparators – Begin w/ groups, emphasize positive (at least at
first); later move to individuals, low performers Structured care protocols, forcing functions
– Standardize what can be standardized
So, What Will It Take? (cont.) Hospitalists (& all MDs) need new skill set
– QI/safety, Lean, teamwork, leadership – Work to understand how IT is
helping, and how it’s not – Must have an improvement
and innovation methodology Do your share to promote alignment
– Organization needs to promote/reward MD engagement
Welcome incentives, but be wary of stepping on professionalism and teamwork
Choluteca Bridge, Honduras
Hurricaine Mitch, 1998