the case for health system change
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The Case for Health System Change. Dan Rahn, M.D. Chancellor, University of Arkansas for Medical Sciences. What is Driving Health System Change?. How Does the United States Compare. Health Expenditure Per Capita. Health Expenditures by Country. Health spending % of GDP in 2011: - PowerPoint PPT PresentationTRANSCRIPT
The Case for Health System Change
Dan Rahn, M.D.Chancellor, University of Arkansas
for Medical Sciences
What is Driving Health System Change?
How Does the United States Compare
Health Expenditure Per Capita
Health Expenditures by Country
Health spending % of GDP in 2011:
• United States 17.7%
• Netherlands 11.9%
• France 11.6%
• OECD Average 9.3%
Health Expenditures by Country
• The United States together with Mexico and Chile are the only OECD countries where less than 50% of health spending is publicly financed.
• The overall level of health spending in the United States is so high that public (i.e. government) spending on health per capita is still greater than in all other OECD countries, except Norway and the Netherlands.
Health Expenditures by Country
• In the United States, life expectancy at birth increased by almost 9 years between 1960 and 2011, but this is less than the increase of over 15 years in Japan and over 11 years on average in OECD countries. As a result, while life expectancy in the United States used to be 1 ½ years above the OECD average in 1960, it is now, at 78.7 years in 2011, almost 1 ½ years below the average of 80.1 years.
What is driving health system change?
• National Research Council/IOM report– US males and females in all age groups up
to 75 years of age have shorter life expectancies and higher prevalence and mortality from multiple diseases, risk factors and injuries than 16 other developed nations
• For 45 of 48 years, health care cost growth has outstripped growth in public funds and GDP
What is driving health system change?
Deaths per 1,000 Live Births
SingaporeHong KongJapanSwedenNorwayFinlandSpainChech RepublicGermanyItalyFranceAustriaBelgiumSwitzerlandNetherlandsNorthern IrelandAustraliaDenmarkCanadaIsraelPortugalEngland & WalesScotlandGreeceIrelandNew ZealandUnited StatesCuba
2.53.0
3.23.4
3.8
3.83.9
4.14.4
4.54.5
4.84.8
4.95.15.1
5.25.35.3
5.45.5
5.6
5.76.1
6.26.3
6.9
7.2
Comparison of International Infant Mortality Rate: 2000Infant Mortality
WHY?
Multifunctional
• Health System Design and Performance
• Social Determinants of Health
Social Determinants Side
Institute of Medicine Report: Best Care at Lower Cost: The Path to Continuously Learning Health Care in America
“Health Care in America has experienced an explosion in knowledge, innovation, and capacity to manage previously fatal conditions. Yet, paradoxically, it falls short on such fundamentals as quality, outcomes, cost, and equity. Each action that could improve quality-developing knowledge, translating new information into medical evidence, applying the new evidence to patient care-is marred by significant shortcomings and inefficiencies that result in missed opportunities, waste, and harm to patients.”
• If banking were like health care, automated teller machine (ATM) transactions would take not seconds but perhaps days or longer as a result of unavailable or misplaced records
• If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination.
• If shopping were like health care, product prices would not be posted, and the price charged would vary widely within the same store, depending on the source of payment.
• If automobile manufacturing were like health care, warranties for cars that require manufacturers to pay for defects would not exist. As a result, few factories would seek to monitor and improve production line performance and product quality.
• If airline travel were like health care, each pilot would be free to design his or her own preflight safety check, or not perform one at all.
If…
Waste estimates
• Unnecessary Services $210 billion• Inefficiently delivered services $130 billion• Excess administrative costs $190 billion• Prices that are too high $105 billion• Missed prevention opportunities $55 billion• Fraud $75 billionTotal $765 billion
The Vision
Categories of the Committee’s RecommendationsFoundational Elements
Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.
Recommendation 2: The data utility. Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.
Care Improvement TargetsRecommendation 3: Clinical decision support. Accelerate integration of the best
clinical knowledge into care decisions.Recommendation 4: Patient-centered care. Involve patients and families in
decisions regarding health and health care, tailored to fit their preferences.Recommendation 5: Community links. Promote community-clinical partnerships
and services aimed at managing and improving health at the community level.Recommendation 6: Care continuity. Improve coordination and communication
within and across organizations.Recommendation 7: Optimized operations. Continuously improve health care
operations to reduce waste, streamline care delivery, and focus on activities that improve patient health.
Supportive Policy EnvironmentRecommendation 8: Financial incentives. Structure payment to reward
continuous learning and improvement in the provision of best care at lower cost.Recommendation 9: Performance transparency. Increase transparency on
health care system performance.Recommendation 10: Broad leadership. Expand commitment to the goals of a
continuously learning health care system.
Arkansas’ Healthcare Population
48th in Overall Health
Source: Americas Health Rankings.org 2010
45th in Stroke46th in Occupational Fatalities43rd in Infant Mortality43rd in Obesity45th in Premature Death
50th in Immunization Coverage49th in per Capita Health Spending42nd in Lack of Health Insurance45th in Children in Poverty45th in Physical Activity
45th in Cardiovascular Deaths41st in Adequacy of Prenatal Care44th in Poor Physical Health Days45th in Cancer Deaths
What About Arkansas?
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 201164.0
66.0
68.0
70.0
72.0
74.0
76.0
78.0
80.0
82.0
Life Expectancy at Birth
US Males US Females AR Males AR Females
Year of Death
What about Arkansas?
Infant Mortality by Race in Arkansas
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
2
4
6
8
10
12
14
16
18 2000-2010 Arkansas Resident Infant Death Rates by Race
TotalWhiteBlack
Year
Infa
nt M
orta
lity
Rate
What about Arkansas?
Deaths per 1,000 Live Births
SingaporeHong KongJapanSwedenNorwayFinlandSpainChech RepublicGermanyItalyFranceAustriaBelgiumSwitzerlandNetherlandsNorthern IrelandAustraliaDenmarkCanadaIsraelPortugalEngland & WalesScotlandGreeceIrelandNew ZealandUnited StatesCuba
2.53.0
3.23.4
3.8
3.83.9
4.14.4
4.54.5
4.84.8
4.95.15.1
5.25.35.3
5.45.5
5.6
5.76.1
6.26.3
6.9
7.2
Comparison of International Infant Mortality Rate: 2000What about Arkansas?
2005-2010, 62%45-64 age group
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
0
50
100
150
200
250
300
350
400
450
CHD AR 45-64 CHD US 45-64
Rate
per
100
,000
Age-Specific Death Rates from Coronary Heart Disease, Arkansas & U.S.,
Aged 45-64 years, 1968 - 2010
What about Arkansas?
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
0
50
100
150
200
250
300
350
Cancer AR 45-64 Cancer US 45-64
Rate
per
100
,000
2005-2010, 26%45-64 age group
Age-Specific Death Rates from Cancer, Arkansas & U.S.,Aged 45-64 years, 1968 - 2010
What about Arkansas?
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
0
20
40
60
80
100
120
Stroke AR 45-64 Stroke US 45-64
Rate
per
100
,000
45-64 age group 2005-2010,
54%
Age-Specific Death Rates from Stroke, Arkansas & U.S.,
Aged 45-64 years, 1968 - 2010
What about Arkansas?
Uninsurance
Health Outcomes
Mortality
Morbidity
Socio-Economic Factors
Educational Factors
African American Population
Within countries, cities and communities there are dramatic variations in health among certain groups of people that are closely linked to those groups socioeconomic status
These conditions are the social determinants of health and are defined by the World Health Organization – diet, exercise, tobacco, obesity
What are Social Determinants of Health?
Access to Health Care Poverty Education Work Leisure – diet/exercise Tobacco Obesity Living
conditions/environments Environmental toxins
Social Determinants
Study from England and Wales (Curran, 2009) Between 1972 – 1996 (UK had universal health
insurance) Life expectancy of men in the highest “social
class” increased from 72 yrs in the period of 1972-1976 to 79 yrs in the period 1992-1996, an increase of 7 years and 8%.
For this same period, life expectancy of men in the lowest social class increased from 66 yrs to 68 yrs an increase of only 3%. The gap widened.
Role of Poverty
Study conducted by Steven Woolf at VCU (published in 2009 in JAMA). Mortality for adults aged 25-64 varied by education level
Some education beyond high school: 206/100,000
High school education: 478/100,000 Less than high school education:
650/100,000
Role of Education
Impact of college education on population health - Giving Everyone the Health of the Educated: An examination of whether social change would save more lives than medical advances (Woolf, et. Al., AJPH, 2007) Using US vital statistics data from 1996-2002 Results: Medical advances averted 178,193
deaths during the study period. Correcting disparities in education – associated mortality rates would have saved 1,369,335 lives, a ratio of 8:1
Role of Education
Health Literacy and Outcomes Among Patients with Heart Failure (Peterson, et. al. JAMA 2011) Retrospective review of 2156 patients with
discharge diagnosis of heart failure identified between 2001-2008
Surveyed by mail with median follow up of 1.2 years
Health literacy assessed with a 3 question screen tool: on a scale of 1-5
Impact of Health Literacy
How often do you have someone help you read hospital material?
How often do you have problems learning about your medical condition because of difficulty reading hospital materials?
How confident are you filling out forms by yourself?
Screening Tool
Score less than 10 was called low health literacy.
Of 1494 included responders, 262 had low health literacy. Those with LHL had a 17.6% mortality rate during the study period compared with 6.3% for all others, adjusted for other illnesses, age, economic status, etc.
Screening Tool Outcomes
Low Health Literacy and Health Outcomes: An Updated Systematic Review (Berkman, et. al., AIM 2011)
Low Health Literacy was consistently associated with: More hospitalizations Greater use of emergency care Lower receipt of mammography screening and influenza
vaccine Poorer ability to demonstrate taking medication
appropriately Poorer ability to interpret labels and health messages In elderly patients: poorer overall health status, higher
mortality rates
Overall Impact of Health Literacy of Health Outcomes
Race: inextricably intertwined with economic status and education but infant mortality of black newborns in the US is twice as high as that of white newborns (Woolf, 2009)
If we could eliminate race-based inequalities, five lives would be saved for every life saved by medical advances
Race / Ethnicity
“If medicine is to fulfill her great test, then she must enter the political and social life. Since disease so often results from poverty, physicians are the natural attorneys of the poor and social problems should largely be solved by them.” Rudolf Virchow, 19th century pathologist
Our system is oriented toward assuring that those with illness receive all available treatment rather than on health promotion and addressing the conditions that produce disease.
Economic Impact
Fundamental Change is Required
Strategies for Health System Change
• Accelerate the use of health information technologyo Health information exchangeo Telehealtho Electronic medical records systems
• Restructure the health care payment system to improve the quality of medical care and curb rising costso Arkansas Payment Improvement Initiativeo Patient centered medical homeso Episode-based payments
Strategies for Health System Change
• Reduce the number of uninsured Arkansanso Private health insurance exchanges (ACA)o Arkansas Private Option for Medicaid Population
• Plan for a health care work force that provides appropriate access to medical services particularly in underserved areaso Health Work Force Strategic Plano Forty separate recommendations
A time of disruptive change but it’s not the first…
• Hill Burton Act: 1946• Medicare/Medicaid: 1965
“We are against forcing all citizens, regardless of need, into a compulsory government program. It is socialized medicine. If it stands, one of these days you and I are going to spend our sunset years telling our children and our children's children, what it once was like in America when men were free.” Ronald Reagan
• SCHIP (State Children’s Health Insurance Program) 1997
• Medicare Modernization Act: 2003 (Prescription drug coverage and Medicare Advantage Plans)
• PPACA: 2011• Arkansas Private Option Insurance Expansion• Arkansas Payment Improvement Initiative
All-Cause Mortality for Individuals aged 65+United States, 1950 - 2010
3500
2000 2005 2010
Deat
h ra
te p
er 1
00,0
00 p
opul
ation
4500
5500
6500
7500
Triple Aim
• Better population and individual health• Better patient experience• Lower cost
Patient Protection and Affordable Care Act
Goal: Extend access to insurance for the vast majority of currently uninsured citizens while improving quality and
controlling cost growth
Patient Protection and Affordable Care Act
– Key strategies:• Private Insurance exchanges for individuals and
families with income above 138% of federal poverty level
• Medicaid Expansion for individuals and families with incomes up to 138% of federal poverty level
• Medicaid expansion is funded federally for first three years after which states begin sharing cost up to 10% state share by 2020
• Many other provisions for funding the insurance expansion including reductions in:
– DSH payments,– Payment for avoidable hospital readmissions– Failure to meet quality targets– Other
Patient Protection and Affordable Care Act
– Arkansas Plan: Private Option• Rather than expand traditional Medicaid, use
federal Medicaid dollars to purchase insurance on the health insurance exchange
• Advantages:– Provider networks and Payment rates for providers are
the same for individuals above and below 138% of federal poverty level
– No churn between coverage at 138% of federal poverty– Expands risk pool– Federal waiver
• Cost control and care coordination promoted through linkage with Arkansas Payment Improvement Initiative
for Payment Improvement
Medical Home: Arkansas multi-payer emerging vision
• All Arkansans have access to an advanced PCMH within 2-4 years
• PCMHs proactively manage patients on a 24/7 basis
• Primary care providers should be rewarded for continuous improvements in quality and efficiency
• Primary care providers are stewards of overall system resources and have accountability for total cost of care
• PCMHs support and expect patients to actively engage and manage their own health.
The model rewards a Principal Accountable Provider (PAP) for leading and coordinating services and ensuring quality of care across providers
• Physician, practice, hospital, or other provider in the best position to influence overall quality, cost of care for episode
• Leads and coordinates the team of care providers
• Helps drive improvement across system (e.g., through care coordination, early intervention, patient education, etc.)
• Rewarded for leading high-quality, cost-effective care
• Receives performance reports and data to support decision-making
PAP selection:• Payers review
claims to see which providers patients chose for episode related care
• Payers select PAP based main responsibility for the patient’s care
PAP role What it means…
Core provider for episode
Episode‘Quarterback’
Performance management
Organizational and practice level requirements to successfully transform to meet triple aim and be successful in the new payment environment
• Patient engagement and patient centeredness
• Avoid waste: “non-value added” services• Transform from volume based to outcome
based focus with accountability for patient and population health outcomes
• Patient registries: patient activation and disease management focus to achieve targets for major adult diseases, vaccination rates, etc.
• Denominator focus
• EMR infrastructure: information moving with patient through the system
• Guideline focus: practice in accord with what is known to be best practice: real time decision support
• Organization must be accountable for care outcomes, patient experience and total costs
• Structured relationship for collaboration in care across continuum.
Organizational and practice level requirements to successfully transform to meet triple aim and be successful in the new payment environment
What we cannot do is keep doing
what we have been doing and expect different results.